Keys to Putting Behavioral Health Integration into Practice

Integration with primary care remains an urgent goal for improved behavioral care outcomes.  During a recent webinar, physician leaders from Penn Medicine and the Department of Veteran Affairs described the impact of integration efforts in their organizations.

The June 21 webinar was hosted by the American Medical Association (AMA), which in collaboration with Manatt Health has developed a report articulating the opportunities and challenges of incorporating virtual care (telehealth) and other digital tools to accelerate the adoption of behavioral health integration.

Matthew Press, M.D., is the physician executive of Penn Primary Care and the medical director of the Primary Care Service Line at Penn Medicine. In these roles, he helps lead clinical operations, practice transformation, and population health management across a network of 90 primary care practices in the University of Pennsylvania Health System.

Prior to his positions with Penn Medicine, Press was a member of the senior leadership team at the Center for Medicare and Medicaid Innovation at CMS, where he helped develop and implement several new payment and care delivery models including ACOs, bundled payments, integrated mental health, and medical homes. He also worked with the Health Care Payment Learning and Action Network, a national public-private partnership dedicated to health care payment reform.

Press began by calling behavioral health integration (BHI) the number one issue that we need to tackle in the American healthcare system, because of the great prevalence of mental health problems, the impact that mental health conditions have on both quality and cost of care in the U.S., and the lack of access to high-quality, affordable mental, mental healthcare across the country.

 “When I was at CMS, we were looking for ways that we could help support integrated mental health, and I got to know the collaborative care model. It is an evidence-based model of integrating mental health into primary care that's been around for a few decades,” Press explained. “There are over 80 randomized control trials that show its impact, particularly on mental health outcomes, but also data showing an impact on improving medical comorbidity outcomes as well as lowering total cost of care.”

Press was involved with the creation of billing codes for the collaborative care model while at CMS. “Then when I when I came to Penn Medicine, with the charge of leading primary care transformation and population health management, I felt that we would never be successful in the world of population health management and value-based payment without a really effective, integrated mental health program. So our first priority was to launch an integrated mental health program that is based almost entirely on the collaborative care model. I would refer those who aren't that familiar with the collaborative care model to the AIMS Center at the University of Washington, which has been a pioneer of this model.”

Press described that in his primary care practice, he has a behavioral healthcare manager, a key new role that works very closely with him. “That person and I are supported behind the scenes by a consulting psychiatrist, so you take the really scarce resource of a psychiatrist and you spread it over a much broader population by leveraging the primary care physician and behavioral healthcare manager that's working with the primary care physicians. Patients prefer to get their care in primary care because of the low stigma and easy access.”

For many patients with mild to moderate depression, anxiety, and/or substance use disorder, they can effectively be treated and all of their mental health needs met in the primary care setting through this evidence-based model, Press said. He noted that one tweak is that they centralize the intake process, but otherwise, their model looks just like the collaborative care model described in the AIM Center.

They leverage the collaborative care billing codes to fund the program after some initial upfront investments. “That has allowed us to have a sustainable business model to continue to grow,” Press said. “We launched in each of our practices in the City of Philadelphia in 2018. At this point, we're at about 20 practices. We added 12 or so outside of the City of Philadelphia. We have across our primary care network over 100 practices, and our goal over the next year or two is to get collaborative care into all of those practices.”

Press was followed by Edward Post, M.D., Ph.D., who serves as senior advisor to the Director of Primary Care Operations for the Veterans Health Administration Office of Primary Care, and also co-chair of the Ambulatory Council for VA Electronic Health Record Modernization. From 2007 to 2020, he served as National Primary Care Director of VA Primary Care-Mental Health Integration.

Post said the VA has taken an approach that is more of a hybrid of the collaborative model along with some co-located resources.

“We ultimately start out with a population-based approach where we screen veterans, often on an annual basis, for behavioral health conditions,” he said. “We often have warm handoffs, even if we're having a care manager, it's always great for them to put a face to a name, even before the pandemic, although the use of video and telephone and distance technologies to deliver care has markedly increased during the pandemic. The care management community has often been telephonic or video. Nonetheless, warm handoffs can be key and they're absolutely central to our more co-located component, which is really focusing on crises as well as when there's a need for a diagnostic evaluation.”

The VA does have mental health integration staff within its primary care medical home model, the patient-activated care team. “For those veterans who have lower-acuity behavioral health needs, we do have digital support options, which have been in place not only for patient/provider interaction, pre-COVID,” he said, “but also for population health and other aspects of a full integrated model. But now the majority of our care management behavioral health visits within our program have been conducted virtually.”

In the VA model, nearly 95 percent of the veterans are screened on a regular basis for a variety of poor mental health conditions. Those include depression, PTSD, alcohol use disorder, as well as most recently the concept of suicidality.

Screens in primary care are usually conducted by a medical assistant or a licensed practical nurse. “We made a decision early on that the expertise and the need for supervision for the collaborative care model would really have us focus on nurses or social workers or even clinical pharmacists as care managers within the integrated mental health team,” Post said.

When a positive screen is identified, the primary care physicians can in some cases use counseling dialogues for brief interventions for alcohol use as a function of the clinical reminder system within the electronic health record, and they can conduct that brief intervention, Post explained. Then depending on what the additional needs are, and even for other conditions beyond alcohol, the primary care clinician has the prerogative to either take sole care and follow up depending on the condition or to involve the mental health integration team, who in many circumstances are proximate within the primary care venue. With complex patients, they are able to refer them directly to specialty mental health care. “So there's a whole continuum of mental health, of which the least intensive aspect of our mental health system is essentially forward-deployed into primary care in a manner of speaking.”

The AMA report on this topic seeks to:

1. Define the opportunities and limitations to incorporating technology to advance BHI.
2. Define practical solutions that stakeholders can pursue to advance digitally enabled BHI.
3. Demonstrate how to use AMA's Return on Health framework to measure the value of digitally enabled BHI models.

This effort builds on the AMA's ongoing efforts to advance BHI adoption by physician practices, alongside its Return on Health framework, which defines various ways in which virtual care programs can generate value.