How We Are Integrating Behavioral Health Into Primary Care

More than one in four adults in the United States experience a behavioral health concern each year. For those seeking help, the first stop is often a primary care provider. Yet, many primary care providers lack the knowledge, time, and funding to provide the type and level of care needed, which can affect both mental and physical health outcomes.

Beyond common treatments for diagnosed mental health disorders, patients require support for a wide range of behavioral health needs including mental health disorders, addiction, and other unhealthy behaviors. Support can include lifestyle changes to better manage chronic disease—for example, changing eating and exercise habits to better manage diabetes—as well as techniques to better manage mental well-being—such as practicing mindfulness to manage anxiety.

Primary care providers at TriHealth—grant-making initiative bi3’s partner integrated health care delivery system in Cincinnati, Ohio—have long identified mental health as a key focus area for improving adult patient care. Change is hampered by the fact that there is often no clear referral path for patients due to a lack of mental health providers and other barriers to access.

Even with a successful referral, there may be little communication between the patient’s providers, further limiting options. As an invested partner in TriHealth, bi3 sparks innovation by funding the development of new care models that enable TriHealth to think differently about population health solutions and deliver value-based care.

In 2015, bi3, the grant-making initiative of Bethesda Inc., awarded a $3.3 million grant to TriHealth, to develop a patient-centered approach to integrating behavioral health into primary care practices. Bethesda Inc., along with CommonSpirit Health, is a co-sponsor of TriHealth.

During the grant period:

  • Patients showed improved mental and physical health scores.
  • 95 percent of participating primary care physicians reported increased job satisfaction and improved ability to meet their patients’ needs.
  • Patient access to same-day behavioral health visits was shown to be one of the most beneficial components of integrated behavioral health.

Today, TriHealth continues to build its capacity to make these services available at each of its 38 primary care practices by 2022. The increased adoption and reimbursement of telehealth services during the COVID-19 pandemic has paved the way for successful, sustainable implementation of integrated services .

Movement From Sick Care To Health Care

Integrated behavioral health has been a component of military and community mental health systems for years but has not been common in primary care practices. Now, evolving care standards, payment reform, and a focus on population health and value-based contracting are driving efforts to integrate behavioral health services into health systems. Identifying patient mental and behavioral health needs is rapidly becoming a required quality metric for improving population health.

Identifying And Implementing The Right Model

The 2015 bi3 grant to TriHealth supported the identification and implementation of a model to integrate behavioral health into primary care. TriHealth selected Mountainview Consulting Group’s Primary Care Behavioral Health Model (PCBH) to pilot in five primary care practices in which patients’ insurance patterns averaged 20 percent Medicare, 4 percent Medicaid, and 67 percent commercial insurance.

Lessons Learned

In addition to producing positive outcomes, TriHealth’s Behavioral Health Integration Project generated important lessons for behavioral health and primary care.

(1) It identified a shortage of behavioral health consultants, which include psychologists and social workers. There is a limited pool of these independently licensed clinicians in the Cincinnati region, so TriHealth established partnerships with local universities to develop curriculum and internships to build a pipeline of potential candidates for future open positions. Prior to the COVID-19 pandemic, TriHealth began piloting telehealth through a same-day handoff from primary care providers to a remote behavioral health consultant, but there were limitations. The pandemic created an opportunity to expand the availability of behavioral health services as more sites (offices) could participate, not only making remote behavioral health services more available to patients but also making consultations between professionals more accessible. Importantly, the Ohio Department of Health’s new reimbursement guidelines also allowed telehealth services to be reimbursed through most payors.

(2) It worked to reduce turnover of clinicians. To better support behavioral health consultants by combating isolation and reducing turnover, TriHealth developed a robust on-boarding process, which includes didactic training, “shadow” opportunities with primary care providers and experienced behavioral health consultants, and ongoing mentoring and professional development.

(3) It managed the lack of uniformity in reimbursement for behavioral health services. Reimbursement for behavioral health services is universally low, and benefits vary greatly among payors. Seeing both the primary care provider and behavioral health consultant in the same day for a behavioral health concern, such as depression, can result in two charges to the patient. To reduce financial barriers to care, TriHealth waived the patients’ fees for same-day first appointments with behavioral health consultants to encourage the handoff and establish that first quick connection. TriHealth continues to explore funding and reimbursement structures to support the sustainability of such services.

(4) It defined roles and workflow. Defining how behavioral health consultants embed in practices—from which space is available to meet with patients, to where behavioral health fits within a primary care practice—is an ongoing challenge for implementation. The behavioral health consultant must be proactive in developing relationships, identifying patients for potential referral by primary care physicians, maintaining communication with busy providers, and helping the practice meet population health goals.

(5) It gained physician buy-in and adoption. Integrating behavioral health services into primary care is an enormous culture change. Each field—behavioral health and primary care—has its own approach to patient care and outcomes. Even with shared endorsement, bridging these two fields takes time, trust, and tenacity.

(6) It built a business case for integrated behavioral health. The greatest challenges to proving the business case for behavioral health integration are the lack of consensus on which outcomes to measure and the inability to isolate and monetize specific cost savings associated with improving behavioral health access.

Going Forward: Refine, Scale, Sustain

TriHealth continues to refine the model and identify strategies to scale and sustain integrated behavioral health services. bi3 granted a funding extension to scale the model to new practice locations.

While reimbursement for behavioral health services continues to lag behind the actual costs of care, there may be opportunities to leverage fee-for service payments to support the full range of integrated behavioral health services. In other words, insurance would be billed for behavioral services and consultations similar to billing for physical care services, like a wellness visit or knee replacement.

The participation of TriHealth’s primary care practices in the Comprehensive Primary Care Plus payment structure resulted in additional committed dollars and a greater requirement to support behavioral health services in primary care practices. Comprehensive Primary Care Plus provides complementary funding through an alternative payment model and requires behavioral health to be a part of the services. However, it does not replace fee-for-service reimbursement.

Expansion of behavioral health consultant services across the primary care practices will be incremental and will be based upon multiple criteria, including but not limited to the number of patients assigned to a practice, the number of primary care providers in a practice, geographic location, physical space available, and primary care physician support for having services on site.

Integrating behavioral health into primary care continues to promise easier access and improved outcomes for patients.

This blog post was adapted from a bi3 Learning Series paper, “Integrating Behavioral Health into Primary Care: Best Practices and Learnings,” which was published in Spring 2020.

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