Integrated BH in Primary Care

1. Integrated Behavioral Health:
Primary Care Models of Service Delivery
Scott S. Meit, PsyD, MBA, ABPP
Vice Chair for Psychology & Section Head,
General and Health Psychology
Department of Psychiatry & Psychology

2. Learning Objectives
I. To briefly review the “Medical Cost Offset” literature
and understand its influence upon integrated
primary care (IPC)
II. To appreciate Public Health’s impact upon emerging
IPC models
III. To explore the evolution from parallel delivery
systems to integrated primary care/behavioral health
IV. Traditional BH care and IPC: Viva La Difference

3. Psychological Distress contributes to over
utilization of health care
At Group Health Cooperative of Puget Sound
 10% of medical utilizers accounted for one
third of outpatient resources and one half of
inpatient resources!
 One half had psychiatric diagnoses!
From Katon, Von Korff, Lin, Lipscomb, Wagner & Polk, 1990

4. And yet…
 Less than 30% of people seek care for their mental and/or
addictive disorder
Schurman, Kramer, Mitchell, 1985
 Of the same population, 78% receive health care
services Mauksch & Leahy, 1993
- 60-90% of all visits to physicians at least partially due to psychological, emotional, and
behavioral factors (Benson, 1996)
 Of those who seek treatment for mental and/or addictive
disorders, 40-50% seek that care from PCPs
Miranda, Hohman, Attkisson, 1994

5. Treating behavioral health disorders reduces
cost of overall health care!
(Medical Cost Offset)
 Kaiser-Permanente Experience
 Cummings NA, and Follette WT, Health Policy Quarterly, 1968
 Follette W, and Cummings NA, Medical Care, 1967
 Cummings NA, and VandenBos, GR, Health Policy Quarterly, 1981
 Findings supported in meta-analysis & in other research “camps”
 Jones KR and Vischi TR, Medical Care (Suppl), 1979–a review of research
literature
 Friedman R, Sobel D, Meyers P, et al, Health Psychology, 1995
 Chiles J. et al. Clinical Psychology: Science and Practice, 1999 (57 controlled
studies show a net 27% cost savings )

6. Yet patients present to PCPs instead of
Psychologists (and other behavioral health providers) – Why?
 Perceive themselves as having poor health
 Often multiple somatic complaints
 Established rapport with PCP
 Avoidance of stigma
 Cultural and socioeconomic factors
 Better insurance coverage/lower co-pay
 HMO/Behavioral Health carve outs

7. Why Integrate Primary Care and Behavioral
Health Care?
1. That’s where the Pts present!
 50% of all MH care delivered by PCPs
 92% of all elderly patients receive MH care from PCPs
2. Primary Care Process of Care Realities
 90% of the most common PC complaints = no organic basis
 70% of all PC visits have psychosocial drivers (Fries, Koop, & Beadle, 1993)
 67% of psychotropic agents prescribed by PCPs (Beardsley et al, 1988)
K. Strosahl, PhD, Mountainview Consulting Group, Inc.

8. Public Health & Population-based Care:
A “by the numbers” approach
Public health & epidemiology
– Focuses on raising health of population
– Emphasis on early identification & prevention
– Designed to serve high percentage of
population
– Provides triage and clinical services in
stepped care fashion
– Balanced emphasis on who is and is not
accessing service

9. The Continuum of Integration
Model Desirability Attributes
Separate Space -- Traditional BH
& Mission Specialty Model
1:1 Referral Preferred
Relationship + provider/
Some information
exchange
Co-location ++ On-site BH Unit/
Separate Team
Collaborative +++ On site/shared
Care cases w/ BH
specialist
Integrated Care +++++ PC Team Member

10. Another view…

11. So, how do you do this?
 Care Matching (primary care in primary care)
 Triage & “EAP” like services (mid-levels)
 Group & psycho-educational services
 Psychologist as director of exam room BH
care, provider of brief on-site therapy, &
liaison to tertiary BH services
 Embrace the differences between traditional
BH services and integrated primary care
behavioral health services

12. Care Matching
 Not every problem requires intensive
intervention
 Inappropriate matching = waste
 And can lead to iatrogenic complications
Iatros means physician in Greek, and -genic,
meaning induced by. Combined, they become
iatrogenic, meaning physician-induced.
Iatrogenic disease, then, is disease which is
caused by a physician.

13. Tailoring the “mix” by setting…

14. Put another way…

15. BHC
Primary Goals
 Act as consultant and member of health care team.
 Support PCP decision making.
 Build on PCP interventions.
 Teach PCP “core” behavioral health skills.
 Educate patient in self management skills through
training.
 Improve PCP-patient working relationship.
 Monitor, with PCP, “at risk” patients.

16. BHC
Goals (cont.)
 Manage chronic patients with PCP in primary
provider role
 Assist in team building
 Simultaneous focus on health and behavioral
health issues
 Effective triage of patients in need of specialty
behavioral health
 Make IPC/BH services available to a large
percentage of eligible population

17. Behavioral Health Consultant
Session Structure
 Limited to 1-3 visits in typical case
 15-30 minute visits
 Critical pathway programs may involve 4-8
appointments (e.g. Diabetes & Depression,
Chronic Pain)
 May use classes and group care clinics
 Multi-problem patients seen regularly but
infrequently over time

18. Behavioral Health Consultant
Intervention Structure
 Informal, revolves around PCP assessment and
goals
 Low intensity, between session interval longer
 Relationship generally not primary focus
 Visits timed around PCP visits
 Long term follow up rare; reserved for high risk
patients

19. Behavioral Health Consultant
Intervention Methods
 Limited face to face contact
 Uses patient education model
 Consultant is a technical resource to patient
 Emphasis on home-based practice to promote
change
 May involve PCP in visits with patient

20. BHC
Termination and Follow-up
 Responsibility returned to PCP (the BHC is a
subject matter expert & resource; the Pt is and
remains the Pt of the PCP)
 PCP provides relapse prevention or maintenance
treatment
 BHC may provide planned booster sessions for at
risk patients

21. Behavioral Health Consultant
Information “Products”
 Consultation report to PCP
 Part of medical record
 “Curbside consultation”
 Written relapse prevention plans (e.g. “Mood
First-Aid Kit”)

22. Qualities of A Successful Integrate
Primary Care Service
 Provides timely access for PCP
 Service is integrated within primary care setting
 Service is viewed as a form of primary care
 Service is provided in collaboration with the PCP
 Service is provided as part of the health care
process
 Improved clinical outcomes, satisfied patients (and
health care providers), and managing productivity &
financial risk as key goals

23. Economic Benefits of Integration
 Increased Productivity Capacity
– Estimate of revenue ceiling of a health care system is
closely tied to productive capacity of medical
providers
– PC capacity is commonly impacted by behavioral
health management demands of (50% of medical
practice time directed toward BH conditions)
– Integrated behavioral health re-directs BH patients and
“leverages” PCP practice time
– PCP’s are freed to see medical patients with higher
RVU conditions

24. Cost Effectiveness
Measuring the impact of adding additional dollars to a medical
procedure for value received (e.g. better diagnostic accuracy, clinical
effectiveness)
– Collaborative Care increased initial depression
treatment costs but improved the cost-effectiveness
of treatment for patients with major depression
– Cost offset for specialty mental health costs
– A positive cost effectiveness index of $491 per case
of depression treated
Von Korff et. al., 1998. Treatment costs, cost offset, and cost-effectiveness of
collaborative management of depression Psychosomatic Medicine, Vol 60,
Issue 2 143-149.

25. In Summary
IPC Benefits the Patient (and a broader Pt.
Population)
 Mind-Body dualism avoided
 More diagnostic accuracy
 Greater range of treatment options

26. IPC/BH Benefits PCPs
 Assistance with diagnostic differential
 Less time/fewer visits required with PCP
 Concomitant medical conditions often improve
 BHC typically obtains more information
regarding psychosocial factors
 BHC may assist in monitoring
pharmacotherapy treatment adherence

27. IPC benefits BH Providers
 PCP can endorse the BH Provider and
psychotherapy
 PCP will evaluate for medical illness and/or
medication effects
 PCP can prescribe pharmacotherapy (often
diminishing a need for psychiatrist consult)
 PCP often has helpful background information,
with established Pts

28. How do you train for this?
(if you want to)
 Alexander Blount, Ed.D. - UMass Dept of Family
Medicine, Certificate Program in Primary Care
Behavioral Health
 Connect with the integrated primary care/BH
initiatives of the Family Medicine Education
Consortium (Laurence Bauer, MSW, M.Ed., Chief
Executive Officer – and in Dayton!)
www.fmec.net
 and Read, Read, Read

29. Who pays for this?
The Family Medicine Education Consortium recently
conducted a series of meetings and a summit in
Pittsburgh to begin to organize a tri-state (OH-PA-
WV) IPC initiative.
 They have previously facilitated efforts in the Pacific
NW & New England regions.
 Promoting a broad and inclusive membership of
providers, consumer groups, & payors is their model
 In NE, this resulted in the President of the regional
BC/BS group authorizing 10% higher
reimbursements for all PCP services where IPC/BH
model of services are in place.

30. Recommended Books
 Seaburn, DB. (Editor), et al
Models of Collaboration: A Guide for Mental He
New York: Basic Books ©1996
 Cummings, NA, O’Donohue, WT, &
Ferguson (Editors). Behavioral Health as
Primary Care: Beyond Efficacy to
Effectiveness Reno, NV: Context Press ©
2003

31. Books (cont.)
 Frank, R., McDaniel, S., Bray, J., Heldring,
M. Primary Care Psychology, Washington,
DC: APA Press. © 2003
 James, LC & Folen, RA (Editors). The
Primary Care Consultant: The Next
Frontier for Psychologists in Hospitals
and Clinics, Washington, DC: APA Press. ©
2005

32. Books (cont.)
 O'Donohue;, WT, Michelle R. Byrd, MR,
Cummings, NA, & Henderson, DA (Editors).
Behavioral Integrative Care: Treatments
That Work in the Primary Care Setting
New York: Routledge. © 2005.
 Blount, Alexander (Editor).
Integrated Primary Care: The Future of Medical
New York: W. W. Norton. © 1998.

33. Good Web Sites
www.integratedprimarycare.com/
www.integratedprimarycare.com/Blount.htm (Blount Link)
www.behavioral-health integration.com/news.php
(Strosahl’s site, Mountainview Consulting)
www.healthpsych.com/practice/ipc/primarycare1.html
(a little dated, but a good basis for understanding evolution of IPC)

34. Discussion