Integrating primary care and mental health key to improving patient care, lowering costs
Primary care physicians play important role in detecting mental, behavioral health issues
This year 62 million Americans will, for the first time, have access to mental health and substance abuse benefits as a result of the Affordable Care Act (ACA). And most health plans are now required to cover preventive services such as depression screening for adults and behavioral assessments for children. That means more patients will be turning to their primary care doctors for help with emotional and behavioral health problems.
Currently, more than 70% of visits to primary care physicians (PCPs) are related to psychosocial issues. One-quarter of adults experience a mental illness in a given year, and more than half receive no treatment, according to the National Alliance on Mental Illness.
“We should be able to provide mental health services because our patients really need them,” says Russell Phillips, MD, director of the Center for Primary Care at Harvard Medical School in Cambridge, Massachusetts. “Unfortunately, primary care practices often lack the resources, tools and expertise to address these issues.”
In recent years, some clinics have started to call on psychiatrists, social workers and even clinical pharmacists to address the needs of their patients. Physicians at large health systems, including the Veterans Health Administration and Kaiser Permanente, treat mental health problems with psychiatrists’ oversight. And many other practices across the country are following suit. For example, six primary care practices affiliated with Harvard Medical School recently began offering mental health services through consultations with social workers and psychiatrists.
Saving lives, lowering healthcare costs
The benefits of integrating mental and behavioral health services in primary care are numerous.
By working with mental health professionals, you can get patients back to work sooner and possibly even save lives. A study published last year in the British Medical Journal found that when primary care practices used a care manager (a social worker, nurse or psychologist) to help them treat older adults with depression, the patients were 24% less likely to die compared with those in usual care.
Another important benefit: increasing patients’ compliance with medical treatment. Depression occurs in up to 20% of patients with diabetes and coronary heart disease—two of the most common conditions in primary care—and patients who suffer from both problems are less likely to make lifestyle changes and adhere to medication regimens.
Not surprisingly, depression has been shown to increase medical costs in patients with these problems by 50% to 70%, according to recent research published in the Archives of General Psychiatry. In that study, when nurse care managers monitored patients diagnosed with depression and either diabetes or heart disease, the patients had lower mean outpatient costs of $594 per person and 114 more depression-free days compared with patients who received usual care.
Including mental health services in primary care practices may even reduce physician burnout. Some physicians lose sleep worrying about patients with mental health problems. “If I can find a mental health practitioner to help me care for these patients, then I can help the patient and rest better as well,” says Phillips.
A team approach to care
PCPs play a key role in detecting depression and other mental health disorders.
They should evaluate and diagnose patients, then encourage them to pursue treatment if necessary.
Still, “we need a team approach to be able to [treat patients] in a consistent and reliable way over time,” says Phillips. “To be sure a patient is doing well, we need to be checking in with them.”
At the Harvard-affiliated practices, the team often includes a population manager—possibly a nurse—who reaches out to patients regularly and monitors their symptoms; a social worker, who provides psychotherapy; and a clinical pharmacist, who makes adjustments to medications. A medical assistant screens patients for mental health disorders using tools such as the Patient Health Questionnaire (PHQ-9), which is used to screen for depression. The practices maintain lists of patients who have depression and other mental health disorders. From time to time, the population manager re-administers the PHQ-9, which indicates whether the prescribed medication or therapy has worked.
“If a patient has depression, we want to make sure he or she has a 50% reduction in their PHQ-9 score in 16 weeks,” says Fiona McCaughan, a nurse manager for Somerville Hospital Primary Care, a Harvard-affiliated practice. “If they haven’t, we need to try something else.”
Some practices are adding mental health professionals to their staff. The Harvard practices have hired psychiatric social workers to work in their clinics. “When I see a patient who might have depression, I can introduce him or her to a social worker, initiate treatment and continue to follow him or her over time,” says Phillips. “That way, we know the patient is going to create a relationship. When patients are depressed, it’s very difficult to initiate relationships with providers. So if you leave it up to the patient to do so, it may become a barrier to treatment. There’s also a stigma of going somewhere else for psychiatric care.” Indeed, studies show that more than half of primary care doctors are not successful at referring patients to mental health providers.
“Patients like to have their care delivered by the doctor they trust,” says Joji Suzuki, MD, associate psychiatrist at Brigham and Women’s Hospital in Boston. Another benefit of having a mental health professional on staff: the PCP can do a “hallway consult.” “Because the providers are physically here, they can talk to each other and make minor changes to a patient’s treatment plan without referring a patient to a psychiatrist or taking up an entire visit,” says Mccaughan.
The practices affiliated with Harvard’s Center for Primary Care are working with other mental health professionals—psychiatrists, addiction specialists and psychopharmacologists—via telemedicine and videoconferencing. These specialists are on call for the practice, and PCPs can contact them if they have a difficult case or questions about medications.
One tool that works well at several clinics in Cambridge, Massachusetts, is integrated case review, in which a PCP sends a patient record with a question to the psychiatrist on call. The psychiatrist reviews the record and makes a recommendation to the PCP.
“It simplifies treatment for me, and the patient doesn’t need to see someone else,” says Phillips. “As I do more of these consults over time, they raise my level of expertise at managing mental health problems.” Currently, the practices are conducting regular videoconference sessions, in which teams from the practices discuss patients with their mental health expert. Eventually, the practices may use telemedicine to enable patients to have consultations with psychiatrists.
There are many different models for integrating mental health services into primary care practices. Collaborative care (also known as IMPACT), involves using a care manager and a psychiatric consultant. The care manager—who may be a clinical social worker or psychiatric nurse—coordinates patients’ care and does the counseling. Research has shown that the collaborative care model is twice as effective as usual care in terms of clinical outcomes. Practices can review the evidence behind each model and choose the approach that will work best for them.
Making the numbers work
Clinics that have added mental health services have found that the start-up period can be difficult financially.
To employ the collaborative care model, for example, practices must hire a care manager and set up a contract with a psychiatric consultant. Research shows, however, that using the model can produce significant cost savings over time. Over a four-year period, there was a savings of nearly $3,400 per patient in every category—mental health, medical and pharmacy, according to a study published in The American Journal of Managed Care. During the first year, practices spend about $500 per patient delivering collaborative care, but by the third and fourth year, they start to accrue savings.
“A lot of organizations try to get seed money for the start-up part of the program,” says Diane Powers, associate director of IMPACT. Five practices that are currently implementing the collaborative care model have received federal grants for start-up costs through President Barack Obama’s Social Innovation Fund.
Once your program is in place, the challenge is finding a way to get reimbursed. “It can be difficult to cover the costs based on the fee-for-service system,” says Phillips. Many insurers won’t pay for phone consultations, and psychiatrists typically can’t bill for patients they don’t see face-to-face. Still, there are ways to get reimbursed in a fee-for-service environment.
Health plans that pay capitated fees are easier to work with. In Massachusetts, where the Harvard practices are located, the majority of physicians are paid a set fee per patient per year.
“If we spend more than that, we take some risk,” says Phillips. “If we spend less, we get to share the savings. So it’s up to us to decide how to spend the money, and we can use it to pay for mental health care. We’re finding that by coordinating care better, we can reduce the number of hospitalizations and readmittance rates, so we’re achieving substantial savings.”
Despite the challenges, the team-based approach to mental and behavioral health care seems to be worth the extra effort.
“There’s incredible excitement about it,” says Phillips. “Everyone feels this is at the heart of what our patients and practices need.”