The case for behavioral health integration into primary care

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Behavioral Health

The case for behavioral health integration into primary care

J Fam Pract. 2019 June;68(5):278-284

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References

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11. Peek CJ; the National Integration Academy Council. Lexicon for behavioral health and primary care integration: concepts and definitions developed by expert consensus. AHRQ. https://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf. Published April 2013. Accessed May 29, 2019.

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13. Integrating physical and behavioral health care: promising Medicaid models. The Henry J. Kaiser Family Foundation. https://www.kff.org/wp-content/uploads/2014/02/8553-integrating-physical-and-behavioral-health-care-promising-medicaid-models.pdf. Published February 2014. Accessed May 29, 2019.

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15. Gerrity M. Evolving models of behavioral health integration: evidence update 2010-2015. Milbank Memorial Fund. https://www.milbank.org/wp-content/uploads/2016/05/Evolving-Models-of-BHI.pdf. Published May 2016. Accessed May 29, 2019.

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OTHER MODELS OF BHI

Higher levels of BHI such as co-location and integration do not have the same quality of evidence as CCM.

A 2009 Cochrane review of 42 studies involving 3880 patients found that mental health workers delivering psychological therapy and psychosocial interventions in primary care settings brought about significant reductions in primary care physician consultations (SMD = ‐0.17; 95% CI, ‐0.30 to ‐0.05); a relative risk reduction of 23% in psychotropic prescribing (RR = 0.67; 95% CI, 0.56–0.79); a decrease in prescribing costs (SMD = ‐0.22; 95% CI, ‐0.38 to ‐0.07); and a relative risk reduction in mental health referral of 87% (RR = 0.13; 95% CI, 0.09–0.20) for the patients they were seeing.³² The authors concluded the changes were modest in magnitude and inconsistent across different studies.³²

Collaborative care has improved depression outcomes at little to no increase in treatment costs compared with usual care.

Embedding medical providers in behavior health centers—ie, the reverse co-location model—also has very limited evidence. An RCT involving 120 veterans found that patients enrolled in a reverse co-location clinic did significantly better than controls seen in a general care clinic in terms of continuity of care and preventive care such as screening for hypertension (84.7% vs 65.6%; X ² = 5.9, P = .01), diabetes (71.2% vs 45.9%; X ² = 7.9, P < .005), hepatitis (39% vs 14.8%; X ² = 9, P = .003), and cholesterol (79.7% vs 57.4%; X ² = 6.9, P = .009).³³

HOW TO IMPLEMENT A SUCCESSFUL BHI PROGRAM

A demonstration and evaluation project involving 11 diverse practices in Colorado explored ways to integrate behavioral health in primary care. Five main themes emerged^34,35:

Frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care.
Deﬁne relationships and protocols up front, understanding that they will evolve.
Build inclusive, empowered teams to provide the foundation for integration.
Develop a change management strategy of continuous evaluation and course correction.
Use targeted data collection pertinent to integrated care to drive improvement and impart accountability.

The one feature that is consistent with improved outcomes is the presence of a care manager.

The Institute for Clinical and Economic Review has organized an extensive list of resources³⁶ for implementing BHI models, a sampling of which is shown in TABLE 2.

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