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THE LONG AND EVOLVING JOURNEY
TO MAKE EFFECTIVE MENTAL HEALTH CARE AVAILABLE IN MEDICAL SETTINGS --
an INTERVIEW with DR. LORI RANEY
Bringing effective mental health care into medical settings, particularly primary care, where all adults go for treatment, has been a very long care delivery reform in the making.
The initial elements of how to incorporate effective mental health care in primary care were established nearly two decades ago (Katon et al, N Eng Jnl Med, 2010, 363:2611-20). Yet we are only now moving forward with actual clinical implementation.
Encouragingly, in the past 5 years, real progress has been made with behavioral health integration(BHI) largely accepted, in concept, by most medical practices (and introduced in specialty BH care). Though much works needs to be done to convince the majority of primary care practices to come along.
Further progress has come from large health organizations (Mayo, KP, etc) shifting physician payment from fee-for-service to value-based where doctors will be held accountable for their patients’ health outcomes and paid accordingly. Primary care physicians (PCPs) are finding if they do not treat their patients’ behavioral issues, their physical conditions do not improve and may worsen. Yet PCPs often feel the BH system has failed them, as they cannot refer patients to BH and get immediate action. And finally, pediatric medicine has recently called for BH screening for all children. All this represents tangible, if slow, limited, progress towards making effective mental health care available in primary care.
Those practices moving ahead with BHI confront a continually evolving process, as well as complicated and demanding implementation requirements. And practices with limited resources, all the more so.
In midst of this complex, transformative environment, NHMH sat down with the distinguished psychiatrist and expert in “integrated care”, Dr. Lori Raney of Colorado to discuss her new book “Integrated Care: A Guide for Effective Implementation.” (Integrated Care – A Guide for Effective Implementation, Raney, L. et al, American Psychiatric Assn Publishing, 2017) and talk about where we are in this care delivery reform. Dr. Raney also chairs the APA Committee on Integrated Care.
Dr. Raney describes in her book an emerging three-part framework that will help guide practices to providing effective behavioral health services: (a) core principles, (b) implementation findings, and (c) practice experience. She discusses 4 possible approaches practices may consider in doing BHI:
First, the collaborative care approach which is a specific and intensive intervention that incorporates psychiatric consultants and behavioral care managers into the multi-disciplinary care team also consisting of primary care physicians (PCP) and staff. The care team typically treats mild to moderate behavioral health conditions and follows a systematic approach of stepped-care. This includes screening for behavioral health issues, assessment, treatment to target, evidence-based brief interventions (e.g. cognitive behavioral therapy, motivational interviewing, patient activation, etc), close patient monitoring and follow-up, adjusting treatment when needed, weekly caseload review with a psychiatric consultant, patient registries to track progress, and referral to higher levels of specialty BH treatment for patients not reaching care goals. It is a model that treats both the individual patient with co-morbid medical and behavioral conditions, and a population of such patients. While challenging in implementation, it has a deep research base supporting efficacy for health outcomes and new doctor payment codes from Medicare for the psychiatric consultant and care manager.
A second approach, primary care behavioral health (PCBH), involves placement of a behavioral health professional , usually a psychologist, social worker, or licensed professional counselor, as a behavioral health consultant (BHC) in the primary care team. This professional provides immediate behavioral interventions to co-morbid patients who have a variety of behavioral health issues. The interventions by the BHC can be to treat acute life stressors, crises, substance use disorders, stress-related physical symptoms and behavioral health diagnoses. The BHC can also provide referral to higher-level behavioral health specialists. This approach is of real value to PCPs due to the immediate availability of the behavioral professional to address these issues, and keep the clinic workflow on track.
However, the PCBH model does not include sophisticated elements such as systematic, repeat measurement of progress tracked in a registry, and psychiatric consultation to adjust treatment for patients not improving.
Nonetheless, for many, if not most, primary care practices, the PCBH model is the favored jumping-off point for providing integrated care services, with collaborative care a longer-term vision or goal.
The third approach is a blended variation, combining the PCBH model and the collaborative care model. It can be used when practices are in the fortunate position of having enoughbehavioral health resources (i.e. BH personnel) available, to help patients with episodic stressors in an immediate fashion, as well as having a group of co-morbid patients in the practice with identified, specific behavioral health problems who can receive the more rigorous, intensive collaborative care intervention.
The collaborative care model is a heavy-lift for the majority of U.S. practices which are 5 and fewer clinicians. The blended model is similarly a heavy lift, requiring sufficient resources to mount both a PCBH and the collaborative care requirements. That leaves, as mentioned above, the PCBH approach as the most common one now being adopted by most practices.
A fourth approach involves a call for practices, and the medical and behavioral fields, to think beyond BHI models per se, and focus instead on what is necessary for any approach to change outcomes. This thinking is in line with value-based payment accountability, focused on outcomes as the key item practices need to focus on improving.
Under this outcomes-focused dimension, there could be blended/blended/blended approaches that pick and choose various processes and care team dynamics that demonstrate good outcomes.
For example, use of a BHC in a primary care practice to deal with acute stressors and behavior changes, while also offering some elements of the collaborative care model. In the latter case where a defined diagnosis for depression or anxiety will be treated and tracked until targeted outcomes are reached. A practice with insufficient resources for a electronic patient registry, may have a care team that agrees to use a measurement-based, treat-to-target approach for BH conditions such as depression, anxiety, or childhood attention deficit disorder.
Individual practices, with their own unique characteristics, must decide which approach is most appropriate and effective for their needs and resources, and will improve their patients outcomes while engaging patients in the process to change behaviors.
A fertile new ground for creative are the new consultative interactions between medical and behavioral professionals as to how they can work together in primary care teams. Various examples so far include the ECHO program, tele-teaming and eConsult. These new inter-disciplinary consultative arrangements as to how to bring effective mental health care into primary care are just beginning.
NHMH fully supports outside-the-box thinking in both medical and behavioral health fields. We urge practices to also include patients in the dialogue. All the more so since recent studies at the University of Utah Health show that doctors’ priority and focus on outcomes may not be shared by their own patients, who are focused on affordability and lower co-pays, (see attached).
We know effective treatment for the majority of mild to moderate behavioral conditions (affecting 40-50 million Americans) can take place in primary care, while preserving the critically necessary specialty behavioral health setting for those with serious and persistent mental disorders (4 million Americans) who can be referred there by their PCPs. A crucial benefit to treatment of BH conditions in primary care is that we may prevent their development into serious mental illness later.
Dr. Raney stresses allowing latitude for medical and behavioral professionals in picking the approach that works best in their particular primary care practice … as she stresses the 4 or 5 core elements of integrated care that -whatever you do -should make outcomes better: team-based care; measurement-based care; evidence-based care; population-based care; and accountable care.
Making effective mental health care available in primary care has only just begun, and the fields, patients, policy-makers and advocacy organizations must collectively and determinedly persist through to making it a reality across the U.S., not in another two decades, but in the next 5 years.
Lori Raney, M.D. is a Principal with Health Management Associates in Denver, CO, where, when not engaged in mental health reform, enjoys mountain biking, skiing and hiking in the surrounding Rocky Mountains.
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