EXECUTIVE SUMMARY

Recent Medicare funding for care management services, related to integrated behavioral health and primary care, has provided more incentives for healthcare organizations to use this approach.

  • The Agency for Healthcare Research and Quality (AHRQ) Academy for Integrating Behavioral Health and Primary Care provides free online information, models, and tools.
  • The AIMS Center at the University of Washington in Seattle also provides free online tools, definitions, and other information about collaborative care.
  • The focus of these models often is on care/case management that helps patients meet their behavioral health disorder needs, as well as maintain their health while coping with comorbidities.

Some of the major designers of collaborative or integrated behavioral health and primary care models have spent years creating tools and models that will work in communities across the nation.

A review of 79 studies, including 24,308 patients, found that collaborative care increases the number of patients adhering to their medication regimens and can improve mental health.1

Integrated behavioral healthcare also can help improve healthcare spending. One study found that adults with multiple chronic diseases and high needs related to social-behavioral issues, had nearly three times greater healthcare costs as adults with only multiple chronic diseases.2

“We’ve come to realize that 5% of the population accounts for 50% of healthcare expenditures,” says Garrett E. Moran, PhD, project director at the Agency for Healthcare Research and Quality (AHRQ) Academy for Integrating Behavioral Health and Primary Care. Moran also is vice president at Westat in Rockville, MD, which contracts with AHRQ to operate the academy.

“That’s widely known, and it’s a focus of a lot of case management activity,” he says. “There are a lot of folks trying to take those high-cost, high-need patients and work with them to improve their engagement and activation and to help them avoid costly, unnecessary, and inappropriate utilization of healthcare services.”

More recently, health scientists and others have realized that behavioral health disorders are major drivers of healthcare costs and problems, Moran says.

It’s not that people with comorbid conditions spend more because they seek behavioral health services, he says. When all physical ailments are the same, the people who also have depression or anxiety or another behavioral health disorder spend more on their medical care and treatment. Their costs are higher because they’ll head to the ED to be hospitalized for physical flare-ups more often than do people without a behavioral health disorder.

Studies that show this financial effect have received the healthcare industry’s attention, Moran notes.

“When research made a financial case for addressing behavioral health disorders, people started paying attention,” Moran says.

Now that Medicare provides funding for care/case management in these programs, there is cautious hope that more health systems and communities will embrace integration.

“I think we have made progress and are making progress,” Moran says. “We have new medical codes to pay for collaborative care, but not many insurance programs have adopted [them]. It’s still difficult to pay for integrated care in a fee-for-service environment, with Medicare being the exception.”

The Medicare funding codes for care management will have an effect to the extent that other insurers, including Medicaid, follow Medicare’s example, Moran says. “In that case, it can really make a difference.”

So far, CMS’s change, made less than a year ago, has shown promise. But the world has not yet changed, he adds. (For more information, see related article in this issue.)

“The rationale for integrated care is that it’s so important that we not only treat people’s physical concerns, but we also treat their mental health needs, and this is done in the primary care setting,” says Sherri Branski, RN, MSN, deputy director of AccessCare in Morrisville, NC. Branski is one of the authors of a poster presentation about enhanced roles for care managers in integrated health models.

“Medicare increasingly is generating new codes to allow practices to bill for the kind of integrated care that many people with mental health disorders need,” Branski says.

The AccessCare poster featured the collaborative care model, formerly called the Impact Model, which originated at the University of Washington in Seattle. The model involves a behavioral care case manager working in a primary care setting, whose services are billed by a primary care physician, she says.

AccessCare’s poster and integrated/collaborative care model initiative were created to help primary care practices become more integrated, Branski says.

“We do Medicaid case management across the state of North Carolina, and we work closely with providers to help them build capacity to do behavioral health services and meet patient needs,” she explains. “The whole nation is working on building capacity for managing mental health needs for patients.”

From a case management perspective, collaborative care is the future. “We’re always looking for opportunities to utilize case managers in different capacities and different settings,” Branski says.

The collaborative care model involves identifying patients that are struggling with multiple comorbidities, including behavioral health issues such as anxiety and depression, says Anne Shields, RN, MHA, associate director of the AIMS Center at the University of Washington.

“It’s a vicious cycle,” Shields says. “Families and patients are dealing with a lot, and it’s hard to deal with your diabetes when you’re feeling low and struggling in other ways in your life.” Substance abuse, depression, and anxiety all contribute to poor health, she says.

Organizations like the AIMS Center have been working on the collaborative care model since before the Affordable Care Act (ACA) was passed. However, the ACA has helped promote the model through some funding and pilot programs as part of its population health and preventive care focus. Even with the ACA’s help, organizations need grants to provide a funding stream for sustaining integration program efforts, Shields notes.

Now, with the Medicare codes for care management, there is a possibility that more healthcare organizations could start care collaboration initiatives. And when they do, AIMS and the AHRQ Academy are there to help with free, evidence-based strategies and tools.

For example, AHRQ developed the Playbook, an interactive online guide to integrating behavioral health in ambulatory settings. The Playbook is available online at: http://bit.ly/2ydvFrq.

The Playbook starts with a checklist for organizations to determine their level of integration. There also is a section on developing a game plan and the folllowing six examples of common integration approaches:

  1. Collaborative Care. This focuses on tracking identified patient populations in a registry, using a care team of a primary care physician, a mid-level care manager on site, and a consulting psychiatrist.
  2. Combined Federally Qualified Health Center—Community Mental Health Center. A generalist behavioral health provider addresses a wide range of behavioral health problems and provides rapid access to behavioral interventions.
  3. Federally Qualified Health Center and Community Mental Health Center Partnerships. Characterized by close collaboration between behavioral health and primary care, this model has whole-person care in both settings. Patients move between settings, depending on acuity.
  4. Comprehensive Primary Care. A team-based approach, this includes behavioral health in primary care settings.
  5. Integrated Comprehensive Health Systems. Such systems assume responsibility for all patient care and feature whole-person approaches with inpatient, outpatient, and specialty care.
  6. Massachusetts Child Psychiatry Access Project. This project works to improve access to child psychiatry services when fully integrated care is unavailable. It includes universal behavioral health screening, telephone child psychiatry consultations, in-person child psychiatry appointments as needed, and support for primary care providers and families.

The AIMS Center offers a number of free tools and information, including a two-page sample job description for a behavioral healthcare manager. The following are sample items from the list of duties and responsibilities:

  • Support the mental and physical healthcare of patients on an assigned patient caseload. Closely coordinate care with the patient’s medical provider and, when appropriate, other mental health providers.
  • Screen and assess patients for common mental health and substance abuse disorders. Facilitate patient engagement and follow-up care.
  • Document patient progress and treatment recommendations in the electronic health record and other required systems to be shared with medical providers, psychiatric consultation, and other treating providers.
  • Develop and complete a relapse prevention self-management plan with patients who have achieved their treatment goals and are soon to be discharged from the caseload.

“We have a plethora of free resources on our website that push integrated and proven practices out to the world,” Shields says. “We work diligently with some organizations on a limited or more extended basis to train their staff and design their model of integrated care.”

One of the more popular approaches among healthcare organizations that are employing a collaborative care model is to take a stepped approach, she notes.

“They try to match the right level of integrated resource to the patient’s needs,” Shields says. “Some patients might do well under the care of just their primary care provider or a specialty provider — without need for additional resources.”

Other patients will need more help, including therapy and other support, to help them return to their usual levels of function, she adds.

“Collaborative care is a great strategy to give patients a whole lot more support for a period of time, and most are in the program for around six months,” Shields says. “Studies suggest that at least two contacts by a care manager within those early months of care is very important.”

REFERENCES

  1. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety. Cochrane Database Syst Rev. 2012; Oct. 17. Available at: http://bit.ly/2xLdS9r. Accessed Oct. 3, 2017.
  2. Hayes SL, Salzberg CA, McCarthy D, et al. High-need, high-cost patients: Who are they and how do they use health care? A population-based comparison of demographics, health care use, and expenditures. Issue Brief (Commonwealth Fund). 2016; Aug. 14:1-14. Available online at: http://bit.ly/2xEx0Xk. Accessed Oct. 3, 2017.