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How to Integrate Behavioral Health with Primary Care

Janelle Schrag
November 4, 2014

In the United States, one in four adults suffers from diagnosable mental illness. Many in this population also suffer from preventable physical health conditions. Because behavioral and medical health services often operate in individual siloes, people who have these types of co-occurring conditions may not receive the treatment they need.

Integrating behavioral health and primary care services is one way to overcome these siloes, but integration itself comes with a range of issues. Essential hospitals Contra Costa Health Services, Eskenazi Health, Hennepin County Medical Center (HCMC), and New York City Health and Hospitals Corporation (HHC) share their strategies for overcoming several of these issues, improving access to care for these complex patients.

Relieving Concerns about Stigmatization  

Some people are uneasy about the idea of receiving care in a behavioral health facility. For them, it carries a negative stigma they don’t want to be associated with, so they avoid seeking medical care at all.

Contra Costa worked to help patients overcome this barrier with pilot projects that co-locate behavioral health and primary care staff. By placing a psychiatrist at the primary care site, Contra Costa has helped patients gain behavioral health care without worrying about their fears of going to a mental health facility.

Eskenazi Health initially employed licensed social workers, marriage therapists, clinical nurse specialists, and psychiatrists at each of its community health centers to assist primary care providers in treating patients with anxiety, depression, and substance abuse issues. But here as well, patients worried they would be stigmatized for seeing mental health professionals. In a clear patient-centered response, Eskenazi switched to a more consultative approach, in which behavioral health care providers are available on an as needed basis. Patient feedback indicates they prefer this more discreet approach to receiving behavioral health services.

Simplifying Systems and Targeting Care

Complex patients may struggle with other social issues outside the realm of traditional health care. By reducing the complexity of the system, providers can allocate patients effectively and are less likely to lose track of them during follow-up.

After studying patient utilization patterns, HCMC identified a unique group of behavioral health patients who were receiving inappropriate care due to the system’s intricate infrastructure. The hospital observed common misuse of services – e.g., primary care instead of necessary specialized care – as well as issues related to follow-up care. To address these challenges, HCMC created a system of customized clinics, including a coordinated care clinic where patients are able to access both primary care and specialty psychiatric care.

HHC’s Office of Behavioral Health developed a care model that provides four levels of treatment for patients with co-occurring behavioral and physical ailments. Each facility within HHC customizes and adapts care based on the treatment needs of its patient cohort and provider expertise. For example, level three patients receive co-located services from embedded primary care or behavioral health clinicians who complement the patient population’s primary need.

Both HCMC and HHC utilize a patient screening process upon enrollment to ensure patients are allocated appropriately to one of the system’s tiered clinics. At HHC, level one medical homes provide mental health and substance abuse screenings using the Patient Health Questionnaire (PHQ-9) for all patients. If the screening identifies substance abuse or depression, staff members use the Wagner Chronic Disease Model to treat the patient. This model connects the key players in patient care – the community, the health care organization, and the patient – and facilitates patient-centered care focused on self-management and wellness.

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