Quality Matters reported on emerging models and trends in health care delivery reform and interviews with leaders in the field. Please read its successor, Transforming Care.
By Sarah Klein
Even without a direct source of reimbursement, several health systems, hospitals, and community health centers are working to integrate behavioral health services into primary and specialty care practices, emergency departments, and hospital units in an attempt to improve outcomes and reduce costs. The following profiles provide a snapshot of these efforts.
Cherokee Health Systems
Cherokee Health Systems, a federally qualified health center and community health center headquartered in Knoxville, Tenn., was founded in 1960 as a community mental health center but expanded into primary care out of necessity when it found its patients, many of whom lived in rural areas, lacked access to basic medical services. It now operates 24 primary care clinics and 20 school-based clinics.
In its clinics, primary care physicians screen every patient for substance abuse and mood disorders and engage embedded behavioral health consultants (now psychologists, but potentially also clinical social workers) in co-managing the care of patients who screen positive for these conditions and other behavioral health challenges that emerge in the course of a visit. The psychologists, who are often brought into the exam room, are also called upon to help when psychosocial challenges interfere with a patient’s health and treatment and/or when patients would benefit from a behavior change (such as quitting smoking or dieting) or better self-management of chronic conditions. They also see patients during all prenatal and well-child visits to assess psychosocial challenges, review screening results, and provide guidance and coaching to parents. Psychiatrists are also available for consults.
When Cherokee analyzed medical use patterns, it found when Medicaid patients saw a behavioral health consultant to improve the self-management of non-behavioral health conditions, utilization of medical services fell by 28 percent over the next two years. The system also saw a 20 percent decrease in the use of medical services among commercially insured patients over a two-year period. Data from a large commercial payer also showed Cherokee Health Systems patients had the lowest rates of psychiatric hospital admissions among all community health centers in the state.
Funding: The clinics bill for care coordination and behavioral health services when possible.
“For behavioral health services there is no rescheduling, no coming back in two weeks. It’s part of the flow of the primary care visit,” says Parinda Khatri, Ph.D., chief clinical officer, Cherokee Health Systems.
Carolinas HealthCare System
Carolinas HealthCare System, a North Carolina-based integrated delivery system with more than 40 hospitals and 900 care locations, is using remote behavioral health teams—composed of a psychiatrist, a pharmacologist, a nurse, a coach, therapist, and intake staff—to provide virtual care to patients in settings with limited access to behavioral health services, including primary care clinics. The teams are accessed through the system’s 27/4 behavioral health call center, which is staffed by nurses, social workers, and licensed counselors.
The teams, which were established this year, have also been making virtual rounds in 12 Charlotte-area emergency departments (EDs) to address the needs of patients with behavioral health diagnoses, many of whom spend long periods in EDs because of a shortage of inpatient psychiatric beds. This approach has reduced the length of stay in the emergency department by about half. And in the primary care practices where this program has been launched, the scores on depression screenings have fallen by about half in just four months, says John Santopietro, M.D., chief clinical officer for behavioral health services. Carolinas HealthCare System plans to expand the primary care teams’ reach to 10 practices by year’s end and to 225 practices within five years while expanding the ED program to more facilities as well. The program builds on a tele-psychiatry program that dates back 17 years.
Funding: Staffing for this virtual behavioral health team and call center is self-funded now, but the system hopes to fund and expand its efforts using the shared savings it anticipates from future accountable care and value-based contracts.
“Our goal is to treat people upstream, where the barriers are low and the gain is high. And to leverage the skill of our precious behavioral health workforce by using team-based and virtual care,” Santopietro says.
Advocate Health Care
Advocate Health Care, a Downers Grove, Ill.–based integrated delivery system with more than 250 sites of care including 12 hospitals, is developing a behavioral health hub-and-spoke system that will enable teams of psychologists and master’s level therapists, nurse practitioners, and psychiatrists at the hub to provide 24/7 telehealth and telephone consults to physicians in their system. The hub’s providers will screen ED patients who may be at high risk for depression, anxiety, and substance abuse, including those who make frequent use of emergency departments and/or have one of seven chronic conditions (e.g., congestive heart failure and diabetes.) For those with identified behavioral health issues, the team will follow standard protocols to begin treatment, including prescribing medications and establishing follow-up appointments with primary care doctors or behavioral health specialists.
Team members will also screen patients admitted to the medical floors of the hospitals, either through face-to-face visits or telehealth technology, focusing on those who have had multiple admissions or readmissions as well as those with chronic conditions.
Part of Advocate’s behavioral health integration plan includes having primary care physicians perform behavioral health screenings during office visits for all adults (starting with depression, and later moving on to anxiety and substance abuse). They will follow best-practice protocols to treat patients’ behavioral health issues and make referrals. Some large primary care practices will have embedded behavioral health practitioners to provide assessment, education, and treatment. The behavioral health team working in Advocate's hub will also be available to primary care physicians for consultations.
Advocate is also developing partnerships with community agencies to promote access to services that meet high standards for access, communication, safety, and quality.
Funding: The system is covering most of the cost of the initiative. Because it is fully at risk for Medicare Advantage patients, it may benefit if its behavioral health program reduces hospital and emergency department use and other medical services, as expected. The state’s Medicaid program also pays for telehealth services.
“Through earlier identification and enhanced access to care for patients with medical and behavioral health needs, this program will allow earlier provision of effective treatment, leading to improved patient quality of life at lessened overall cost,” said David Leader, M.D., psychiatric co-medical director for Advocate Health Care.
Intermountain Healthcare, an integrated delivery system with 22 hospitals and 185 ambulatory care clinics in Utah and Idaho, began working to integrate behavioral health services into primary care 15 years ago.
A key element of its approach is supporting primary care practices classified as mental health integration clinics with training and staff to screen all patients for behavioral health problems, evaluate patient and family support systems, and determine treatment preferences. Patients deemed to be at mild risk are treated by primary care physicians with assistance from a care manager. For patients with more moderate and severe conditions, primary care practices receive support from on-site mental health professionals, including psychiatric nurse practitioners, social workers, and psychologists, who can intervene and guide care as necessary or refer patients to more intensive inpatient and outpatient psychiatric care. (Primary care practices also refer patients to community-based organizations such as the National Alliance on Mental Illness that provide peer support.)
Intermountain is in the process of expanding its behavioral health integration efforts to engage providers in its sleep, spine, and ob-gyn practices in assessing patients and providing treatment as needed. In such settings, patients' underlying behavioral health problems, including depression, may influence outcomes.
Funding: Paid for by the health system
“At a minimum we expect primary care physicians to provide 80 percent of mental health care,” says Brenda Reiss-Brennan, M.S.N., mental health integration leader, Intermountain Healthcare.
St. Charles Health System in conjunction with PacificSource Community Solutions
St. Charles Health System is a four-hospital system headquartered in Bend, Oregon, that joined with health plans, provider groups, dentists, community organizations, and others in the region to create the Central Oregon Health Council, the governance entity for PacificSource Community Solutions, one of 16 care coordination organizations (CCO) in the state that accepts a global budget for providing and/or ensuring access to physical and behavioral health services, as well as dental care, for all Medicaid patients living in a region.
As part of the CCO’s efforts to improve care for Medicaid beneficiaries, it added 10 clinical psychologists to community-based primary care and pediatric practices, federally qualified health centers, and throughout the hospital, to help identify patients with underlying behavioral health needs and develop a treatment plan.
The psychologists follow standard care pathways to identify and treat behavioral health problems that may be associated with chronic pain, sleep disorders, pediatric obesity, and adult and pediatric attention deficit hyperactivity disorder. Psychologists may see these patients for three to four sessions (patients with chronic pain are offered 10 group therapy sessions.)
The hospital system separately embedded a psychologist in its neonatal intensive care unit (NICU) to work with families to reduce stress and help them recognize and foster their babies' neurological development. The initiative led to a reduction in NICU length of stay because parents were more comfortable taking their children home earlier.
St. Charles Health System is looking to expand its efforts by using remote monitoring and other technology to create a bridge between behavioral health providers, community health workers, and patients outside of clinic settings. Its goal is to increase monitoring and patient education as a means of encouraging compliance with treatment and lifestyle changes that may improve health. They began with children with diabetes.
Funding: The CCO pays for behavioral health services in primary care practices. St. Charles Health System funded the NICU psychologist initially, but as it demonstrated cost savings from decreased lengths of stay, the Medicaid program and private payers agreed to pay for the service.
“Every time we get a win, we go back in and have conversations with insurers about paying for these services,” says Robin Henderson, Psy.D., chief behavioral health officer and vice president of strategic innovation for St. Charles Health System.