Caring for People with
Mental Health and
Substance Use Disorders
in Primary Care Settings
PROCEEDINGS OF A WORKSHOP
Laurene Graig, Kaitlyn Friedman, and Joe Alper, Rapporteurs
Forum on Mental Health and Substance Use Disorders
Board on Health Care Services
Board on Health Sciences Policy
Health and Medicine Division
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This activity was supported by Purchase Order No. 75FCMC19P0036 with the Centers for Medicare & Medicaid Services, Contract No. HHSN263201800029I, Order No. HHSN26300025 with the National Institutes of Health, and by Alkermes, Inc., American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric Association, American Psychiatric Nurses Association, American Psychological Association, Association for Behavioral Health and Wellness, Centers for Disease Control and Prevention, Council on Social Work Education, Education Development Center, Health Resources and Services Administration, Janssen Research & Development, LLC, National Academy of Medicine, National Association of Addiction Treatment Providers, Optum Behavioral Health, Think Bigger Do Good Policy Series (a partnership of the Scattergood Foundation, Peg’s Foundation, Patrick P. Lee Foundation, and Peter & Elizabeth Tower Foundation), U.S. Department of Veterans Affairs, and Well Being Trust. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-68268-8
International Standard Book Number-10: 0-309-68268-1
Digital Object Identifier: https://doi.org/10.17226/25927
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Caring for people with mental health and substance use disorders in primary care settings: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25927.
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PLANNING COMMITTEE ON CARING FOR PEOPLE WITH MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN PRIMARY CARE SETTINGS1
DEIDRA ROACH (Co-Chair), Medical Project Officer, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health
RUTH SHIM (Co-Chair), Luke and Grace Kim Professor in Cultural Psychiatry, Associate Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis
JEFFREY A. BUCK, Senior Advisor for Behavioral Health, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services
W. PERRY DICKINSON, Director, Practice Innovation Program; Professor, Department of Family Medicine, University of Colorado (Representing the American Board of Family Medicine)
RICHARD G. FRANK, Professor of Health Economics, Department of Health Care Policy, Harvard Medical School
HOWARD H. GOLDMAN, Professor of Psychiatry, University of Maryland at Baltimore School of Medicine
PAMELA GREENBERG, President and Chief Executive Officer, Association for Behavioral Health and Wellness
CAREN HOWARD, Advocacy Manager, Mental Health America
R. KATHRYN McHUGH, Director, Stress, Anxiety, and Substance Use Laboratory; Associate Psychologist, Center of Excellence in Alcohol, Drugs, and Addiction, McLean Hospital; Assistant Professor of Psychology, Department of Psychiatry, Harvard Medical School (Representing the American Psychological Association)
KATHY PHAM, Director of Policy and Professional Affairs, American College of Clinical Pharmacy
MARTIN ROSENZWEIG, Chief Medical Officer, Optum Behavioral Health
ALEXANDER ROSS, Senior Behavioral Health Advisor, Office of Planning, Evaluation, and Analysis, Health Resources and Services Administration
MATTHEW TIERNEY, Associate Clinical Faculty, University of California, San Francisco, School of Nursing (Representing the American Psychiatric Nurses Association)
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
Project Staff
LAURENE GRAIG, Director, Forum on Mental Health and Substance Use Disorders, and Senior Program Officer
KAITLYN FRIEDMAN, Research Associate
ANESIA WILKS, Senior Program Assistant
SHARYL NASS, Senior Director, Board on Health Care Services
ANDREW M. POPE, Senior Director, Board on Health Sciences Policy
Consultant
JOE ALPER, Writer
FORUM ON MENTAL HEALTH AND SUBSTANCE USE DISORDERS1
COLLEEN L. BARRY (Co-Chair), Johns Hopkins Bloomberg School of Public Health
HOWARD H. GOLDMAN (Co-Chair), University of Maryland at Baltimore School of Medicine
MARGARITA ALEGRÍA, Harvard Medical School
DARA BLACHMAN-DEMNER, Office of Behavioral and Social Sciences Research, National Institutes of Health
CARLOS BLANCO, National Institute on Drug Abuse, National Institutes of Health
DARLA SPENCE COFFEY, Council on Social Work Education
W. PERRY DICKINSON, University of Colorado (Representing the American Board of Family Medicine)
ROBERT FORMAN, Alkermes, Inc.
RICHARD G. FRANK, Harvard Medical School
CHELSEY GODDARD, Education Development Center
ALTHEA N. GRANT-LENZY, Centers for Disease Control and Prevention
PAMELA GREENBERG, Association for Behavioral Health and Wellness
LARKE NAHME HUANG, Substance Abuse and Mental Health Services Administration
KRISTIN KROEGER, American Psychiatric Association
LAUREN B. LOWENSTEIN, Centers for Medicare & Medicaid Services
HUSSEINI K. MANJI, Janssen Research & Development, LLC
R. KATHRYN McHUGH, McLean Hospital and Harvard Medical School (Representing the American Psychological Association)
BENJAMIN MILLER, Well Being Trust
ANNIE PETERS, National Association of Addiction Treatment Providers
KATHY PHAM, American College of Clinical Pharmacy
JOE PYLE, Scattergood Foundation (Representing Think Bigger Do Good Policy Series)
DEIDRA ROACH, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health
MARTIN ROSENZWEIG, Optum Behavioral Health
ALEXANDER ROSS, Health Resources and Services Administration
RUTH SHIM, University of California, Davis
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
MATTHEW TIERNEY, University of California, San Francisco, School of Nursing (Representing the American Psychiatric Nurses Association)
MICHAEL TOEDT, Indian Health Service
Forum on Mental Health and Substance Use Disorders Staff
LAURENE GRAIG, Director, Forum on Mental Health and Substance Use Disorders, and Senior Program Officer
KAITLYN FRIEDMAN, Research Associate
ANESIA WILKS, Senior Program Assistant
MICAH WINOGRAD, Senior Finance Business Partner
SHARYL NASS, Senior Director, Board on Health Care Services
ANDREW M. POPE, Senior Director, Board on Health Sciences Policy
Reviewers
This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
KIRSTEN BERONIO, National Association for Behavioral Healthcare
LYDIA CHWASTIAK, University of Washington
BETH McGINTY, Johns Hopkins Bloomberg School of Public Health
GREGORY E. SIMON, Kaiser Permanente
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings, nor did they see the final draft before its release. The review of this proceedings was overseen by KENNETH B. WELLS, University of California, Los Angeles. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.
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Acknowledgments
The National Academies of Sciences, Engineering, and Medicine’s Forum on Mental Health and Substance Use Disorders wishes to express its sincere gratitude to the planning committee co-chairs Deidra Roach and Ruth Shim for their valuable contributions to the development and organization of this workshop. The forum wishes to thank all the members of the planning committee, who collaborated to ensure a workshop complete with informative presentations and rich discussions. Finally, the forum wants to thank the speakers and moderators, who generously shared their expertise and their time with workshop participants.
Support from the many sponsors of the Forum on Mental Health and Substance Use Disorders is critical to the forum’s work. The sponsors include the Centers for Medicare & Medicaid Services and National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, and Office of Behavioral and Social Sciences Research of the National Institutes of Health and Alkermes, Inc., American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric Association, American Psychiatric Nurses Association, American Psychological Association, Association for Behavioral Health and Wellness, Centers for Disease Control and Prevention, Council on Social Work Education, Education Development Center, Health Resources and Services Administration, Janssen Research & Development, LLC, National Academy of Medicine, National Association of Addiction Treatment Providers, Optum Behavioral Health, Think Bigger Do Good Policy Series (a partnership of the Scattergood Foundation, Peg’s Foundation, Patrick P. Lee Foundation, and Peter & Elizabeth Tower Foundation), U.S. Department of Veterans Affairs, and Well Being Trust.
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Contents
MODELS OF CARE FOR PEOPLE WITH MHSUDs
Key Elements of Integrated Care
Policies to Support Integrated Care
Panel Reactions and Discussion
Question and Answer Session with the Webinar Participants
Closing Remarks of the First Webinar
ESSENTIAL COMPONENTS OF CARE FOR THREE MHSUD CONDITIONS IN PRIMARY CARE SETTINGS
Exploring the Essential Components of Care for Alcohol Use Disorder in Primary Care Settings
The Case for Integrating MHSUDs into Primary Care
Implementing Collaborative Care Treatment for Depression
Sustaining Successful Interventions in Primary Care Practices
Panel Reactions and Discussion
Question and Answer Session with Webinar Participants
IMPLEMENTATION OF ESSENTIAL COMPONENTS OF CARE IN PRIMARY CARE SETTINGS
Implementing the Essential Components of Care in Primary Pediatric Practices
Successful Strategies for Implementing Alcohol SBIRT into Adult Primary Care
Integrating Primary Care and Behavioral Health
Breaking Down Silos to Improve Integrated Care
Panel Reactions and Discussion
Question and Answer Session with Webinar Participants
Closing Remarks of the Second Webinar
IMPROVING THE WORKFORCE TO SUPPORT PROVIDING ESSENTIAL COMPONENTS OF CARE
Developing the Workforce to Support Health Centers
The Role of Peer-Support Services in Delivering Collaborative Care to Treat MHSUDs
Behavioral Health Workforce to Optimize Medication Outcomes
Digital Enhancement of the Primary Care Workforce
Supporting a Workforce for the Provision of the Essential Components of Care
Panel Reactions and Discussion
Question and Answer Session with Webinar Participants
Can Primary Care Afford Behavioral Health?
The Addiction Recovery Medical Home Model
Panel Reactions and Discussion
Question and Answer Session with Webinar Participants
Boxes, Figures, and Tables
BOXES
2The 5Ds: How Children Differ from Adults in Behavioral Health Care
3The 10 Guiding Principles of the Addiction Recovery Medical Home Alternative Payment Model
FIGURES
2Principles of collaborative care for effective implementation
3Percentage of depression, anxiety, and behavior disorders, by age
4Core components of the Common Elements Treatment Approach (CETA)
5Mental health care professional shortage areas: Percent of need met
6The treatment gap for mental health and substance use disorders
Acronyms and Abbreviations
ACO | accountable care organization |
AIMS | Advancing Integrated Mental Health Solutions |
CETA | Common Elements Treatment Approach |
CMMI | Center for Medicare & Medicaid Innovation |
CMS | Centers for Medicare & Medicaid Services |
COVID-19 | coronavirus disease 2019 |
CPC+ | Comprehensive Primary Care Plus |
DBSA | Depression and Bipolar Support Alliance |
ED | emergency department |
EHR | electronic health record |
FQHC | federally qualified health center |
HRSA | Health Resources and Services Administration |
IBH-PC | integrated behavioral health in primary care |
IMPACT | Improving Mood-Promoting Access to Collaborative Treatment |
IOM | Institute of Medicine |
MAT | medication-assisted treatment |
MHSUD | mental health and substance use disorder |
NIAAA | National Institute on Alcohol Abuse and Alcoholism |
OBAT | Office-Based Addiction Treatment |
OTP | opioid treatment program |
OUD | opioid use disorder |
PCMH | patient-centered medical home |
Pharm.D. | doctor of pharmacy |
PHQ-9 | Patient Health Questionnaire major depressive disorder module |
SBI | Screening and Brief Intervention |
SBIRT | Screening, Brief Intervention, and Referral to Treatment |
SUD | substance use disorder |
VA | U.S. Department of Veterans Affairs |