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The Kennedy Forum releases issue brief - Fixing Behavioral Health Care in America - A National Call for Integrating and Coordinating Specialty Behavioral Health Care with the Medical System.

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Fixing Behavioral Health Care in America

A National Call for Integrating and Coordinating Specialty Behavioral Health Care with the Medical System

Prepared by: John Fortney, PhD, Rebecca Sladek, MS, and Jürgen Unützer, MD from the Advancing Integrated Mental Health Solutions (AIMS) Center, Department of Psychiatry and Behavioral Sciences, University of Washington in conjunction with The Kennedy Forum senior leadership team, including Patrick Kennedy, Henry Harbin, MD, Bill Emmet, Lauren Alfred, and Garry Carneal, JD.

Published by The Kennedy Forum

In Partnership with

Advancing Integrated Mental Health Solutions (AIMS) Center, Department of Psychiatry and Behavioral Sciences, University of Washington and The Kennedy Center for Mental Health Policy and Research, Satcher Health Leadership Institute, Morehouse School of Medicine

Kennedy Forum Focus Group Participants:*

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Executive Summary

One in four individuals will struggle with a mental health or substance use disorder at some point in their lives. In fact, these disorders are responsible for nearly 25% of all worldwide disability as well as substantial increases in overall health care costs. Although effective treatments exist for most behavioral health conditions, many people don’t receive the care they need due to lack of access, poor quality care and ineffective coordination between the medical and behavioral systems.

Data from the National Comorbidity Study show that access to behavioral health treatment is limited. Only 40% of people with a mental health or substance use disorder receive treatment in any given year, meaning that 60% of people are not getting any treatment at all. Only 12% receive care from a psychiatrist, and only 22% receive care from any mental health specialist. Slightly more (23%) are treated by a primary care provider or other general medical provider.

While barriers such as long wait times, cost and stigma surrounding mental illness explain why so few people access specialty care, the reality is that the specialty mental health care system is underequipped to treat the vast number of people with mental health and substance use disorders. More than half of counties in the U.S. do not have a single practicing mental health professional, a problem particularly acute in rural areas.

Primary care has become the de facto location for these patients to receive treatment, but unfortunately, the majority of their care is suboptimal due to time constraints and lack of access to behavioral specialists that could enhance their services. Only 13% of people diagnosed with a behavioral health condition receive minimally adequate treatment in a general medical setting; for substance abuse, that number drops to a dismal 5%.

Numerous studies show that primary care providers (PCPs) often do not have the time or resources to provide effective treatment for many behavioral health conditions, including depression, anxiety disorders, post-traumatic stress disorder, substance use and bipolar disorder. Less than 20% of PCPs feel “very prepared” to identify substance use disorders, and most patients with a substance use disorder say their primary care provider did nothing to address their disorder. Of the millions of people who receive an antidepressant each year, many do not receive them in sufficient doses or take them for a long enough amount of time to be effective.

Conversely, many patients in behavioral health homes with serious mental illnesses (SMIs), including schizophrenia, bipolar disorder and schizoaffective disorder, are not getting effective medical care. Patients with SMIs die at rates two to three times higher than in the general population. The implications of untreated medical conditions in specialty mental health combined with untreated behavioral health conditions in primary care are enormous, leading to missed suicide warnings, clogged emergency rooms, high hospital readmission rates and structural and financial strains on the entire health care system. Patients with mental health and substance use disorders have two to three times higher overall health care costs than those without.

No one part of the health care delivery system is equipped to provide effective care for all those with behavioral health problems. Although improvement is needed across the entire spectrum, especially in terms of the coordination of handoffs and improved medical care for SMI patients, strengthening the behavioral health care services in primary care is critically needed for four reasons:

1. The majority of people with behavioral health conditions get their mental health care in primary care
2. The quality of behavioral health care in primary care is often suboptimal due in part to lack of access to behavioral experts
3. There are now excellent evidenced-based interventions that add behavioral health expertise to primary care practices that can significantly improve outcomes
4. Effectively treating patients with behavioral health conditions within primary care offers enormous medical cost savings and improved patient satisfaction.

Researchers and clinicians have looked at ways to improve the detection and treatment of mental health disorders in primary care settings for over thirty years. Efforts initially focused on screening for common mental disorders, co-location of mental health providers in primary care clinics, provider education and training, facilitated referral to mental health specialty care and disease management. These approaches, alone and in combination, have not been found to improve patient outcomes. Although other promising approaches are emerging, the Collaborative Care model has the most robust evidence for effective integration of behavioral health care into primary care.

COLLABORATIVE CARE

Collaborative Care is a specific type of integrated care that treats common mental health and substance use conditions such as depression and anxiety in primary care settings. In usual primary care, the treatment team has two members: the primary care provider and the patient. Collaborative Care adds two additional vital roles: a care manager (typically embedded) and a psychiatric consultant (typically engaged by phone or video link). Collaborative Care is:

• Team‐based, led by a primary care provider with support from a care manager and consultation from a mental health specialist who provides treatment recommendations for patients who are not achieving clinical goals;
• Population‐based, whereby the care team uses a registry to monitor treatment engagement;
• Patient‐centered, with proactive outreach to engage, activate, promote self‐management and treatment adherence and coordinate services;
• Measurement‐based, with screening and monitoring of patient-reported outcomes over time to assess treatment response;
• Evidence‐based, with demonstrated cost‐effectiveness in diverse practice settings and patient populations;
• Practice‐tested, with sustained adoption in hundreds of clinics across the country; and
• Accountable for the care provided and for continuous quality improvement to meet care goals.

The evidence behind Collaborative Care is clear and compelling. More than 80 randomized controlled trials have shown Collaborative Care to be more effective than usual care for common mental health conditions such as depression and anxiety. Several recent meta-analyses, including a 2012 Cochrane Summary that reviewed 79 randomized controlled trials and 24,308 patients worldwide, further substantiated the model. Collaborative Care has been developed in multiple settings and research protocols in the U.S. and around the world. The research is particularly strong for depression, but increasingly for other conditions as well including anxiety disorders, posttraumatic stress disorder and comorbid medical conditions such as heart disease, diabetes and cancer. Research shows Collaborative Care improves patient functioning at home and at work, reduces disability, improves clinical outcomes and increases patient satisfaction and quality of life. Although the research evidence on Collaborative Care’s ability to effectively treat substance use disorders is less extensive, people who have comorbid mental health and substance use problems can benefit from Collaborative Care. Some mature Collaborative Care programs handle a variety of substance use disorders, and alcohol screening and brief interventions are effective for decreasing alcohol use in patients with risky drinking and can be easily incorporated into Collaborative Care programs. In addition, Collaborative Care programs can engage patients in care for alcohol use disorders when they are not ready for specialty treatment.

Collaborative Care not only improves patient care experiences and health outcomes, but it also reduces overall health care costs. Results from the largest trial of Collaborative Care to date, the Improving Mood – Promoting Access to Collaborative Treatment (IMPACT) study for depression care that tested the model on older adults treated in primary care clinics in five states, found substantial reductions in long term overall health care costs in patients who had received Collaborative Care. The overall return on investment was $6 in health care costs saved for each dollar spent on depression care.

In short, there is extensive evidence that Collaborative Care for common behavioral health conditions results in improved clinical outcomes, increased patient satisfaction and reduced overall health care costs—the Triple Aim of health care reform.

OVERALL RECOMMENDATIONS

The Kennedy Forum strongly endorses the following policies:

1. Wide Implementation of the Collaborative Care Model. Primary care clinics should implement the Collaborative Care model to treat patients with common mental health disorders due to its proven effectiveness in improving clinical outcomes, increasing patient access and satisfaction and lowering overall health care costs.
2. Promotion of Evidence-Based Treatments for Patients with Both Mental Health and Substance Use Disorders within the Collaborative Care Model. Primary care clinics that treat patients with comorbid mental health and substance use problems should incorporate evidence-based brief interventions, such as “Screening, Brief Intervention, and Referral to Treatment” (SBIRT), into the Collaborative Care model to improve the outcomes for patients with addictions. Care management programs that create treatment plans that incorporate and factor in a patient’s comorbidities will have the most success.
3. Integration with Primacy Care is High Priority Even for the Severe Behavioral Health Cases. Specialty mental health providers who treat patients with severe and persistent medical illness should integrate and/or coordinate with the general medical system to improve the treatment of the medical conditions of these patients. Those models that show a positive evidence-base should be expanded.
4. Implementation of Ongoing Coordination of Care is Paramount. All parts of the health care system should provide effective coordination and transitions of care for the patients they serve who have mental health and substance use problems. For example, someone who is discharged from an emergency room or a psychiatric hospital needs effective follow-up, and programs should assure that referrals to effective behavioral care are successfully completed.

The main barriers to achieving the above recommendations are: 1) an absence of a payment structure that supports evidence-based integrated care practices for treating mental health and substance use disorders in primary care; 2) a lack of a large enough mental health workforce skilled in supporting primary care providers; and 3) a lack of support by some primary care practices to implement Collaborative Care.

Widespread adoption of our recommendations will require engagement at all levels of the health care system; opportunities abound for diverse stakeholders to advance, promote and support this evidence-based model.

The Kennedy Forum offers several key additional recommendations as detailed below.

Payers and Purchasers

Under traditional fee-for-service payment models, key components of effective integrated care approaches like Collaborative Care are generally not reimbursable. Payers, purchasers and regulators need to:

• Improve Reimbursement Methodologies
• Promote Implementation through Incentives
• Implement Quality Benchmarking
• Create Patient Registries
• Develop Accreditation Standards

Providers and Provider Organizations

Collaborative Care has many benefits to medical providers, including better patient outcomes, increased patient satisfaction and lower overall health care costs. Providers and provider organizations need to:

• Increase Awareness
• Promote Enhanced Reimbursement Methodologies
• Report on Outcomes
• Implement a Synergistic Environment Integrated care awareness and skills should be part of the health professional training program.
• Promote Early Behavioral Health Training
• Use a Team-Based Approach
• Implement an Interdisciplinary Approach
• Leverage and Share Existing Best Practices
• Develop Interdisciplinary Certification Standards

Patients and Patient Advocacy Groups

Although Collaborative Care has been proven to result in greater access, higher patient satisfaction and better patient outcomes, few patients know about the model as an option to help them overcome their mental health and substance use disorders:

• Behavioral health and consumer advocates should educate consumers about Collaborative Care and coach them to ask for this type of care.
• Patients and their family members should understand the value of and ask for Collaborative Care and expect remission from their symptoms.

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