Evolving Models of Integrated Behavioral Health and Primary Care
- 135 Downloads
Purpose of Review
Mental and physical disorders commonly co-occur leading to higher morbidity and mortality in people with mental and substance use disorders (collectively called behavioral health disorders). Models to integrate primary and behavioral health care for this population have not yet been implemented widely across health systems, leading to efforts to adapt models for specific subpopulations and mechanisms to facilitate more widespread adoption.
Using examples from the UK and USA, we describe recent advances to integrate behavioral and primary care for new target populations including people with serious mental illness, people at the extremes of life, and for people with substance use disorders. We summarize mechanisms to incentivize integration efforts and to stimulate new integration between health and social services in primary care. We then present an outline of recent enablers for integration, concentrating on changes to funding mechanisms, developments in quality outcome measurements to promote collaborative working, and pragmatic guidance aimed at primary care providers wishing to enhance provision of behavioral care.
Integrating care between primary care and behavioral health services is a complex process. Established models of integrated care are now being tailored to target specific patient populations and policy initiatives developed to encourage adoption in particular settings. Wholly novel approaches to integrate care are significantly less common. Future efforts to integrate care should allow for flexibility and innovation around implementation, payment models that support delivery of high value care, and the development of outcome measures that incentivize collaborative working practices.
KeywordsIntegrated care Collaborative care Mental health services Primary care Co-occurring conditions
This report was supported through two grants from the Commonwealth Fund of New York awarded to the New York State Psychiatric Institute. The views expressed here are those of the authors and not necessarily those of the Commonwealth Fund.
Compliance with Ethical Standards
Conflict of Interest
Erin Ferenchik, Mary Docherty, and Brigitta Spaeth-Rublee declare no conflict of interest.
Parashar Ramanuj has received honoraria from the Institute for Healthcare Improvement not related to this work.
Harold Alan Pincus declares he is a member of the Council on Quality of Care at the American Psychiatric Association for which he receives no remuneration.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.National Institute of Mental Health. 2017. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml. Accessed 5 Jul 2018.
- 2.McManus S, Bebbington P, Jenkins R, Brugha T. Adult Psychiatric Morbidity Survey 2014: Mental health and wellbeing in England. NHS Digital 2016http://webarchivenationalarchivesgovuk/20180328140249/http://digitalnhsuk/catalogue/PUB21748 Accessed 11 Aug 2018.
- 3.•• Druss BG, Walker ER. Mental disorders and medical comorbidity. Synth Proj Res Synth Rep. 2011;21:1–26 This article highlights that people with physical and mental comorbidities represent a significant and costly proportion of the population. It underscores that the most effective and cost-effective treatment for people with such comorbidities is an integrated approach. Google Scholar
- 4.Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;3:216–26.Google Scholar
- 11.Peek CJ, National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. Agency for Healthcare Research and Quality. https://integrationacademy.ahrq.gov/node/3158 Accessed 1 Jul 2018.
- 12.•• Huffman JC, Niazi SK, Rundell JR, et al. Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: a publication by the academy of psychosomatic medicine research and evidence-based practice committee. Psychosomatics. 2014;55:109–22 Review of important and high-quality articles on collaborative care models for the treatment of psychiatric disorders in medical settings. PubMedGoogle Scholar
- 14.•• Unützer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. J Am Med Assoc. 2002;288:2836–45 The first randomized controlled trial that showed the potential benefits of the Collaborative Care Model, which still remains the most evidenced model of integrated care delivery in primary care. Google Scholar
- 15.American Psychiatric Association & Academy of Psychosomatic Medicine. Dissemination of integrated care within adult primary care settings: the Collaborative Care Model. 2016. https://www.integration.samhsa.gov/integrated-care-models/APA-APM-Dissemination-Integrated-Care-Report.pdf Accessed on 20 Jul 2018.
- 16.• Goodrich DE, Kilbourne AM, Nord KM, Bauer MS. Mental health collaborative care and its role in primary care settings. Curr Psychiatry Rep. 2013;15:383 A good evidence summary of the potential benefits of mental health collaborative care and how it may be implemented in primary care. PubMedPubMedCentralGoogle Scholar
- 18.• Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Sys Rev. 2012;10:CD006525 Review of randomised controlled trials (RCTs) that assess the effectiveness of collaborative care for patients with depression or anxiety.Google Scholar
- 19.• Camacho EM, Davies LM, Hann M, et al. Long-term clinical and cost-effectiveness of collaborative care (versus usual care) for people with mental-physical multimorbidity: cluster-randomised trial. Br J Psychiatry. 2018;213:456–63 Report on long-term clinical and cost-effectiveness of collaborative care for people with depression and physical multimorbidity as part of the Collaborative Interventions for Circulation and Depression (COINCIDE) trial from the perspective of the English National Health Service. PubMedGoogle Scholar
- 20.•• Green C, Richards DA, Hill JJ, et al. Cost-effectiveness of collaborative care for depression in UK primary care: economic evaluation of a randomized controlled trial (CADET). PLoS ONE. 2014. https://doi.org/10.1371/journal.pone.0104225 Report on results of an economic evaluation of collaborative care versus usual care carried out in the UK alongside the CADET trial.
- 21.•• Camacho EM, Ntais D, Coventry P, Bower P, Lovell K, Chew-Graham C, et al. Long-term cost-effectiveness of collaborative care (vs usual care) for people with depression and comorbid diabetes or cardiovascular disease: a Markov model informed by the COINCIDE randomised controlled trial. BMJ Open. 2016;6:e012514.PubMedPubMedCentralGoogle Scholar
- 22.McCance-Katz EF, Satterfield J. SBIRT: a key to integrate prevention and treatment of substance abuse in primary care. Am J Addic. 2012;21:176–7.Google Scholar
- 23.Saitz R, Palfai TPA, Cheng DM, Alford DP, Bernstein JA, Lloyd-Travaglini CA, et al. Screening and brief intervention for drug use in primary care: the ASPIRE randomized controlled trial. J Am Med Assoc. 2014;312:502–13.Google Scholar
- 25.Kaner EFS, Beyer FR, Muirhead C, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Sys Rev. 2018;2:CD004148.Google Scholar
- 27.Platt L, Melendez-Torres GJ, O’Donnell A, et al. How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and metaregression analysis. BMJ Open. 2016;6:e011473. https://doi.org/10.1136/bmjopen-2016-011473.CrossRefPubMedPubMedCentralGoogle Scholar
- 29.Katon W, Unützer J, Wells K, Jones L. Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. Gen Hosp Psychiatry. 2010;32:456–64. https://doi.org/10.1016/j.genhosppsych.2010.04.001.CrossRefPubMedGoogle Scholar
- 30.•• Ramanuj PP, Talley R, Breslau J, Wang SS, Pincus HA. Integrating behavioral health and primary care services for people with serious mental illness: a qualitative systems analysis of integration in New York. Community Ment Health J. 2018. https://doi.org/10.1007/s10597-018-0251-y A system-wide analysis that challenges the conventional thinking of integration extending from minimal to fully integrated along a single continuum, proposing that integration actually depends on a multitude of factors interacting in a network and along simultaneous, parallel continuums.
- 33.Miskowiec D, Rosenberg L. What is a CCBHC? Washington DC: National Council for Behavioral Health; 2015.Google Scholar
- 34.Perinatal Mental Health Project, The perinatal mental health mid-year report: January–June 2013. Cape Town, SA; 2013.Google Scholar
- 40.• Osborn D, Burton A, Hunter R, et al. Clinical and cost-effectiveness of an intervention for reducing cholesterol and cardiovascular risk for people with severe mental illness in English primary care: cluster randomised controlled trial. Lancet Psychiatry. 2018. https://doi.org/10.1016/S2215-0366(18)30007-5 A high-quality cluster RCT examining the impact of a primary care intervention on decreasing cardiovascular disease risk in people with severe mental illnesses which found a potential association between the intervention and reduced psychiatric admissions.
- 41.McCrone P, Wright S, Zala D, et al. Location of care for people with serious mental illness (LOCAPE): implications for service use and costs using a mixed-methods approach. NIHR Journals Library. Health Services and Delivery Research, No. 4.34. 2016. https://www.ncbi.nlm.nih.gov/books/NBK401613/ Accessed 14 Aug 2018.
- 42.Healthy London Partnership. A review of the scientific literature informing the development of models of primary care in mental health. 2017. https://www.healthylondon.org/wp-content/uploads/2017/11/Literature-review-Primary-care-mental-health-service-development.pdfAccessed 5 Jul 2018.
- 45.Gilbody S, Lewis H, Adamson J, Atherton K, Bailey D, Birtwistle J, et al. Effect of collaborative care vs. usual care on depressive symptoms in older adults with subthreshold depression: the CASPER randomized clinical trial. J Am Med Assoc. 2017;317:728–37.Google Scholar
- 49.Coventry P, Lovell K, Dickens C, Bower P, Chew-Graham C, McElvenny D, et al. Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease. BMJ. 2015;350:h638.PubMedPubMedCentralGoogle Scholar
- 50.• Naylor C, Taggart H, Charles A. Mental health and new models of care: lessons from the vanguards. London: The King’s Fund; 2017. https://www.rcpsych.ac.uk/pdf/MH_new_models_care_Kings_Fund_May_2017.pdf Accessed 11 August 2018. A useful summary of the adoption (or lack thereof) of integrated care in English integrated care systems. It provides case examples of good practice as well as key learning points as integrated care is rolled out from pilot sites to across the National Health Service in England and Wales. Google Scholar
- 61.Kolko DJ. Options for the delivery of mental health services. In: McInerny TK, Adam HM, Campbell DE, Kamat DM, Kelleher KJ, editors. American Academy of Pediatrics textbook of pediatric care. Elk Grove Village: American Academy of Pediatrics; 2008. p. 1168–76.Google Scholar
- 62.Straus JH, Sarvet B. Behavioral health care for children: the Massachusetts child psychiatry access project. Health Aff. 2014;33:2153–61.Google Scholar
- 63.Watkins KE, Paddock SM, Hudson TJ, Ounpraseuth S, Schrader AM, Hepner KA, et al. Association between quality measures and mortality in individuals with co-occurring mental health and substance use disorders. J Subst Abus Treat. 2016;69:1–8.Google Scholar
- 69.Oslin DW, Lynch KG, Maisto SA, Lantinga LJ, McKay JR, Possemato K, et al. A randomized clinical trial of alcohol care management delivered in Department of Veterans Affairs primary care clinics versus specialty addiction treatment. J Gen Int Med. 2014;29:162–8.Google Scholar
- 72.Delgadillo J, Kay-Lambkin F. Closing the science-practice gap: introduction to the special issue on psychological interventions for comorbid addictions and mental health problems. Adv Dual Diag. 2016. https://doi.org/10.1108/ADD-06-2016-0013.
- 73.Storholm ED, Ober AJ, Hunter SB, Becker KM, Iyiewuare PO, Pham C, et al. Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: a qualitative longitudinal study. J Subst Abus Treat. 2017;83:45–54.Google Scholar
- 74.Ducharme LJ, Chandler RK, Harris AH. Implementing effective substance abuse treatments in general medical settings: mapping the research terrain. J Subst Abus Treat. 2016;60:110–8.Google Scholar
- 76.Hunt GE, Siegfried N, Morley K, et al. Psychosocial interventions for people with both severe mental illness and substance misuse. Cochrane Database Syst Rev. 2013;10:CD001088.Google Scholar
- 80.Beers A, Spencer A, Moses K, Hamblin A. Center for Health Care Strategies. Promoting better health beyond health care: state-level multi-sector actions for addressing the social, economic, and environmental factors that impact health. Hamilton: Center for Health Care Strategies, Inc.; 2018.Google Scholar
- 82.Winfield L, DeSalvo K, Muhlestein D. Social determinants matter, but who is responsible? Salt Lake City: Leavitt Partners; 2018.Google Scholar
- 83.Chazin S,Freda B, Kozick D, Spencer A. Bridging community-based human services and health care: case study series. Partnership for Healthy Outcomes, coordinated by the Nonprofit Finance Fund, the Center for Health Care Strategies, and the Alliance for Strong Families and Communities. 2017. https://www.chcs.org/resource/bridgingcommunity-based-human-services-health-care-case-studies/. Accessed 14 Aug 2018.
- 84.Bonney J, Chang DI. Community care coordination systems: connecting patients to community services. AcademyHealth and Nemours Children’s Health Systems . 2018. https://www.academyhealth.org/sites/default/files/community_care_coordination_systems_may2018.pdf Accessed 14 Aug 2018.
- 86.Miller E, Nath T, Line L. Working together toward better health outcomes. Partnership for healthy outcomes, coordinated by the nonprofit finance fund, the Center for Health Care Strategies, and the Alliance for Strong Families and Communities. 2017. https://www.chcs.org/resource/working-together-toward-better-health-outcomes/ Accessed 14 Aug 2018.
- 88.Lewis VA, Colla CH, Tierney K, van Citters AD, Fisher ES, Meara E. Few ACOs pursue innovative models that integrate care for mental illness and substance abuse with primary care. Health Aff. 2014;33:1808–16.Google Scholar
- 90.NHS England. Report of the review of the Quality and Outcomes Framework in England. 2018 https://www.england.nhs.uk/wp-content/uploads/2018/07/05-a-i-pb-04-07-2018-qof-report.pdf Accessed 5 Jul 2018.
- 91.Wilding A, Kontonpantelis E, Munford L, Sutton M. Impact of removing indicators from the Quality and Outcomes Framework: retrospective study using individual patient data in England. Report to NHS England. Policy Research Unit in Commissioning and the Healthcare System . 2018. http://blogs.lshtm.ac.uk/prucomm/files/2018/07/QOF-Removal-report-2-July-2018-.pdf Accessed 14 Aug 2018.
- 93.• Pincus HA, Li M, Scharf DM, et al. Prioritizing quality measure concepts at the interface of behavioral and physical healthcare. Int J Qual Health Care. 2017;29:557–63 Delphi study which identifies candidate measure concepts to guide future healthcare quality measures development at the interface of behavioral and physical health care.PubMedPubMedCentralGoogle Scholar
- 94.Goldman ML, Spaeth-Rublee B, Pincus HA. Quality indicators for physical and behavioral health care integration. J Am Med Assoc. 2015;314:769–70.Google Scholar
- 98.Osborn R, Moulds D, Schneider EC, Doty MM, Squires D, Sarnak DO. Primary care physicians in ten countries report challenges caring for patients with complex health needs. Health Aff. 2015;34:2104–12.Google Scholar
- 100.Chung H, Rostanski N, Glassberg H, Pincus HA. Advancing integration of behavioural health into primary care: a continuum-based framework. United Hospital Fund, New York City, NY; 2016. https://uhfnyc.org/publications/881131 Accessed on: 13 August 2018.
- 101.•• Chapman E, Chung H, Pincus HA. Using a continuum-based framework for heath integration into primary care in New York State. Psychiatr Serv. 2017;68:756–8 This article posits a practical framework to help providers integrate behavioral health into primary care settings and delineates clear steps as practices move from beginning to intermediate to advanced stages of integrated care.. PubMedGoogle Scholar
- 102.Williams AB. Issue brief: behavioral health and health IT. Washington DC: The Office of the National Coordinator for Health Information Technology; 2013. https://www.healthit.gov/sites/default/files/bhandhit_issue_brief.pdf Accessed on: 13 August 2018.Google Scholar
- 104.Bates DW, Saria S, Ohno-Machado L, Shah A, Escobar G. Big data in health care: using analytics to identify and manage high-risk and high-costs patients. Health Aff. 2014;33:1123–31.Google Scholar