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Integration of Behavioral and Mental Health Providers in Primary Care: Challenges and Opportunities
Ashley D. Halle, OTD, OTR/L, University of Southern California, Integrated Primary Care SIG member
The signing of the Patient Protection and Affordable Care Act (ACA) in 2010 indicated the beginning of one of the most significant re-workings of the U.S. health care system in national history. This changing and unpredictable health care landscape can be unsettling, as it requires providers to practice in the present but with a watchful eye on the future. However, it also provides extraordinary opportunities for health care administrators and practitioners to more closely examine the benefits that result from the integration of behavioral and mental health providers in primary care.
In order to have a more holistic understanding of the issues surrounding integrated primary care and the emerging opportunities, I contacted two individuals involved in transformative primary care efforts at the University of Southern California (USC) to ask them to share their distinct perspectives. They are family medicine physician Jehni Robinson, MD, and occupational therapist Chantelle Rice, OTD, OTR/L, CDE.
Dr. Robinson is an associate professor of clinical family medicine and the vice chair of clinical affairs for the USC Keck Department of Family Medicine. She completed her residency at Harbor-UCLA Family Medicine in 2000 and spent many years designing and providing collaborative primary care services in community clinics before coming to USC.
Dr. Rice is the director of the USC Occupational Therapy Faculty Practice, a private clinic where occupational therapists deliver lifestyle-based interventions to patients with a variety of medical diagnoses and conditions. A Certified Diabetes Educator®, she works predominantly with Lifestyle Redesign® Weight Management and Diabetes Management clients.
IPC SIG: What are the behavioral/mental health needs you see in primary care practice at USC that are common or are not being adequately addressed at present?
Robinson: There is a tremendous need for mental health and behavioral health services in primary care. About one-third of the patients coming to a primary care clinic have a need such as depression or anxiety, especially in patients with chronic diseases. Mental and physical health are connected. There needs to be proactive self-management by the patient. If patients are suffering from depression and thinking, "What's the point?" it makes it hard for them to eat right, exercise, and manage their chronic illnesses.
Rice: People are probably coming in to primary care clinics with things like stress, depression, anxiety, and other mental health concerns. Those conditions are coming up in those sessions, but they're not being referred out and they're not being seen regularly to address those things specifically. They're probably addressing some of the more chronic conditions, like physical disabilities, diabetes, and hypertension, but not the mental health issues that come up with those as well.
I think that many health practitioners in these settings are not necessarily addressing habits and routines and the impact that they can have on physical and mental health and chronic disease management. This includes things like eating routines, sleep patterns, physical activity, engagement in meaningful leisure activities, and social relationships. All of those things have an impact on health, and I don't think that that's being emphasized or addressed to the extent it should in primary care settings at this time.
IPC SIG: What are some of the major obstacles to integrating behavioral/mental health providers in primary care at USC?
Robinson: The way that health care services and insurance are structured. So the fact that we have carved out mental health services makes providing those services incredibly challenging. I always tell patients, "Your head is connected to the body, and we have to address those simultaneously." But the fact you have to call the number on the back of your card to find mental health services covered by your insurance plan is not a collaborative way to practice. It would be great to have someone on site.
Another thing is that I cannot bill for mental health services. If I try to address those needs, I won't get paid for those services. We still do it; we have to do it every day. But we have billing staff that come back and say we can't bill for it, it won't go through. Even for things like obesity. This is a major problem.
Rice: Reasons we're not more integrated is we don't have a venue yet in primary care where we come together to discuss our patients with everyone collaborating in the ways we know we ideally could. But it's getting better and better. So we are creating more and more opportunities to connect and collaborate with other health professionals. I would say that we are getting to a place where [the other providers] really understand occupational therapy, and they feel just as frustrated that we can't collaborate more. To a certain extent, there are just some administrative barriers to getting to that ideal place of being co-located and having team meetings and integrated care.
IPC SIG: Based on your experiences at USC, what do you perceive as the benefits of integrating behavioral/mental health providers in future primary care efforts?
Robinson: There is tremendous potential for improved patient satisfaction, provider satisfaction, and cost savings. Patients with unaddressed mental health issues will continue to visit different health care settings-urgent care and emergency care-with symptoms that are due to their mental health. Patients may have very real physical complaints that are coming from mental health or anxiety issues. By identifying these people in primary care, we can treat them and provide resources.
Rice: Future efforts that we're looking at include getting occupational therapists into some of these more traditional primary care settings. So having an OT in family medicine or internal medicine here at USC is one such effort. It's hard because administration can be so challenging. They look at those up-front costs, but they're not really seeing how having these behavioral health specialists in primary care could increase their revenue down the road. Getting them to see that is really key.
IPC SIG: What changes or improvements would you like to see in order to enhance the integration of behavioral health in primary care settings (either at USC or on a national level)?
Robinson: Practice co-location is critical. People with mental health problems often have trouble organizing information. We frequently have to ask patients to schedule multiple appointments and come back in order to be seen for their mental and behavioral health needs. And for someone who has trouble organizing information, this is very difficult for them.
Rice: I think first and foremost what we've really been trying to focus on is educating the current practitioners in primary care-physicians, medical assistants, and nurse practitioners-about the value of some of the other professions that they're not used to seeing in primary care, like occupational therapy. There's a really important role that we can play in primary care but we need to educate those stakeholders so they feel open to incorporating us into that practice setting.
A second thing involves critically looking at the reimbursement and how to get paid for some of these services. Whether that is looking at creating a convincing argument to administration to fund positions like this that might end up saving them a lot of money in the long run or increasing revenue in the long run. Or whether that is looking at changes in health care and the way that they think about reimbursing for these kinds of services. So it's about educating who's in there already and finding out how to get paid for it or changing the ways we get paid for it.
IPC SIG: While I think many people appreciate the value and ease of co-located services, space is a frequent limitation. What are some of the ways in which you've been able to overcome space limitations?
Robinson: I think it takes both the team figuring out how much space they all need, as well as good communication to leadership so that we know that there's support for what we're trying to do to ensure space allocation. But again, I think those specific pieces about co-location and how do we facilitate communication are really critical. It's really easy if we're right next to each other.
We should also consider group texting when we're doing team-based care. This can be very efficient so that everyone knows immediately what's going on with the patient. It might be interesting to look at that as a means to facilitate communication when we can't all be in the same space at the same time.
Rice: Being in an academic medical center like USC, space is always a challenge. Even when new space might be available, it's generally accounted for far in advance. So we're really just trying to work with the space we already have, which requires a lot of coordination. When you're talking about introducing new disciplines into primary care, it's an additional challenge to think about, "Where are we going to put these providers?" The value of being co-located has a lot to do with improved communication.
If actual co-located care isn't an option due to space, one of the best ways we've found to ensure collaboration and communication is with the interdisciplinary meetings. Meeting with other health professionals just makes it so much easier to close any loops, even if you're not together in the same space all the time. We have pain management and chronic headache teams that meet that I think use an excellent model. All of the different disciplines are clear about what role they provide and what role the other disciplines provide. They come together on a regular basis to communicate about clients. And then besides good communication, providers also need to manage the process. What I mean by this is being present with the management has been critical, as well as regular team meetings with an interdisciplinary team and the people who refer.
IPC SIG: What ideas do you have for how people can overcome financial constraints, such as those that might result from challenging reimbursement issues and/or insurance reform?
Robinson: Finding solutions to financial constraints are twofold. First, there's larger legislative work that needs to happen so that all parts of the care team can provide those services and be reimbursed appropriately. Secondly, I think we need to be thoughtful about how we're billing patients for team-based care. If they receive individual bills for a lot of different services provided by the team, the expense goes up for them and then we're not going to have the patients seeing us. In terms of our models, we need to think about prioritizing services based on what's important to the patient and getting those reimbursed. Because of our history of spending so much money on health care, we're not going to move toward a system where we can start billing and collecting indiscriminately. Also, there will need to be a legislative fix with regards to the mental health piece in order to have those systems better integrated with physical health.
In summary, we need to figure out how to prioritize and streamline health care provided by teams. We need to establish systems that will help identify the most critical services for each individual patient, determine how can we best provide those services and by which team members, and how can we get those services reimbursed in a cost-effective manner.
Rice: At USC, we're still working in a fee-for-service model. And so there are a lot of limitations with that model because we're restricted to our Local Coverage Determinant (LCD) in hospital-licensed space, such as our current primary care clinics. So there are diagnoses in the LCD document that are common in primary care settings that we can address, but then there are other diagnoses that aren't on the LCD document that are things we could be helping our clients with, such as depression, anxiety, and bipolar disorder. So we can bill for some services, but it's just that when we're working in those specific settings at USC, we have a lot of limitations as far as what we can provide. However, what we can do is consult and screen for those things in primary care, and then refer out to our occupational therapy practices. It's not ideal, but it allows us to provide those services patients need and wouldn't get otherwise.
What's pretty unique is that we have occupational therapy involved in this area, and there are several reasons for that. One is the strength of our occupational therapy clinical arm at USC. We also have evidence of the cost-effectiveness of our services as demonstrated by the Well Elderly studies that have been conducted at USC.
IPC SIG: Any additional advice or lessons you've learned from your work at USC that can be shared with others who are trying to improve the integration of behavioral health in primary care?
Robinson: I think really being able to build a solid business case, which can be challenging to do, is important to justify the appropriate hiring of staff. The other piece is the community and understanding the resources that are available, and establishing the relationship with those resources.
Rice: Be patient. On the one hand, take advantage of every opportunity in the short-term, but make sure that you are in it for the long-term because it's going to take time. There are going to be initiatives that you get involved in that may not lead anywhere. You may not see any significant change or progress by being involved in those, but you never know what sort of doors they're going to open along the way. So I think take advantage of every opportunity in the short-term, but be patient with the process. All of us are sitting back and waiting to see what changes are really going to come about in health care, and so in the meantime we need to make sure we're prepared and that we've pursued every opportunity that comes up.
The challenges at USC may be similar to what many of us experience in primary care-problems of limited space, time, reimbursement, and payment. What is distinctive, however, are the unique strategies that are being used to help solve the numerous obstacles to providing integrated primary care. Sharing these approaches allows us to continue collaborating and learning from each other with the common goal of better addressing the multi-faceted needs of our diverse clients and communities. In order to strengthen the business case for integrated primary care and more successfully seize opportunities, future directions should continue this collaboration by aggregating data.