Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings Proceedings of a Workshop (2020) / Chapter Skim
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Proceedings of a Workshop
Proceedings of a Workshop
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As many as 80 percent of patients with behavioral health conditions seek treatment in emergency rooms and primary care clinics, and between 60 and 70 percent of them are discharged without receiving behavioral health care services (Klein and Hostetter, 2014)
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. While the majority of mental health services are currently delivered in primary care settings, the implementation of integrated care models shown to support delivery of evidence-based mental health services in primary care has been limited to demonstration programs with funding from time-limited grants (McGinty and Daumit, 2020)
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"It is clear that persistent racism and income and health inequities are themselves public health crises with profound implications for mental health," said Barry. "As we dive into a discussion of how to improve care for mental illness and addiction, we can all be motivated by the fact that the crises surrounding us today make the topics we are discussing all the more pressing and important." Barry also remarked that researchers were documenting worsening mental health and substance use in the context of the pandemic, underscoring the importance of this workshop.
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, and collaborative care arrangements, and how essential components of care for MHSUDs might be induced for those care models. The webinar also addressed policy issues related to implementing these models and the essential components of care.
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(Beronio, Phillips, Reif) • goals and incentives in delivery systems to encourage the Set use of high-quality integrated care and improve sustainability.
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(Cobb) • Allow psychiatric pharmacists to serve as the behavioral health specialist on primary care teams and bill for services.
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(Reif) Establishing Integrated Care Models and Processes • Embed a team of addiction champions into multidisciplinary care models.
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(Reif) • flexible when implementing an integrated care model, and do Be not restrict it to one specific disease.
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(Foxworth, Khatri, LaBelle, Snyder) • Highlight the value of integrated care models at the system level to help reduce stigma.
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, Daumit stressed that integrated care models shown to be effective in clinical trials have not been widely implemented outside of demonstration programs or other time-limited mechanisms. "We have unrealized opportunities to address mental illness and SUDs in primary care settings," she said.
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TABLE 1 Core Tenets of the Collaborative Care Model Core Tenets of the Collaborative Care Model Description Population-based • Emphasizes improving quality and outcomes on defined care populations with chronic illness • Requires having a registry to identify the individuals who have a behavioral health condition (Archer et al., 2012) Measurement-based • Requires a clinical measure that primary care practices can care use to diagnose and then monitor treatment progress Stepped care • Applies treatments systematically to enhance care for patients who are not meeting treatment targets SOURCES: As presented by Gail Daumit, June 3, 2020; adapted from McGinty and Daumit, 2020.
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She explained that some studies suggest this approach can improve depression outcomes and reduce the length of general medical inpatient hospitalizations among those with mental illness. She cautioned, however, that "we need more data on these kinds of integrated care models to know how they really work."
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TABLE 2 Key Elements of Integrated Care Key Elements of Integrated Care Process-of-Care Elements Structural Elements • Team-based care by general medical • multidisciplinary care team A and specialty behavioral health • clinician information system that A providers, including a behavioral incorporates a population-based health care manager and a consulting registry psychiatrist • Shared electronic health records, • Information tracking and exchange inpatient and emergency department among providers to determine when use data, and quality improvement to change treatment data • Continual care management that • patient-centered care plan A includes ongoing, proactive follow-up • Decision-support protocols of patients • Financing mechanisms • Measurement-based, stepped care • Self-management support • Linkages with community and social services • Systematic quality improvement SOURCES: As presented by Beth McGinty, June 3, 2020; adapted from McGinty and Daumit, 2020.
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Subsequent qualitative work aimed at exploring the reasons why uptake of billing codes for integrated care is so low found that many practices lack the structural elements needed to provide the services to use the codes, particularly for the collaborative care codes that require a practice to have a consulting psychiatrist and a behavioral health care manager. Turning to PCMHs, McGinty noted that they are focused on improving primary care more broadly rather than focusing explicitly on behavioral health integration.
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Primary care providers are also prohibited from prescribing methadone. Ultimately, in McGinty's view, financing policies are likely to be necessary but not sufficient to truly prompt adoption of complex, effective integrated care models.
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She emphasized that meaningfully addressing the behavioral health workforce problem will require reimbursing behavioral health services at a sufficiently high rate to incentivize clinicians to choose challenging behavioral health careers. As a final comment, McGinty noted that the adverse social determinants of health -- including poverty, unemployment, housing instability, and involvement with the criminal justice system -- are overrepresented among people with behavioral health problems.
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Goldman asked the speakers to describe their key qualitative ingredients of integrated care, including the difficult-to-measure constructs, such as communication or teamwork. Daumit said that she believes these qualitative aspects of integrated care are both important and difficult to measure and pointed to the key qualitative ingredients of integrated care listed in the McGinty and Daumit paper: • The belief of primary care clinicians and other people in a practice about the importance of population health, the goal of improving whole-person health, and shared values around these ideas; • The implementation climate; • How supportive leadership is of integrated care and evidence-based practice around collaborative care; and • Whether clinicians have the self-efficacy to deliver integrated care (McGinty and Daumit, 2020)
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After all, multiple rigorous clinical trials have found that collaborative care-based models can be effective at improving depression symptoms and improving outcomes for people with SUDs. Nevertheless, evaluation of the Depression Improvement Across Minnesota, Offering a New Direction Initiative9 -- a statewide effort to implement depression care in primary care settings (Solberg et al., 2013)
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This discouraging result has researchers trying to determine which key elements of the collaborative care model are not being translated from clinical trials to real-world contexts. Daumit mentioned one possibility, which has yet to be tested empirically: treatment intensification was not occurring in the real-world setting to the degree that it took place in the experimental setting.
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Rather, she said, they need to be paired with policy and system-level changes that empower clinicians to work with people with behavioral health disorders in a way that is effective for all people. There were multiple questions from the webinar participants regarding CMS behavioral billing codes.
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Daumit responded that multiple clinical trials offer evidence that the collaborative care model of integrating behavioral health into primary care is effective for depression and anxiety. Much less evidence exists, she said, regarding efforts to bring physical health care services into behavioral health care settings.
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As consumption increases, so do the associated consequences, Saitz added. Saitz described what he considered the essential components of care: identify the disorder, discuss the diagnosis and treatments with the patient, treat the disorder, and refer the individual for services and specialized care.
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While acknowledging that primary care providers are already stretched for time, Saitz noted that he has never heard a primary care physician say they do not have enough time to treat hypertension or diabetes. In fact, he added, it is more difficult to get someone to take insulin for diabetes than it is to prescribe daily naltrexone for alcohol use disorder.
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Second, because of this, primary care has been given a pass on thinking of these disorders as medical conditions that should be addressed as part of what is normally considered general medical care. As Wakeman observed, multiple studies have shown that these disorders can be effectively treated in primary care with outcomes that are as good as in specialty care settings.
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Wakeman noted that one approach is to use addiction champions -- doctors, nurses, behavioral health providers, and recovery coaches -- who themselves have had experience with an SUD. Addiction champions are valuable members of multidisciplinary teams and can deliver a multidisciplinary care model, much like what is used to care for patients with HIV or diabetes.
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Implementing Collaborative Care Treatment for Depression Lydia Chwastiak, professor in the Department of Psychiatry and Behavioral Sciences and co-director of the Northwest Mental Health Technology Transfer Center at the University of Washington, opened her remarks by noting that the majority of integrated care interventions that have been shown in clinical trials to improve depression outcomes have been some variation of collaborative care. In fact, she said, evidence from more than 80 randomized controlled trials supports the effectiveness of collaborative care for improving depression and anxiety outcomes (Archer et al., 2012)
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hours per week working with the care team, including taking part in a structured weekly caseload review meeting with the care manager. Chwastiak noted that studies have shown that collaborative care is not only significantly more effective than usual care but also associated with a shorter time to depression remission (Garrison et al., 2016)
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Currently, for example, through the Mental Health Integration Program, psychiatrists based at the University of Washington act as consulting psychiatrists for collaborative care programs in more than 100 community health centers across Washington State. There is also evidence that the role of the care manager on the collaborative care team can be conducted virtually and be effective.
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starting in 2017, more than 95 percent achieved some behavioral health integration by 2019, but only 700 of those practices looked anything like the collaborative care model despite it being the only model offered during the program's first 3 years.12 DeGruy explained that the dominant integrated care model implemented over the past 15 years, integrated behavioral health in primary care (IBH-PC) , embeds a care manager and a behavioral health clinician -- usually a psychologist or social worker with or without a psychiatrist or psychiatric nurse practitioner -- in the primary care clinic.
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First, it is critical to fully understand the work of primary care clinicians and reconceptualize interventions according to a revised understanding of the workflow in a primary care setting. "If we wish to develop sustainable interventions that fit into their workflow, I think dealing with disease-specific interventions is not likely to ever get us there," said deGruy.
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Responding to Goldman and deGruy's comments, Chwastiak said that a criticism of the collaborative care model is that it is too complex for many organizations to implement. Yet, all integrated care models face some similar implementation challenges, such as workforce shortages of behavioral health care providers -- which is particularly problematic for rural and frontier communities.
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In turn, deGruy seconded Chwastiak's comment about implementation science and said that he believes that will be the way forward as far as adapting comprehensive care to work in regular primary care settings. Pivoting to a new topic, Goldman asked Wakeman what her institution is doing about policies that reflect racism and structural racism associated with SUDs and alcohol use disorder.
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Often, she said, health care providers believe they are doing something good and protecting patients from trying to access drugs while they are in the hospital, rather than seeing that those actions are actually hurting their patients. Goldman then asked Saitz to talk more about the decision to treat someone in the primary care setting or refer them to a specialty clinic.
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Wakeman noted that students want those positive messages, especially those who are passionate about social justice and view drug and alcohol addiction as a social justice issue. The panelists were asked to comment on whether they saw signs indicating that insurers are becoming more focused on value-based care and if that might help promote models such as integrated care and collaborative
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"I think it is important that we continue to adjust our complexity scores and our patientcentered scores so that that kind of value gets recognized," he said. Chwastiak noted that, in her experience, value-based care for depression has been a primary driver for the uptake of the collaborative care model, beginning when primary care organizations sought strategies to integrate behavioral health services in order to become PCHMs.
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Goldman added that the newest frontier is recognizing the fundamental nature of behavioral health in overall health and the need to address social determinants of health. Panelists were also asked to speak to the concept of flattening hierarchies in the treatment team as it relates to improving patient care and employee satisfaction and whether it was possible to change the way care teams operate to achieve better goals.
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The session ended with a final question about the ways in which the essential components of care and integrated care can help providers do a better job of supporting people in the community who are suffering from the devastation wrought by the COVID-19 pandemic. In reply, deGruy stated that acute problems arise all the time, and the care teams are equipped to deal with those as much as chronic disorders.
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, and Keller noted that in his experience they are frequently a factor in pediatric primary care practices' visits. Access to treatment varies by age, condition, and socioeconomic status.
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According to Keller, looking through the lens of the 5Ds affects how integrated care occurs for children. He offered the development of the maternal and child health system as an example.
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recently funded the Pediatric Mental Health Care Access Program16 that is now being piloted in 21 states and the District of Columbia. This program makes a child psychiatry consultant available to primary care clinicians who are trying to manage children with depression in their practices.
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This model was introduced in July 2013 to serve all of Kaiser Permanente of Northern California's adult primary care patients through approximately 2,500 primary care providers. Kaiser had conducted more than 12.4 million screenings and delivered almost 800,000 brief interventions as of May 2020 (Palzes et al., 2020; Sterling et al., 2020)
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Sterling further explained that using a train-the-trainer model, based on work by Saitz and colleague Dan Alford, the alcohol champions at each medical center trained their fellow primary care physicians on the brief intervention and referral process, and nurse managers trained medical assistants on the screening process (Alford et al., 2008)
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Over the course of her integration work, it became clear that traumainformed, patient-centered collaborative care is a critical element of integrated care. "We know and have learned through mistakes that this is foundational," said Snyder.
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In closing, Snyder emphasized that while it is critically important to understand the components of integrated care, it is also important to accept that there will be persistent challenges that should be anticipated and addressed whenever taking new steps in integration. Snyder pointed out that these challenges include
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Murray, senior scientist in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health, discussed the Common Elements Treatment Approach (CETA) as a means of breaking down silos to improve integrated care (see Figure 4)
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"We still have a deeply embedded siloed care approach in our care settings, and in funding, and until we de-silo this, we are going to have many [ongoing] challenges," she said.
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Keller remarked that while it is great to have an extensive team, he did not want to leave the impression that integrated care cannot be successful with a much smaller team. He recounted working in environments where his team included one part-time licensed clinical social worker, some medical assistants, and a few nurses and nurse practitioners.
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Dickinson asked Keller for some key lessons he has learned as to how to best support practices as they implement integrated care. The most important one, replied Keller, is having facilitators who meet practices where they are and listen nonjudgmentally to where the practice is and where it wants to go.
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Snyder remarked that she often has patients apologizing for asking for care related to issues of mental health, substance use, and social determinants. "When that stops happening," she said, "then we know we are getting somewhere as providers and patients." She also noted that payment policies need to change, given the importance of where the money goes.
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The team is now adding community health specialists and medical assistants who can conduct the screening, at which point the primary care provider can decide to handle the brief intervention themselves or have the community health specialists or medical assistants do it, depending on the workflow. Snyder explained that her team is now piloting this approach at six sites, and early results are encouraging.
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Murray's hope is that this trend continues, because it can ensure that all behavioral health professionals receive training in evidence-based care, which is not the case today. A webinar participant asked the speakers about financing strategies that help break down silos.
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ACCESS is also working with safety departments in the Chicago suburbs on court diversion for MAT and partnering with social agencies to fund housing and medical care for people in MAT or with chronic mental illness. Closing Remarks of the Second Webinar Roach said that while a virtual event cannot replace a face-to-face experience, she and her fellow committee members still felt a strong sense of connection to everyone who participated.
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He noted that the speakers in the webinar's first session would illustrate how the field can effectively train clinicians to provide the essential elements of care discussed in the preceding webinars. Developing the Workforce to Support Health Centers Colleen LaBelle, program director of the State Technical Assistance Treatment Expansion Office-Based Opioid Treatment with Buprenorphine21 and a member of the Boston University School of Medicine's Clinical Addiction Research and Education Unit, began her remarks by noting that she and her colleagues at the Boston Medical Center launched a pilot program in 2003 in which nurse care managers play the lead role in delivering buprenorphine in primary care practices to individuals with SUDs.
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All of these resources would be directed at treating the whole person, she said in closing. The Role of Peer-Support Services in Delivering Collaborative Care to Treat MHSUDs Phyllis Foxworth, vice president of advocacy for the Depression and Bipolar Support Alliance22 (DBSA)
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The demonstration project she discussed, a collaborative care model that integrates primary care and mental health care, was conducted in partnership with Facey Medical Group in Mission Hills, California, and the AIMS Center at the University of Washington. The goal of this ongoing project is to improve overall health by treating both physical and mental health using one-on-one, communitybased peer support.
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Concluding her remarks, Foxworth noted the importance of using individuals who are certified paraprofessionals when implementing a peer support program as an adjunct to the clinical care team. She said that 48 states and the VA have established credentialing requirements for peer support specialists.
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Cobb discussed how this care model fits with the key elements of integrated behavioral health that McGinty and Daumit described in the first 23 Project ECHO is a collaborative model of medical education and care management that empowers clinicians everywhere to provide better care to more people, right where they live. For more information, see https://echo.unm.edu/about-echo (accessed September 3, 2020)
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As another example, Cobb noted that FQHC clients discharged from an inpatient stay for an alcohol use disorder have a joint appointment with the behavioral health provider and a psychiatric pharmacist before meeting with their primary care physician. Together, the behavioral health provider and psychiatric pharmacist review the individual's psychosocial and medication history and examine different options for medications to treat alcohol use disorder if that is something the patient might desire.
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We have to think in terms of proactively reaching out and identifying people who are at risk, whether or not they present themselves as somebody at risk, and secondly about motivating them to make changes and to take advantage of available services." One approach Ondersma shared is to have primary care clinicians provide these services using an approach known as SBI (Screening and Brief Intervention)
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However, he cautioned that unintended consequences could create more problems. Supporting a Workforce for the Provision of the Essential Components of Care Parinda Khatri, chief clinical officer at Cherokee Health Systems, explained that blending behavioral health and primary care has been at the core of her organization's mission since the early 1980s and is an integral part of its care model.
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On a final note, Khatri said that Cherokee Health has started including a developmental psychologist in every well-child check for mothers seen in the obstetrics clinic who were addicted to opiates or other substances. Such intersectionality, she said, provides a wonderful opportunity for trainees to see how behavioral health care can be integrated into primary care settings of all types.
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Ross asked Foxworth if she sees peer supporters playing as important a role in treating OUD or alcohol use disorder as they can in depression care management. Foxworth explained that her organization has been a pioneer in creating peer specialist coursework, and DBSA has a contract with the VA to train all of its peer apprentices.
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25 For more information, see https://www.henryford.com (accessed September 11, 2020)
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A webinar participant asked how LaBelle's and Khatri's models incorporate the social determinants of health, and LaBelle said that they are critical: "If you do not address people's housing and food insecurities, you might as well just go home, because the rest does not work," said LaBelle. In Massachusetts, she explained, the Bureau of Substance Addiction Services26 funds care manag 26 For more information, see https://www.mass.gov/orgs/bureau-of-substance-addiction services (accessed September 11, 2020)
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For example, in her experience, this is not a barrier to providing care in the community health centers in Massachusetts, said LaBelle, because the staff are invested in this work as a result of the positive results they have seen in their patients. A webinar participant asked Cobb about policy actions that could help increase the number of clinical pharmacists trained to engage in integrated behavioral health or resources that can help families who want to access pharmacist team members.
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Today, the collaborative care model billing code cannot be used for psychiatric pharmacists unless there is a partner psychiatrist or psychiatric nurse practitioner on the team. A webinar participant with a family member in a state hospital due to severe mental illness and an SUD described the difficulty in getting care for their loved one.
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Foxworth replied to a question about where to find courses to become a peer specialist or peer navigator by recommending that people start with their state department of mental health to find out what the requirements are to become a peer support specialist or recovery coach. She noted that some states refer to those positions by other names, such as "certified support recovery coach." A webinar participant asked LaBelle why registered nurses are the basis for the model she and her colleagues developed.
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ADDRESSING FINANCING, PAYMENT, PRACTICE, AND SYSTEMS-LEVEL ISSUES, POLICIES, AND INCENTIVES TO SUPPORT PROVISION OF ESSENTIAL COMPONENTS OF CARE To start the final session of the webinar, Richard Frank, professor of health economics in the Department of Health Care Policy at Harvard Medical School, said that a long-held belief has been that some simple policy fixes would go a long way to promoting the integration of behavioral health and other types of medical care into primary care. The final session, he said, would focus on what is needed beyond those simple fixes to advance the goal of integration.
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. These investigators looked at two different models of care: • Collaborative care, in which primary care manages in-person care and pharmacotherapy, with registered nurses or a master's level behaviorist providing follow-up care by phone; and • Primary care behaviorist, in which a Ph.D.
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Reif noted that the availability of system-wide training, technical assistance, or expert report models can address barriers within primary care settings, such as a lack of knowledge or confidence about screening for and treating MHSUDs, by providing support and reassurance, particularly during the early phases of adoption. She stated that funding and incentives are essential "carrots" or "sticks" to encourage primary care practices to adopt integrated care and that supporting the infrastructure needed for integrated care can reduce silos and encourage collaboration and holistic care.
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In addition, said Reif, quality of care always remains at the forefront, and delivery systems can set goals and incentives to encourage high-quality integrated care. However, the quality metrics and data used in the separate primary care and specialty systems may not remain the same for integrated care systems.
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Such an approach should include systems such as social services or specialty care, each of which requires relationships with the integrated care setting and an understanding of how these other care systems work and how to engage patients in need. One concern with delivery system approaches, explained Reif, is that they can include system-level interventions imposed from the top down and may not diffuse to direct care providers or be incorporated fully into a practice.
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Another possible issue, she explained, is that payment for the behavioral health specialist has to flow through the primary care provider, creating an administrative burden for the primary care provider and a disincentive for the behavioral health specialist. Beronio said that a more recent Medicare action to create interprofessional consult billing codes31 does present an opportunity for obtaining coverage for the consultation part of these integrated care models.
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She noted that the November 2018 State Medicaid Director letter contains a table that maps different components of the collaborative care model to specific Medicaid benefits (CMS, 2018)
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. Over an 8-month period, Smith and his colleagues developed the Addiction Recovery Medical Home Alternative Payment Model.38 The model was originally designed to be a thought exercise, but publishing it (Polak et al., 2018)
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He further explained that risk-bearing providers or providers in pay-for-performance arrangements have three mechanisms through which they assume risk, earn bonus payments, and achieve a nontraditional payment adjustment from the model: episodes of integrated care, a quality achievement payment, and a performance bonus. In closing, Smith pointed out that the model looks different in different markets, but each implementation of the model has generally adhered to the principles listed above.
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4. A well-managed and broad continuum of care ranging from emergent and stabilizing acute care settings to community based services and support is essential to managing patient needs across the stages of personal and family recovery.
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Reif added that given most Washington State residents with OUD are on Medicaid, the networks can engage with state Medicaid decision makers to try to address some of the regulatory barriers to implementing integrated care models. Smith commented that one challenge to scale any of these models on a national level is that regulatory and cultural conditions differ from community to community -- the same factors that often befuddle large companies when they try to expand overseas.
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. 43 For more information, see https://innovation.cms.gov/innovation-models/bpci advanced/participant-resources (accessed September 5, 2020)
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He also pointed out the incredible FQHC infrastructure in this country that has largely been sidelined for years but that could be expanded to improve care in parts of the country in which mental health care has been undersupported. Reif added that it is important to create pathways that would drive people to integrated care or at least collaborative care.
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He noted that without an easy way to refer patients, providers are reluctant to screen. Question and Answer Session with Webinar Participants Referring to LaBelle's presentation, a webinar participant asked about what can be learned from the nurse-led community health center model's successful scaling and sustainability at the state level.
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Beronio noted that she has seen that having a behavioral health care manager can help alleviate some of the pressures on primary care providers. She also suggested showing providers that working with people with MHSUDs does improve patients' lives as a means of reinforcing the positive benefits of participating in integrated care.
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CLOSING REMARKS To conclude the session, Frank noted that all the day's discussions focused on what has been done to the behavioral health field, and he wanted the webinar attendees to think about what the behavioral health provider system needs to do in terms of accountability and changing the culture of primary care to include behavioral health. "I think work on accountability and culture are important to move the ball forward," said Frank.
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2020. Effect of a collaborative care model on depressive symptoms and glycated hemoglobin, blood pressure, and serum cholesterol among patients with depression and diabetes in India: The INDEPENDENT randomized clinical trial.
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2017. A collaborative care team to integrate behavioral health care and treatment of poorly-controlled type 2 diabetes in an urban safety net primary care clinic.
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2015. 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.
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2013. Collaborative care for mental health and substance use issues in primary health care.
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2018. A randomized controlled trial of screening and brief interventions for substance misuse in reproductive health.
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2015. Collaborative care approaches for people with severe mental illness.
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2013. Collaborative care approaches for people with severe mental illness.
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2002. Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial.
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2020. Abstinence outcomes among women in reproductive health centers administered clinician or electronic brief interventions.
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