Families, Systems, & Health 2015, Vol. 33, No. 2, 160 –162
© 2015 American Psychological Association 1091-7527/15/$12.00 http://dx.doi.org/10.1037/fsh0000136
COMMENTARY
Open Communication: Recommendations for Enhancing Communication Among Primary Care and Mental Health Providers, Services, and Systems
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.
Shale L. Wong, MD, MSPH and Ayelet Talmi, PhD University of Colorado School of Medicine
“Please break the silence,” by Greene, Ford, Ward-Zimmerman, and Foster (2015), highlights the need to improve communication between primary care and mental health care providers to better serve children and families. The report reaffirms that parents understand the value and necessity of collaborative care, as evidenced by the identification of gaps in consistency of bidirectional communication between providers in traditional and separate practice settings and the desire for improved care coordination. This example of patient-centered care surveys parents to better understand the shortcomings of their experiences when accompanying children for mental health care in primary care or specialty clinic settings. The authors suggest that improved communication between mental health and primary care providers would be appreciated by parents, as well as improve care to the child. In addition, the findings recognize that collaboration and communication is equally important, regardless of the child’s age or complexity of illness. Undoubtedly, it is true that open communication among health professionals is both expected and prioritized in progressive systems of care and yet inevitably fails in the context of fragmented services and systems. Transforming practices extends well beyond improving inter-
Shale L. Wong, MD, MSPH, Department of Pediatrics, Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine; Ayelet Talmi, PhD, Departments of Psychiatry and Pediatrics, University of Colorado School of Medicine. Correspondence concerning this article should be addressed to Shale L. Wong, MD, MSPH, Department of Pediatrics, Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine, 13123 East 16th Avenue, B032, Aurora, CO 80045. E-mail: [email protected]
provider communication. Recognizing communication challenges reveals a systems failure that requires an overhaul of systems and policies to educate, facilitate, and incentivize integrated care across mental health and primary care. Improved service delivery models and payment reform to support innovative delivery would amplify value facilitating both communication and quality of care to improve patient outcomes. Integrated behavioral health services provided in the context of a medical home promote enhanced utilization of appropriate health care in settings where children and families seek services, improve communication and coordination of care among health professionals, and promote family-centered and culturally responsive care (Bunik et al., 2013; Talmi, Stafford, & Bucholz, 2009). Pediatric primary care is the gateway to behavioral health identification, triage, and treatment (Kelleher, Campo, & Gardner, 2006), often providing the only opportunity to address critical concerns and presenting problems. It is an essential setting for early identification and support that can alleviate distress and promote optimal development before diagnosable disorders even emerge, thus achieving primary prevention for mental health conditions and providing health promotion services to optimize developmental outcomes and enhance well-being. Families depend upon primary care providers for guidance, and universal screening allows for enhanced identification of factors that adversely impact development. A variety of strategies and mechanisms can facilitate team-based delivery and open communication to achieve true integration of care within and across treatment settings. When integrated services are provided in primary care settings, health records, joint treatment planning, and comprehensive, whole-person approaches to
160
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.
OPEN COMMUNICATION
care enhance the quality of care and improve patient experiences. Children and families being seen in integrated settings have access to mental health resources as needs emerge and benefit from screening that allows for early and targeted recommendations and referrals to address challenges before they progress. In traditional care paradigms, where physical and behavioral health needs are addressed in separate settings, establishing clear protocols for communication between providers and ensuring that the necessary releases are in place to allow for such communication are essential components of a functional system. It is hard to imagine that laboratory tests and results would not be shared, reviewed, and documented in a medical record. In contrast, however, mental health and psychosocial referrals are frequently made without follow-up or access to documentation of services and supports received. When primary care providers are managing psychotropic medication and collateral therapy services are needed, the necessity for coordination is even more pronounced. As suggested in this report, the burden of communicating between physical and mental health services typically falls on family members. Barriers to achieving coordinated and integrated care are not limited to provider proximity or communication. Strictly defined and separate billing and reimbursement systems often preclude primary care and behavioral health providers from working together (Mauch, Kautz, & Smith, 2008; Talmi & Fazio, 2012). Payment reform could facilitate both access to behavioral health and reimbursement rates via mechanisms such as bundled payments, accountable care organization quality measures, and other incentives for providers to provide team-based care. Perhaps most intriguing from this brief report is the finding that Medicaid patients experienced better coordination and collaboration compared with populations that were privately insured. This finding warrants deeper investigation to explore and illuminate the strengths of the Medicaid system. What enhanced the communication among Medicaid providers? Any number of possibilities exist, including shared electronic records, required documentation to promote referrals, alignment across community health systems streamlining referral processes and ensuring access to services, access to claims databases for tracking diagnostic and treatment codes and referral uptake, Early
161
Periodic Screening Detection and Treatment (EPSDT) programs and case management services, or perhaps capitated behavioral health programs where contracted entities provide and manage behavioral health services for designated populations. It is evident that Medicaid innovations have the capacity to drive practice transformation and advance payment reform across pediatric systems. Opportunities to explore Medicaid payment reform could also lead to more integrated care. Current demonstration projects from the Centers for Medicare and Medicaid Innovation Initiative through the State Innovation Models will explore a variety of payment reform strategies that could inform and empower this change. The authors conclude, “overwhelming support for the sharing of information between their children’s providers suggests that regulations and procedures that embody ethical and responsible handling of patient information, while facilitating the efficient coordination of care, would be looked upon favorably by all parties involved” (Greene et al., 2015, p. 159). We agree on the value of improved communication and coordination of care. Leveraging policies to overcome systematic and entrenched barriers to effective care delivery and reimbursement will be necessary to achieve sustainable change, scale innovative models, and ensure higher quality of care. With integrated primary care and behavioral health, we elevate the importance of health promotion and prevention that decreases the need for advanced mental health care by focusing on early identification, treatment, and support. Successful implementation of integrated models of care will require education and training of providers across primary care and mental health professions to establish team-based approaches and seamless care delivery. References Bunik, M., Talmi, A., Stafford, B., Beaty, B., Kempe, A., Dhepyasuwan, N., & Serwint, J. R. (2013). Pediatric Residency Integrated Survey of Mental Health in Primary Care: A National CORNET study. Academic Pediatrics, 13, 551–557. Greene, C. A., Ford, J. D., Ward-Zimmerman, B., & Foster, D. (2015). Please break the silence: Parents’ views on communication between pediatric primary care and mental health providers. Families, Systems, & Health, 33, 155–159. http://dx.doi .org/10.1037/fsh0000117
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.
162
WONG AND TALMI
Kelleher, K. J., Campo, J. V., & Gardner, W. P. (2006). Management of pediatric mental disorders in primary care: Where are we now and where are we going? Current Opinion in Pediatrics, 18, 649 – 653. http://dx.doi.org/10.1097/ MOP.0b013e3280106a76 Mauch, D., Kautz, C., & Smith, S. A. (2008). Reimbursement of mental health services in primary care settings (HHS Publication No. SMA– 08 – 4324). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.
Talmi, A., & Fazio, E. (2012). Commentary: Promoting health and well-being in pediatric primary care settings: Using health and behavior codes at routine well-child visits. Journal of Pediatric Psychology, 37, 496 –502. http://dx.doi.org/10.1093/ jpepsy/jss047 Talmi, A., Stafford, B., & Buchholz, M. (2009). Providing perinatal mental health services in pediatric primary care. Zero to Three, 29, 10 –16. Received April 8, 2015 Accepted April 9, 2015 䡲
© 2015 American Psychological Association 1091-7527/15/$12.00 http://dx.doi.org/10.1037/fsh0000136
COMMENTARY
Open Communication: Recommendations for Enhancing Communication Among Primary Care and Mental Health Providers, Services, and Systems
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.
Shale L. Wong, MD, MSPH and Ayelet Talmi, PhD University of Colorado School of Medicine
“Please break the silence,” by Greene, Ford, Ward-Zimmerman, and Foster (2015), highlights the need to improve communication between primary care and mental health care providers to better serve children and families. The report reaffirms that parents understand the value and necessity of collaborative care, as evidenced by the identification of gaps in consistency of bidirectional communication between providers in traditional and separate practice settings and the desire for improved care coordination. This example of patient-centered care surveys parents to better understand the shortcomings of their experiences when accompanying children for mental health care in primary care or specialty clinic settings. The authors suggest that improved communication between mental health and primary care providers would be appreciated by parents, as well as improve care to the child. In addition, the findings recognize that collaboration and communication is equally important, regardless of the child’s age or complexity of illness. Undoubtedly, it is true that open communication among health professionals is both expected and prioritized in progressive systems of care and yet inevitably fails in the context of fragmented services and systems. Transforming practices extends well beyond improving inter-
Shale L. Wong, MD, MSPH, Department of Pediatrics, Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine; Ayelet Talmi, PhD, Departments of Psychiatry and Pediatrics, University of Colorado School of Medicine. Correspondence concerning this article should be addressed to Shale L. Wong, MD, MSPH, Department of Pediatrics, Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine, 13123 East 16th Avenue, B032, Aurora, CO 80045. E-mail: [email protected]
provider communication. Recognizing communication challenges reveals a systems failure that requires an overhaul of systems and policies to educate, facilitate, and incentivize integrated care across mental health and primary care. Improved service delivery models and payment reform to support innovative delivery would amplify value facilitating both communication and quality of care to improve patient outcomes. Integrated behavioral health services provided in the context of a medical home promote enhanced utilization of appropriate health care in settings where children and families seek services, improve communication and coordination of care among health professionals, and promote family-centered and culturally responsive care (Bunik et al., 2013; Talmi, Stafford, & Bucholz, 2009). Pediatric primary care is the gateway to behavioral health identification, triage, and treatment (Kelleher, Campo, & Gardner, 2006), often providing the only opportunity to address critical concerns and presenting problems. It is an essential setting for early identification and support that can alleviate distress and promote optimal development before diagnosable disorders even emerge, thus achieving primary prevention for mental health conditions and providing health promotion services to optimize developmental outcomes and enhance well-being. Families depend upon primary care providers for guidance, and universal screening allows for enhanced identification of factors that adversely impact development. A variety of strategies and mechanisms can facilitate team-based delivery and open communication to achieve true integration of care within and across treatment settings. When integrated services are provided in primary care settings, health records, joint treatment planning, and comprehensive, whole-person approaches to
160
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.
OPEN COMMUNICATION
care enhance the quality of care and improve patient experiences. Children and families being seen in integrated settings have access to mental health resources as needs emerge and benefit from screening that allows for early and targeted recommendations and referrals to address challenges before they progress. In traditional care paradigms, where physical and behavioral health needs are addressed in separate settings, establishing clear protocols for communication between providers and ensuring that the necessary releases are in place to allow for such communication are essential components of a functional system. It is hard to imagine that laboratory tests and results would not be shared, reviewed, and documented in a medical record. In contrast, however, mental health and psychosocial referrals are frequently made without follow-up or access to documentation of services and supports received. When primary care providers are managing psychotropic medication and collateral therapy services are needed, the necessity for coordination is even more pronounced. As suggested in this report, the burden of communicating between physical and mental health services typically falls on family members. Barriers to achieving coordinated and integrated care are not limited to provider proximity or communication. Strictly defined and separate billing and reimbursement systems often preclude primary care and behavioral health providers from working together (Mauch, Kautz, & Smith, 2008; Talmi & Fazio, 2012). Payment reform could facilitate both access to behavioral health and reimbursement rates via mechanisms such as bundled payments, accountable care organization quality measures, and other incentives for providers to provide team-based care. Perhaps most intriguing from this brief report is the finding that Medicaid patients experienced better coordination and collaboration compared with populations that were privately insured. This finding warrants deeper investigation to explore and illuminate the strengths of the Medicaid system. What enhanced the communication among Medicaid providers? Any number of possibilities exist, including shared electronic records, required documentation to promote referrals, alignment across community health systems streamlining referral processes and ensuring access to services, access to claims databases for tracking diagnostic and treatment codes and referral uptake, Early
161
Periodic Screening Detection and Treatment (EPSDT) programs and case management services, or perhaps capitated behavioral health programs where contracted entities provide and manage behavioral health services for designated populations. It is evident that Medicaid innovations have the capacity to drive practice transformation and advance payment reform across pediatric systems. Opportunities to explore Medicaid payment reform could also lead to more integrated care. Current demonstration projects from the Centers for Medicare and Medicaid Innovation Initiative through the State Innovation Models will explore a variety of payment reform strategies that could inform and empower this change. The authors conclude, “overwhelming support for the sharing of information between their children’s providers suggests that regulations and procedures that embody ethical and responsible handling of patient information, while facilitating the efficient coordination of care, would be looked upon favorably by all parties involved” (Greene et al., 2015, p. 159). We agree on the value of improved communication and coordination of care. Leveraging policies to overcome systematic and entrenched barriers to effective care delivery and reimbursement will be necessary to achieve sustainable change, scale innovative models, and ensure higher quality of care. With integrated primary care and behavioral health, we elevate the importance of health promotion and prevention that decreases the need for advanced mental health care by focusing on early identification, treatment, and support. Successful implementation of integrated models of care will require education and training of providers across primary care and mental health professions to establish team-based approaches and seamless care delivery. References Bunik, M., Talmi, A., Stafford, B., Beaty, B., Kempe, A., Dhepyasuwan, N., & Serwint, J. R. (2013). Pediatric Residency Integrated Survey of Mental Health in Primary Care: A National CORNET study. Academic Pediatrics, 13, 551–557. Greene, C. A., Ford, J. D., Ward-Zimmerman, B., & Foster, D. (2015). Please break the silence: Parents’ views on communication between pediatric primary care and mental health providers. Families, Systems, & Health, 33, 155–159. http://dx.doi .org/10.1037/fsh0000117
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.
162
WONG AND TALMI
Kelleher, K. J., Campo, J. V., & Gardner, W. P. (2006). Management of pediatric mental disorders in primary care: Where are we now and where are we going? Current Opinion in Pediatrics, 18, 649 – 653. http://dx.doi.org/10.1097/ MOP.0b013e3280106a76 Mauch, D., Kautz, C., & Smith, S. A. (2008). Reimbursement of mental health services in primary care settings (HHS Publication No. SMA– 08 – 4324). Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.
Talmi, A., & Fazio, E. (2012). Commentary: Promoting health and well-being in pediatric primary care settings: Using health and behavior codes at routine well-child visits. Journal of Pediatric Psychology, 37, 496 –502. http://dx.doi.org/10.1093/ jpepsy/jss047 Talmi, A., Stafford, B., & Buchholz, M. (2009). Providing perinatal mental health services in pediatric primary care. Zero to Three, 29, 10 –16. Received April 8, 2015 Accepted April 9, 2015 䡲
