Families, Systems, & Health 2014, Vol. 32, No. 2, 149 –150
© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000040
COMMENTARY
Behavioral Health Integration: A Critical Component of Primary Care and the Patient-Centered Medical Home Marci Nielsen, PhD, MPH This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Patient-Centered Primary Care Collaborative, Washington, DC
The Patient-Centered Primary Care Collaborative, an organization representing a diverse group of stakeholders promoting primary care and the patient-centered medical home, strongly agrees that patients need a primary care system that better integrates behavioral and mental health. Most individuals’ principal connection to the complicated world of health and health care is via their primary care providers, who play a particularly important role for patients, families, and consumers dealing with chronic illnesses—including mental illness. Research has identified several reasons for integrating mental health into primary care, including interconnected mental and physical health needs (Collins, Heuson, Munger, & Wade, 2010), increased access for mental health services, reductions in stigma and discrimination, and positive outcomes and cost-effectiveness resulting from treating mental health disorders with collaborative primary care (Ivbijaro & Funk, 2008). With its focus on whole-person care, the patient-centered medical home (PCMH) serves as a natural fit to address the integration of behav-
Founded in 2006, the PCPCC is dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home. Today, PCPCC’s membership represents more than 1,000 organizations throughout the United States, working to advance public policy that supports care delivery and payment innovations. Led by a team of primary care and behavioral health care experts, the PCPCC’s Special Interest Group on Behavioral Health works to identify and promote strategies and key components for integrating behavioral health into patient-centered team-based primary care. Learn more at www.pcpcc.org Correspondence concerning this article should be addressed to Marci Nielsen, PhD, MPH, Chief Executive Officer, Patient-Centered Primary Care Collaborative, 601 13th Street, Northwest, Suite 430 North, Washington, DC 20005. E-mail: [email protected]
ioral and mental health into primary care. A stronger primary care model could improve access to mental health services and treatment (Druss et al., 2009; Kilbourne et al., 2011), increase adherence to treatment and medication (Mertens, Flisher, Satre, & Weisner, 2008; RoyByrne, Katon, Cowley, & Russo, 2001), and result in better health outcomes (Rost, Pyne, Dickinson, & LoSasso, 2005). Several states are leading the nation in efforts to study and implement integrative primary care, and are showing impressive improvements in cost and health outcomes (Bartels et al., 2004). These types of health care delivery reforms that are complemented by a patient-centered medical home offer a cost-effective, well researched, and effective means to ensure that Americans have access to needed mental and behavioral health services. As outlined in our September 2013 letter to Congress, integrating behavioral and mental health into primary care can be difficult work, and without incentives to help drive change, integration will come slowly. Although recognition or certification as a PCMH is not necessarily synonymous with being one, we need to include measures—and commensurate payment reforms—for behavioral health integration, patient engagement, satisfaction and/or activation, as well as team-based care into recognition criteria. In terms of team-based care, some health professionals and patients may still find the framework of the Joint Principles problematic— even with the addition of behavioral health (The Working Party Group on Integrated Behavioral Healthcare et al., 2014)—given their focus on who must lead the team. Our collective challenge is to focus on the patient’s needs first and foremost— from there, decisions about who should lead the team become more obvious. Although a number of the individual elements of the medical home are well-grounded in
149
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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NIELSEN
the literature, the evidence base for which components of the model are most important, in terms of impacting patient outcomes, high performance, operational feasibility, and sustainability, is still being developed. As the medical home model of care evolves in light of the scientific evidence, we must not lose sight of measuring what impacts patients and their families most—and PCMH recognition/certification programs should include the integration of mental and behavioral health if we are sincere in achieving the Triple Aim. References Bartels, S., Coakley, E., Zubritsky, C., Ware, J., Miles, K., Arean, P., . . . Levkoff, S. E. (2004). Improving access to geriatric mental health services: A randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. The American Journal of Psychiatry, 161, 1455–1462. doi:10.1176/appi.ajp.161.8.1455 Collins, C., Heuson, D., Munger, R., & Wade, T. (2010). Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. Retrieved from http://www.milbank.org/uploads/ documents/10430EvolvingCare/EvolvingCare.pdf Druss, B., von Esenwein, S., Compton, M., Rask, K., Zhao, L., & Parker, R. (2009). A randomized trial of medical care management for community mental health settings: The Primary Care Access, Referral and Evaluation (PCARE) study. The American Journal of Psychiatry, 167, 151–159. doi: 10.1176/appi.ajp.2009.09050691
Ivbijaro, G., & Funk, M. (2008). No mental health without primary care. Mental Health in Family Medicine, 5, 127–128. Retrieved from http://www .ncbi.nlm.nih.gov/pmc/articles/PMC2777569/ Kilbourne, A., Pirraglia, P., Lai, Z., Bauer, M., Charns, M., Greenwald, D., . . . Welsh, D. (2011). Quality of general medical care among patients with serious mental illness: Does co-location matter? Psychiatric Services, 62, 922–928. doi: 10.1176/appi.ps.62.8.922 Mertens, J., Flisher, A., Satre, D., & Weisner, C. (2008). The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug and Alcohol Dependence, 98(1–2), 45–53. doi:10.1016/j.drugalcdep.2008.04.007 Rost, K., Pyne, J., Dickinson, M., & LoSasso, A. (2005). Cost-effectiveness of enhancing primary care depression management on an ongoing basis. Annals of Family Medicine, 3, 7–14. doi:10.1370/ afm.256 Roy-Byrne, P., Katon, W., Cowley, D., & Russo, J. (2001). A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Archives of General Psychiatry, 58, 869 – 876. doi:10.1001/archpsyc.58.9.869 The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . deGruy, F. (2014). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm .1633 Received February 28, 2014 Revision received March 10, 2014 Accepted March 11, 2014 䡲
© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000040
COMMENTARY
Behavioral Health Integration: A Critical Component of Primary Care and the Patient-Centered Medical Home Marci Nielsen, PhD, MPH This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Patient-Centered Primary Care Collaborative, Washington, DC
The Patient-Centered Primary Care Collaborative, an organization representing a diverse group of stakeholders promoting primary care and the patient-centered medical home, strongly agrees that patients need a primary care system that better integrates behavioral and mental health. Most individuals’ principal connection to the complicated world of health and health care is via their primary care providers, who play a particularly important role for patients, families, and consumers dealing with chronic illnesses—including mental illness. Research has identified several reasons for integrating mental health into primary care, including interconnected mental and physical health needs (Collins, Heuson, Munger, & Wade, 2010), increased access for mental health services, reductions in stigma and discrimination, and positive outcomes and cost-effectiveness resulting from treating mental health disorders with collaborative primary care (Ivbijaro & Funk, 2008). With its focus on whole-person care, the patient-centered medical home (PCMH) serves as a natural fit to address the integration of behav-
Founded in 2006, the PCPCC is dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home. Today, PCPCC’s membership represents more than 1,000 organizations throughout the United States, working to advance public policy that supports care delivery and payment innovations. Led by a team of primary care and behavioral health care experts, the PCPCC’s Special Interest Group on Behavioral Health works to identify and promote strategies and key components for integrating behavioral health into patient-centered team-based primary care. Learn more at www.pcpcc.org Correspondence concerning this article should be addressed to Marci Nielsen, PhD, MPH, Chief Executive Officer, Patient-Centered Primary Care Collaborative, 601 13th Street, Northwest, Suite 430 North, Washington, DC 20005. E-mail: [email protected]
ioral and mental health into primary care. A stronger primary care model could improve access to mental health services and treatment (Druss et al., 2009; Kilbourne et al., 2011), increase adherence to treatment and medication (Mertens, Flisher, Satre, & Weisner, 2008; RoyByrne, Katon, Cowley, & Russo, 2001), and result in better health outcomes (Rost, Pyne, Dickinson, & LoSasso, 2005). Several states are leading the nation in efforts to study and implement integrative primary care, and are showing impressive improvements in cost and health outcomes (Bartels et al., 2004). These types of health care delivery reforms that are complemented by a patient-centered medical home offer a cost-effective, well researched, and effective means to ensure that Americans have access to needed mental and behavioral health services. As outlined in our September 2013 letter to Congress, integrating behavioral and mental health into primary care can be difficult work, and without incentives to help drive change, integration will come slowly. Although recognition or certification as a PCMH is not necessarily synonymous with being one, we need to include measures—and commensurate payment reforms—for behavioral health integration, patient engagement, satisfaction and/or activation, as well as team-based care into recognition criteria. In terms of team-based care, some health professionals and patients may still find the framework of the Joint Principles problematic— even with the addition of behavioral health (The Working Party Group on Integrated Behavioral Healthcare et al., 2014)—given their focus on who must lead the team. Our collective challenge is to focus on the patient’s needs first and foremost— from there, decisions about who should lead the team become more obvious. Although a number of the individual elements of the medical home are well-grounded in
149
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
150
NIELSEN
the literature, the evidence base for which components of the model are most important, in terms of impacting patient outcomes, high performance, operational feasibility, and sustainability, is still being developed. As the medical home model of care evolves in light of the scientific evidence, we must not lose sight of measuring what impacts patients and their families most—and PCMH recognition/certification programs should include the integration of mental and behavioral health if we are sincere in achieving the Triple Aim. References Bartels, S., Coakley, E., Zubritsky, C., Ware, J., Miles, K., Arean, P., . . . Levkoff, S. E. (2004). Improving access to geriatric mental health services: A randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. The American Journal of Psychiatry, 161, 1455–1462. doi:10.1176/appi.ajp.161.8.1455 Collins, C., Heuson, D., Munger, R., & Wade, T. (2010). Evolving models of behavioral health integration in primary care. Milbank Memorial Fund. Retrieved from http://www.milbank.org/uploads/ documents/10430EvolvingCare/EvolvingCare.pdf Druss, B., von Esenwein, S., Compton, M., Rask, K., Zhao, L., & Parker, R. (2009). A randomized trial of medical care management for community mental health settings: The Primary Care Access, Referral and Evaluation (PCARE) study. The American Journal of Psychiatry, 167, 151–159. doi: 10.1176/appi.ajp.2009.09050691
Ivbijaro, G., & Funk, M. (2008). No mental health without primary care. Mental Health in Family Medicine, 5, 127–128. Retrieved from http://www .ncbi.nlm.nih.gov/pmc/articles/PMC2777569/ Kilbourne, A., Pirraglia, P., Lai, Z., Bauer, M., Charns, M., Greenwald, D., . . . Welsh, D. (2011). Quality of general medical care among patients with serious mental illness: Does co-location matter? Psychiatric Services, 62, 922–928. doi: 10.1176/appi.ps.62.8.922 Mertens, J., Flisher, A., Satre, D., & Weisner, C. (2008). The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients. Drug and Alcohol Dependence, 98(1–2), 45–53. doi:10.1016/j.drugalcdep.2008.04.007 Rost, K., Pyne, J., Dickinson, M., & LoSasso, A. (2005). Cost-effectiveness of enhancing primary care depression management on an ongoing basis. Annals of Family Medicine, 3, 7–14. doi:10.1370/ afm.256 Roy-Byrne, P., Katon, W., Cowley, D., & Russo, J. (2001). A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Archives of General Psychiatry, 58, 869 – 876. doi:10.1001/archpsyc.58.9.869 The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . deGruy, F. (2014). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm .1633 Received February 28, 2014 Revision received March 10, 2014 Accepted March 11, 2014 䡲
