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Behavioral health primary care integration

Health Factors: Quality of Care
Decision Makers: Healthcare Professionals & Advocates
Evidence Rating: Scientifically Supported
Population Reach: 100% of WI's population
Impact on Disparities: Likely to decrease disparities

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Description

Integrating behavioral health into primary care practice brings mental health and/or substance abuse screenings and treatments into a primary care setting. These efforts can include coordination between primary care providers, case managers or behavioral health consultants, and mental health specialists (e.g., psychiatrists), and often require training and redefinition or realignment of staff roles (SAMHSA-HRSA Integrate, CG-Mental health). Telehealth tools such as electronic health records (EHRs), text messaging, mobile applications (apps), and online therapies may be used to support integration (Raney 2017). Mental health conditions and substance abuse issues often occur with other chronic medical conditions; patients with severe conditions are referred to specialty care (SAMHSA-HRSA Integrate). 

Expected Beneficial Outcomes

Improved mental health
Increased adherence to treatment
Improved quality of life
Increased patient engagement
Increased patient satisfaction
Reduced drug and alcohol use

Evidence of Effectiveness

There is strong evidence that integrating behavioral health into primary care practice improves mental health (Asarnow 2015, Cully 2017, ICER-Tice 2015, Cochrane-Bower 2011), especially depression symptoms (ICER-Tice 2015, CG-Mental health, Butler 2011, Gilbody 2006a). Integrating care also increases patients’ adherence to treatment (Kolko 2014, Thota 2012), improves their quality of life (Thota 2012), and increases patient satisfaction (ICER-Tice 2015, Kolko 2014) and engagement with health care providers (Wissow 2013).

Integrating depression screening and treatment into primary care has been shown to improve depression symptoms for adolescent, adult, and elderly patients (CG-Mental health, Butler 2008). Such care appears effective in various settings, including practices with limited resources and practices in rural and urban areas (CG-Mental health, Berger-Jenkins 2012, Serrano 2011). Integrated care improves youth mental health outcomes, including depression and substance use, more than usual care (Asarnow 2015). Integrated care in pediatric practices increases initiation and completion of treatment, improves behavior problems, and reduces hyperactivity and parental stress (Kolko 2014). Experts suggest that increasing incentives to integrate primary care and behavioral health care may improve children’s health (Asarnow 2015).

Collaborative care approaches that use case managers to organize and integrate behavioral and primary care improve response to treatment, increase remission and recovery from symptoms, and increase satisfaction with care among patients with depression in the short- and long-term (CG-Mental health, Gilbody 2006a). Coordination which includes regular and planned psychiatrist supervision of case managers has been shown to be more effective than efforts with unplanned supervision (Gilbody 2006a). Collaboration and communication between medical and behavioral health providers has also been shown to increase success and sustainability of integration efforts (Muse 2017).

Integrated care has been shown to reduce depression and anxiety for veterans with heart failure and chronic obstructive pulmonary disease (COPD), and can improve health-related quality of life for veterans with COPD in the short-term (Cully 2017). For patients suffering from chronic pain and substance abuse disorders in addition to depression, multiple interventions in primary care settings (e.g., motivational interviewing and cognitive behavioral therapy) may improve mental health and reduce drug and alcohol use more effectively than a single intervention (Haibach 2014).

Universal mental health screening during pediatric appointments can increase parent, youth, and primary care provider willingness to discuss mental health concerns. Framing screening as universal, confidential, and designed to improve communication may further support patient and family engagement (Wissow 2013). A Bronx-based study of a pediatric behavioral health integration program suggests programs that use pediatric psychologists and psychiatrists to integrate care can increase referral rates to pediatric mental health practitioners and increase primary care provider comfort managing school-age and adolescent attention deficit hyperactivity disorder-related behaviors (ADHD) more than clinics that use social workers to integrate behavioral health (German 2017). Experts suggest that psychologists who integrate behavioral health into pediatric primary care use principles of culturally adapted care to meet the needs of racial and ethnic minority youth (Arora 2017).

Economic studies indicate that integrating behavioral health and primary care to treat depression is associated with greater costs and better health outcomes than traditional care models. Overall, studies have shown integrated care to be cost effective in terms of quality adjusted life years (QALYs) saved (CG-Mental health). Integrated care may reduce costs and medical utilization in rural areas (Peterson 2017).

Implementation

United States

The Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral Health and Primary Care (AHRQ Academy) includes resources, research, and tools to support integrated care (AHRQ-Integrate). The Substance Abuse and Mental Health Services Administration (SAMHSA) includes numerous resources from federal agencies and national organizations on integrating behavioral health and primary care (SAMHSA-Children MH). The Primary Care Team LEAP is another example of an organization that offers guidance on how to integrate behavioral health into primary care through co-location or collaborative agreements (PCT-LEAP).

There are several models to integrate behavioral health into primary care practice. The AIMS Center at the University of Washington, for example, uses a Collaborative Care model based on five core principles: patient-centered team care, population-based care, measurement-based treatment to target, evidence-based care, and accountable care (AIMS-Collaborative care). The Institute for Clinical Systems Improvement’s Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program uses these same components for patients with depression (ICSI-DIAMOND).

Wisconsin

The Wisconsin Initiative to Promote Healthy Lifestyles supports integration of behavioral screening and intervention services in primary care settings across the state to address substance use, depression, or obesity concerns. All patients are systematically screened and patients with moderate concerns receive brief interventions from health educators; those with more serious conditions are referred to more intensive treatments (WIPHL).

Implementation Resources

AHRQ-Integrate - Agency for Healthcare research and Quality (AHRQ). The Academy: Integrating behavioral health and primary care. Accessed on April 23, 2018
AIMS-Collaborative care - Collaborative Care. Advancing Integrated Mental Health Solutions (AIMS). University of Washington. Accessed on April 23, 2018
ICSI-DIAMOND - DIAMOND for depression. Institute for Clinical Systems Improvement (ICSI). Accessed on April 23, 2018
PCT-LEAP - The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP). Behavioral health integration. Princeton: Robert Wood Johnson Foundation (RWJF). Accessed on May 14, 2018
SAMHSA-Children MH - Substance Abuse and Mental Health Services Administration (SAMHSA). Children’s mental health (MH): Behavioral health care integration resources. Accessed on May 14, 2018
SAMHSA-HRSA Integrate - SAMHSA-HRSA Center for Integrated Health Solutions. Integrate behavioral health into primary care. Accessed on May 1, 2018
SNMHI-BHI - Safety Net Medical Home Initiative (SNMHI). Organized, evidence-based care: Behavioral health integration (BHI). Sponsored by The Commonwealth Fund, Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute. Accessed on May 14, 2018
WIPHL - Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL). Accessed on April 23, 2018

Citations - Description

CG-Mental health - The Guide to Community Preventive Services (The Community Guide). Mental health. Accessed on April 23, 2018
Raney 2017 - Raney L, Bergman D, Torous J, Hasselberg M. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Current Psychiatry Reports. 2017;19:86. Accessed on May 14, 2018
SAMHSA-HRSA Integrate - SAMHSA-HRSA Center for Integrated Health Solutions. Integrate behavioral health into primary care. Accessed on May 1, 2018

Citations - Evidence

Arora 2017* - Arora PG, Godoy L, Hodgkinson S. Serving the underserved: Cultural considerations in behavioral health integration in pediatric primary care. Professional Psychology: Research and Practice. 2017;48(3):139-148. Accessed on May 14, 2018
Asarnow 2015 - Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta-analysis. JAMA Pediatrics. 2015;169(10):929-937. Accessed on May 14, 2018
Berger-Jenkins 2012* - Berger-Jenkins E, McCord M, Gallagher T, Olfson M. Effect of routine mental health screening in a low-resource pediatric primary care population. Clinical Pediatrics. 2012;51(4):359-65. Accessed on April 23, 2018
Butler 2008 - Butler M, Kane RL, McAlpine D, et al. Integration of mental health/substance abuse and primary care. Rockville: Agency of Healthcare Research and Quality (AHRQ); 2008. Accessed on April 23, 2018
Butler 2011* - Butler M, Kane RL, McAlpine D, et al. Does integrated care improve treatment for depression: A systematic review. The Journal of Ambulatory Care Management. 2011;34(2):11-25. Accessed on April 23, 2018
CG-Mental health - The Guide to Community Preventive Services (The Community Guide). Mental health. Accessed on April 23, 2018
Cochrane-Bower 2011* - Bower P, Knowles S, Coventry, PA, Rowland N. Counselling for mental health and psychosocial problems in primary care: Review. Cochrane Database of Systematic Reviews. 2011;(9):CD001025. Accessed on April 23, 2018
Cully 2017 - Cully JA, Stanley MA, Petersen NJ, et al. Delivery of brief cognitive behavioral therapy for medically ill patients in primary care: A pragmatic randomized clinical trial. Journal of General Internal Medicine. 2017;32(9):1014-1024. Accessed on May 14, 2018
German 2017 - Germán M, Rinke ML, Gurney BA, et al. Comparing two models of integrated behavioral health programs in pediatric primary care. Child and Adolescent Psychiatric Clinics of North America. 2017;26(4):815-828. Accessed on May 14, 2018
Gilbody 2006a* - Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine. 2006;166(21):2314-21. Accessed on April 23, 2018
Haibach 2014* - Haibach JP, Beehler GP, Dollar KM, Finnell DS. Moving toward integrated behavioral intervention for treating multimorbidity among chronic pain, depression, and substance-use disorders in primary care. Medical Care. 2014;52(4):322-27. Accessed on April 23, 2018
ICER-Tice 2015 - Tice JA, Ollendorf DA, Reed SJ, et al. Integrating behavioral health into primary care. Institute for Clinical and Economic Review (ICER); 2015. Accessed on April 23, 2018
Kolko 2014 - Kolko DJ, Campo J, Kilbourne AM, et al. Collaborative care outcomes for pediatric behavioral health problems: A cluster randomized trial. Pediatrics. 2014;133(4):e981-e992. Accessed on May 14, 2018
Muse 2017* - Muse AR, Lamson AL, Didericksen KW, Hodgson JL. A systematic review of evaluation research in integrated behavioral health care: Operational and financial characteristics. Families, Systems, & Health. 2017;35(2):136-154. Accessed on May 15, 2018
Peterson 2017* - Peterson M, Turgesen J, Fisk L, McCarthy S. Integrated care in rural health: Seeking sustainability. Families, Systems, & Health. 2017;35(2):167-173. Accessed on May 14, 2018
Serrano 2011 - Serrano N, Monden K. The effect of behavioral health consultation on the care of depression by primary care clinicians. WMJ. 2011;110(3):113-119. Accessed on April 23, 2018
Thota 2012* - Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. American Journal of Preventive Medicine. 2012;42(5):525-38. Accessed on April 23, 2018
Wissow 2013 - Wissow LS, Brown J, Fothergill KE, et al. Universal mental health screening in pediatric primary care: A systematic review. Journal of the American Academy of Child and Adolescent Psychiatry. 2013;52(11):1134-1147.e23. Accessed on April 23, 2018

Citations - Implementation

AHRQ-Integrate - Agency for Healthcare research and Quality (AHRQ). The Academy: Integrating behavioral health and primary care. Accessed on April 23, 2018
AIMS-Collaborative care - Collaborative Care. Advancing Integrated Mental Health Solutions (AIMS). University of Washington. Accessed on April 23, 2018
ICSI-DIAMOND - DIAMOND for depression. Institute for Clinical Systems Improvement (ICSI). Accessed on April 23, 2018
PCT-LEAP - The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP). Behavioral health integration. Princeton: Robert Wood Johnson Foundation (RWJF). Accessed on May 14, 2018
SAMHSA-Children MH - Substance Abuse and Mental Health Services Administration (SAMHSA). Children’s mental health (MH): Behavioral health care integration resources. Accessed on May 14, 2018
WIPHL - Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL). Accessed on April 23, 2018

Page Last Updated

May 14, 2018

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