- Email: [email protected]
Behavioral health integration in primary care at Brigham and Women׳s Advanced Primary Care Associates, South Huntington
Healthcare 3 (2015) 169–174
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Into Practice
Behavioral health integration in primary care at Brigham and Women's Advanced Primary Care Associates, South Huntington Katherine Majzoub Perez a,n,1, Lydia Flier a,1, Helen D’Couto a, Meghan Rudder a, Anjali Thakker a, John Weems a, Leah Wibecan a, Zirui Song b, Asaf Bitton c, Jane Erb d, Stuart Pollack e, David Silbersweig f, Lara Sullivan g, Joseph Frolkis e,2 a
Harvard Medical School, USA Department of Medicine, Massachusetts General Hospital and Harvard Medical School, USA c Division of General Medicine, Brigham and Women's Hospital and Department of Health Policy and Center for Primary Care, Harvard Medical School, USA d Brigham Depression Center, Brigham and Women's Hospital and Harvard Medical School, USA e Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, USA f Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, USA g Brigham and Women's Hospital, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 19 November 2013 Received in revised form 4 April 2015 Accepted 8 April 2015 Available online 20 June 2015
Of the many problems facing the US healthcare system, the shortage of behavioral health providers in outpatient settings is particularly profound. To address this issue, Boston's Brigham and Women's Hospital identified ways to incorporate behavioral health into primary care when it opened the South Huntington Primary Care clinic in August 2011. When the needs of its patients were more complex than anticipated, the clinic created assessment tools and refined care processes to identify, triage, and monitor patients with mental illness. Key insights from the South Huntington experience include:
Keywords: Mental health Primary care Behavioral health integration Medical home Team-based care Culture
Hiring for roles instead of training can decrease costs of implementation. A process for reflection, assessment, and adaptation is a critical component of innovation. Innovations must adapt to the specific needs of the local community. Innovations are most effective when they reflect the capabilities of local providers. & 2015 Elsevier Inc. All rights reserved.
1. Background The shortage of outpatient mental health services in the US has been a significant concern for over 30 years.1 According to the National Institute of Mental health, 26.8% of Americans over the age of 18 have a diagnosable mental health disorder and the US lifetime prevalence of having a psychiatric disorder is 47%.2 Anxiety disorders, major depressive disorder (the most frequent cause of disability in people between the ages of 15 and 44), and bipolar disorder are among the most common mental health diagnoses.3 Recently it has been estimated that less than one-third of Americans with a mental health problem are receiving adequate treatment.4,5 In a national survey conducted from 2004–2005, two-thirds
n Correspondence to: 260 Longwood Avenue, Holmes Society, 2nd floor, Boston, MA 02115, USA. E-mail address: [email protected] (K. Majzoub Perez). 1 Co-first authors. 2 Senior author.
http://dx.doi.org/10.1016/j.hjdsi.2015.04.002 2213-0764/& 2015 Elsevier Inc. All rights reserved.
of primary care physicians (PCPs) reported that their patients could not access adequate outpatient mental health services, primarily due to a lack of behavioral health providers.6 Similarly, a national survey of community health centers in 2006 found that there were vacancies for 22.6% of psychiatrist positions, more than any other position at health centers.7 One reason for the shortage of outpatient mental health services and psychiatrists in particular is inadequate reimbursement for behavioral health.8 As a result of this workforce shortage, PCPs are increasingly responsible for their patients' mental health needs, a job for which they have little systematic training. Recent data suggest that over a 15-year span between 1995 and 2010, PCP visits that involved prescriptions for antidepressants, antipsychotics and anxiolytics increased more than psychiatrist visits that involved such prescriptions.9 While neglecting mental health has serious implications in regard to treatment, its impacts on co-morbid chronic illnesses and subsequent health care costs are also significant.10,11 Patients with severe mental illness are two to three times more likely to have
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cardiovascular disease than are patients without mental illness.12 Similarly, diabetic patients with co-morbid depression have been found to have higher HbA1c levels and consequent complications such as diabetic retinopathy, nephropathy, and neuropathy than diabetic patients without depression.13 In addition, greater severity of depression in diabetic patients has been associated with poorer adherence to oral medications and overall physical and mental functioning.14 Research also suggests that treating mental illness can have positive impacts on the outcomes of co-morbidities. In one study, patients with major depression who received enhanced mental health services had 24% lower mortality than those receiving standard care over a two-year period.15 The shortage of mental health services in the United States is therefore a problem not just for the treatment of mental illness, but also for the management of many chronic conditions. Federal programs such as the Veterans Health Administration were among the first to adopt an integrated model of behavioral health care in the United States.16 Health maintenance organizations such as Kaiser Permanente followed suit.17 Other early leaders in the field of behavioral health integration were Intermountain Health Care in Utah and Idaho, Tennessee Cherokee Health, the DIAMOND project in Minnesota, and McMaster University.16,18 In one such case, Intermountain Health Care developed a protocol to assess whether a patient's mental illness required “low care,” “moderate care,” or “high care.” While low care patients were treated by physicians with support from a care manager, moderate care patients received consultations from an on-site psychiatrist, and high care patients were referred to external mental health specialists.16 In another example, the DIAMOND (Depression Improvement Across Minnesota – Offering a New Direction) program employed the Hartford Foundation's IMPACT model for depression care and was funded by bundled payments. The program offered patients opportunities for ongoing mental health assessments, a patient registry that facilitated teambased care, and consultations with psychiatrists.16 A 2014 report produced by the Millbank Memorial Fund at the request of the American Psychiatric Association analyzed the potential economic impact of integrating behavioral and medical health care. It predicted that the widespread integration of behavioral and medical care could save $26–48 billion in health care costs annually.19 These projected savings were attributed to patients' decreased use of emergency rooms and other hospital facilities, as well as their ability to better manage concomitant chronic medical conditions. While a study published in May 2014 found that 43% of primary care physicians in the US are co-located with a behavioral health provider, it is unclear if this physical proximity results in integration and collaboration of services.20 Regardless, there has been increased attention to behavioral health integration on a national level. In 2014, the Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) co-produced a white paper exploring how behavioral health integration would be applied to National Committee for Quality Assurance (NCQA) recognized PatientCentered Medical Homes (PCMHs).21 While the report emphasized that behavioral health integration is not a current requirement for PCMH recognition, it is possible to imagine such a scenario in the future. Aware of these models and concerned about the shortage of outpatient mental health providers, leaders in primary care and psychiatry at Brigham and Women's Hospital (BWH) in Boston identified behavioral health integration as a priority for the hospital's new primary care clinic, Advanced Primary Care Associates, South Huntington.
2. Organizational context The South Huntington clinic, which opened in August 2011, was designed to be a PCMH and received its Level 3 PCMH certification from the NCQA in April 2014.22 Its staff was organized into three care teams, each with one or two attending physicians, one or two residents, a nurse, a social worker, a physician assistant, and two medical assistants, operating in conjunction with a staff pharmacist, a RN care manager, a community resource specialist, and a nutritionist. Behavioral health integration at South Huntington was centered on the involvement of three types of medical personnel: a psychiatrist, trained PCPs and social workers. The part-time psychiatrist, Jane Erb, MD, was also the Medical Director of the Depression Center at BWH. The Department of Psychiatry supported her to spend four hours per week at South Huntington. Dr. Erb used half of these on-site hours to clinically evaluate, but not treat, complicated cases of mental illness. The remaining two hours at South Huntington were spent educating PCPs and social workers about behavioral health management, who then in turn managed less severe cases of mental illness. While PCPs often refer patients to a psychiatrist in the initial stages of mental health management, the South Huntington behavioral health integration team hypothesized that PCPs could provide more care if they were appropriately educated and coached. Expanding the role of PCPs in the management of behavioral health would allow the staff psychiatrist to see the most challenging cases, thereby significantly increasing South Huntington's capacity for providing these services. South Huntington followed the successful examples of many health care organizations when its leadership decided to hire and train social workers as behavioral health specialists.17,18 Although social workers had been involved with behavioral health care at other BWH clinics, those at South Huntington would have responsibilities that were traditionally managed by nurses in the BWH system, including assessing patients' behavioral health needs and directly providing behavioral health interventions. The leaders of South Huntington were confident that social workers would be suitable for these positions due to social workers' long history of involvement in primary care at BWH, knowledge of clinical care management, and familiarity working with patients' behavioral health issues. Because social workers would receive a lower hourly wage than the nurses who traditionally filled these roles, there was also an economic argument for this shift in responsibilities. Notably, the clinic hired a Community Resource Specialist to relieve the social workers of some of their traditional referral responsibilities such as connecting patients with legal aid and housing advocacy in anticipation of the impact of this expanded role on social workers' time.
3. Problem: The unexpected severity of patients' mental health needs Soon after integrating behavioral health into its primary care workflow, South Huntington found that its new patient population was more behaviorally complex and growing more rapidly than predicted. Many of these patients had been uninsured prior to the expansion of public insurance in Massachusetts that began in 2007, and therefore had multiple unmanaged medical problems. The staff at South Huntington had anticipated that they would be screening patients mainly for depression; instead, they were diagnosing patients with personality disorders, psychotic disorders, and bipolar disorders. Many of these patients had significant co-morbidities as well as mental illness, and had been referred directly from the inpatient floors of BWH. In addition, patients coming to South Huntington from
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the community were younger and sicker than predicted, e.g., presenting with new onset bipolar disorder and schizophrenia that South Huntington was not prepared to manage. Of the older patients with mental health needs, many were in crisis, having been without care for several years. South Huntington calculated that 27% of the clinic's population formally interacted with a member of the behavioral health team within the first year of its opening. According to South Huntington's Medical Director Dr. Stuart Pollack, this influx of patients with serious mental illness but without an established primary care physician was a symptom of a system with universal insurance coverage but insufficient access to health care services. South Huntington was identifying patients whose significant mental illnesses had previously impeded their ability to find the psychiatric services they needed. These patients were recognized at South Huntington because, unlike at most primary care clinics, clinicians were actively screening for behavioral health disorders, since they had access to social workers and a psychiatrist. Soon after opening, Dr. Erb's two referral hours per week were filled with complex cases, and her schedule had no availability for months. PCPs directly referred patients to her, and sometimes a patient would specifically request to see a psychiatrist. Social workers were also in high demand and staff members were soon requesting that the clinic's leadership hire more social workers, not more doctors. Six months after opening, the leadership team at South Huntington began discussing the need to restructure behavioral health services. One solution was to establish an expectation with BWH that South Huntington would only take five new inpatient referrals per week. This was helpful but insufficient: South Huntington needed a strategy to care for the complex behavioral health patients from the community who were presenting to the clinic.
4. Solution: Create new systems to triage mental illness In designing South Huntington, the founders had anticipated the need for self-evaluation and adaptation. From hiring staff that expressed an interest in teamwork and innovation, to a 9-day, preopening orientation for all staff that focused on motivational interviewing and the LEAN model of quality improvement, South Huntington's founders had prepared their team for rapid innovation and frequent collaboration. Examples of their intentional steps toward this culture included offices shared by whole teams, weekly all-staff meetings, and avoiding the habit of referring to staff in the possessive (i.e., “my medical assistant”). By April 2012, eight months after the clinic's opening, South Huntington was applying this culture of innovation to develop a new system of behavioral health integration. The team started by adapting and personalizing existing behavioral health integration tools, including some from the IMPACT model23 and Intermountain Health's behavioral health screening tool.24 When existing resources did not meet their needs, the team developed new materials. The result was a four-step process that included enhanced screening, employing social workers as clinicians as well as coordinators, increasing the breadth of differential assessment, and tracking patients in the electronic medical record (EMR) (Fig. 1). In the same way that teams at South Huntington huddled to discuss the identification and treatment of high blood pressure, the psychiatrist, social workers, and any other member of the care team who wished to attend would huddle on a weekly basis to discuss how to identify and treat patients with behavioral health needs.
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4.1. Step 1: Universal pre-screening and assessment The first step of the screening process used the PHQ-2 (and further tools, such as PHQ-9, AUDIT, and GAD-7 as indicated) to identify patients with mood disorders (for more information on these screening tools, see Patient Centered Health Questionnaire25, Bush et al. 26, Spitzer et al.27). 4.2. Step 2: Immediate intervention The second step was designed to discourage PCPs from prescribing a medication as soon as they identified a condition such as depression. Instead, the new protocol provided patients with less severe mental illnesses coaching and self-care strategies before offering medication. PCPs would often manage these cases independently, providing recommendations and motivational coaching when indicated. If a more intense treatment was needed, the provider would initiate a “warm handoff” to a social worker, who would follow up with supportive counseling, short behavioral health interventions such as Cognitive Behavioral Therapy, motivational counseling, and crisis intervention. The social worker would also initiate referrals for intensive treatment and emergency psychiatric evaluations, as needed. Once care had commenced, social workers would continue to monitor patients' behavioral health needs and alert the team when more intervention, including referral to outside providers, was indicated. In the most severe illnesses, such as when a patient's symptoms were interfering with basic functioning, appropriate medication would be offered at the same time as behavioral interventions. 4.3. Step 3: In-depth assessment The third step involved a 5-page packet completed by patients who screened positive for depression on the PHQ-2 and PHQ-9. The packet, which was envisioned by Dr. Erb and created by the behavioral health team, identified history of behavioral health treatment, problems with sleep, obsessive compulsive disorder, eating disorders, psychosis, history of self-harm, family history of psychiatric disturbances, alcohol or other substance abuse, and the patient's support system. The results were used to clarify the diagnosis and help determine treatment options. Despite concerns that patients would resist doing extra paperwork, staff members observed that patients seemed to appreciate being asked about these areas of their lives. The BWH psychiatry department has since adopted the packet in its outpatient practice. 4.4. Step 4: Individualized care plan The final step of the South Huntington triage program was performed at the weekly behavioral health rounds, or “huddles,” attended by the social workers, the psychiatrist, a medical assistant scribe, and any other member of the care team who wished to join. At these rounds, the psychiatrist would discuss her recommendations for the patients she had seen that week. If a patient had been seen by a social worker, she or he would present the patient's management plan. The team also reviewed patients' self-assessments, along with their online medical records and labs. The team's goal was to identify which patients were treatable at South Huntington and which patients should be directed to their associated outpatient clinic, Brigham Psychiatric Specialties. For those treatable at South Huntington, the team would create a treatment plan that might include psycho-pharmaceutical options and recommendations for nonpharmacologic treatment. Once finalized, the plan would be immedi-
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Fig. 1 South Huntington's four-step process for behavioral health assessment and intervention (credit: L. Sullivan).
ately entered into the patient's EMR in order to inform all providers involved in the patient's care. Providers at South Huntington – social workers, psychiatrist, and PCPs alike – believed that their new system of behavioral healthcare delivery was a significant improvement over their previous process. With the new model of triaging, the psychiatrist was available to see patients on much shorter notice, and felt that her time was leveraged so that face-to-face consults happened only when PCPs were unable to handle the case. Similarly, she was pleased that patients with diagnoses beyond the limits of a PCP's purview were being referred immediately to psychiatrists at the Brigham Psychiatric Specialties. Other South Huntington providers described their satisfaction with treating depression by engaging patients in a comprehensive review of organic causes of depression such as sleep, nutrition, concomitant disease, and substance abuse before they recommended medication. For example, a social worker told the story of a patient who would have been prescribed antidepressants except that the behavioral health team discovered that she was not depressed but rather distraught about not having enough food to feed her grandchildren. One of South Huntington's founders, Dr. Asaf Bitton, spoke from the perspective of a primary care physician who has learned from working closely with social workers and psychiatrists to understand more nuanced diagnoses and approaches to common behavioral health issues: “Some issues are addressable, some not, but we approach all of them with more empathic understanding.”
5. Overcoming challenges If a diagnosis was not clear or if the treatment history suggested that more information was needed before a care plan could be created, the patient was scheduled to see the psychiatrist during her reserved hours. These visits were designed for consultation, not treatment. After meeting with the patient, the psychiatrist would discuss her recommendations with the patient's PCP, who would then collaborate with the care team to determine the treatment plan. When patients were resistant to receiving mental health care, there was a discussion among providers about how to address the patients' concerns. Recommendations were recorded in the patient's EMR and immediately messaged to all clinical providers involved in the case. The team would then present the plan to the patient; if the patient disagreed, the PCP would discuss other options with the behavioral health team until consensus was reached. To ensure that the plan was followed, the behavioral health team maintained a registry to track and coordinate their services to patients and to follow up on missed appointments.
6. Unresolved questions and lessons for the field In today's predominantly fee-for-service (FFS) environment, behavioral health integration faces a distinct reimbursement
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challenge. Certain integral functions of the behavioral health team – such as telephone calls – are not billable even though they are often more efficient than an in-person appointment that would be reimbursed. While the privilege of residing within a financially stable integrated delivery system alleviates many of these problems for South Huntington, it poses challenges for dissemination and widespread adoption. If global payment systems become more popular and new billing codes are introduced that acknowledge the role of behavioral health in primary care, mental health integration could become a more realistic possibility for primary care clinics in less integrated settings. For now, however, reimbursement constraints will likely limit the ability of many primary care practices to expand their behavioral health services. Another key limitation of the South Huntington model is that despite high demand, the clinic has been able to care for fewer patients than originally anticipated. The care team attributes this to the fact that South Huntington has attracted complex patients who challenge their ability to balance efficiency in a FFS system with quality of care. As one founder put it, “[South Huntington] is not an efficient practice. It's a great practice.” As metrics for evaluating efficiency are recalibrated during the transition from FFS to a global payment model, many of South Huntington's inefficiencies may become successes as patients' co-morbidities are better managed and therefore less costly. The South Huntington leadership team presented ideas about how to improve its current model of behavioral health integration, including hiring a psychologist to expand their ability to provide non-pharmacologic therapies to patients, identifying cognitive behavioral therapy programs for stress reduction and insomnia, and developing computer-based programs and resources to aid patients in self-care management. Another focus of the clinic would be to improve relationships with the broader medical neighborhood to streamline patient referrals to outpatient mental health services. For each intervention, the leadership needs to establish sound strategies for data collection, analysis, and evaluation of success and progress. South Huntington is developing systems to track data on treatment options, referral outcomes, and whether behavioral health huddles are impacting care. These quantitative assessments will provide opportunities for critical self-reflection and when appropriate, dissemination. The significant co-morbidity associated with mental illness suggests that physical health and behavioral health cannot be separated. Primary care providers are well positioned to screen for mental illness and, with appropriate support, triage patients for treatment. The South Huntington experience of behavioral health integration offers several key lessons that are broadly applicable. While South Huntington is unique in that it was a new clinic committed to innovation, its successes were born of its “adaptive reserve,” something that existing clinics can create through training in processes such as LEAN methodology and investment in hiring individuals who value innovation, reflection, and adaptation. To date, South Huntington has been generous in sharing its experience with interested clinics: it has hosted visits from primary care practitioners coming from other sites in Boston, as well as Utah, Oregon, and Singapore. Key lessons:
Hiring for roles instead of training can decrease costs of
implementation. Although nurses have traditionally managed patients with mental health needs in the primary care setting, South Huntington found that social workers could effectively fill, and exceed, this role at lower cost. A process for reflection, assessment, and adaptation is a critical component of successful innovation. South Huntington's culture of innovation fostered the development of its
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original attempt at behavioral health integration, but it was its commitment to reflection and adaptation that ultimately enabled the clinic to adjust when patient needs were different than anticipated. Innovations must adapt to the specific needs of the local community. Providers at South Huntington anticipated that their efforts in behavioral health integration would focus on training PCPs how to treat low-severity mental illness. Instead, they found that they were diagnosing new bipolar disorder, schizophrenia, and other mental illnesses that required psychiatric expertise. Innovations are most effective when they reflect the capabilities of local providers. The revised system for behavioral health care at South Huntington triaged patients according to the three treatment options that were readily available to them: a PCP trained in managing more straightforward mental illness, an on-site psychiatrist who provided assessment but not treatment, and higher-level psychiatric care at the clinic's associated academic medical center. By triaging to these three levels of care, the clinic was able to maximize the effectiveness of its on-site psychiatrist.
South Huntington was created on the premise that practice innovations are only effective in a culture that is open to adopting them thoughtfully and effectively. As a result of their commitment to applying this culture to improve behavioral health services, South Huntington's leadership and frontline staff appear to have shortened the gap between optimal behavioral healthcare and what a primary care clinic can reasonably provide. Although quantitative analyses are still pending, South Huntington's model suggests that it may be possible for PCPs and social workers to treat a significant portion of patients with behavioral health needs, redirect those whom they cannot, and, most importantly, know how to differentiate between them.
References 1. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch. Gen. Psychiatry. 1978;35:685–693. 2. Kessler RC, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry. 2005;62:593–602. 3. The Numbers Count: Mental Disorders in America. National Institue of Mental Health. At 〈http://www.nimh.nih.gov/health/publications/the-numbers-countmental-disorders-in-america/index.shtml〉. 4. Wang PS, et al. Twelve-month use of mental health services in the united states: results from the national comorbidity survey replication. Arch. Gen. Psychiatry. 2005;62:629–640. 5. Kessler RC, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N. Engl. J. Med.. 2005;352:2515–2523. 6. Cunningham PJ. Beyond parity: primary care physicians' perspectives on access to mental health care. Health Aff.. 2009;28:w490–w501. 7. Rosenblatt RA, Andrilla CA, Curtin T, Hart L. Shortages of medical personnel at community health centers: implications for planned expansion. J. Am. Med. Assoc.. 2006;295:1042–1049. 8. Appelbaum PS. The ‘Quiet’ crisis in mental health services. Health Aff.. 2003;22:110–116. 9. Olfson M, Kroenke K, Wang S, Blanco C. Trends in office-based mental health care provided by psychiatrists and primary care physicians. J. Clin. Psychiatry. 2014;75:247–253. 10. Watson L, et al. Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting. Agency for Healthcare Research and Quality (US); 2012. At 〈http://www.ncbi.nlm.nih.gov/books/ NBK100652/〉. 11. Johnson JA, et al. Controlled trial of a collaborative primary care team model for patients with diabetes and depression: rationale and design for a comprehensive evaluation. BMC Health Serv. Res.. 2012;12:258. 12. Hert MD, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10:52. 13. De Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: a meta-analysis. Psychosom. Med.. 2001;63:619–630.
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14. Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch. Intern. Med.. 2000;160:3278–3285. 15. Gallo JJ, et al. Long term effect of depression care management on mortality in older adults: follow-up of cluster randomized clinical trial in primary care. Br. Med. J.. 2013;346:f2570. 16. Collins Chris, Levis Hewson Denise, Munger Richard , Wade Torlen. Evolving Models of Behavioral Health Integration in Primary Care. Milbank Memorial Fund; 2010. At 〈http://www.milbank.org/uploads/documents/10430Evolving Care/EvolvingCare.pdf〉. 17. Dea RA. The integration of primary care and behavioral healthcare in Northern California Kaiser-Permanente. Psychiatr. Q.. 2000;71:17. 18. Butler M, et al. Integration of mental health/substance abuse and primary care. Evid. Rep./Technol. Assess.. 2008;173:1–362. 19. Melek Stephen P, Norris Douglas T, Paulus Jordan. Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry. Milliman, Inc.; 2014. 20. Miller BF, Petterson S, Burke BT, Phillips RLJ, Green LA. Proximity of providers: colocating behavioral health and primary care and the prospects for an integrated workforce. Am. Psychol.. 2014;69:443–451. 21. SAMHSA-HRSA Center for Integrated Health Solutions. Advancing Behavioral Health Integration within NCQA Recognized Patient-Centered Medical Homes;
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2014. At 〈http://www.integration.samhsa.gov/integrated-care-models/Beha vioral_Health_Integration_and_the_Patient_Centered_Medical_Home_FINAL. pdf〉. NCQA Recognition Directory. Clinician Search Results. At 〈http://recognition.ncqa.org/ PSearchResults.aspx?first=&last=&city=&zip=&org=brigham&state=MA&rp=6〉. University of Washington. IMPACT: Evidence-Based Depression Care. At 〈http:// impact-uw.org〉. Intermountain Healthcare. Behavioral Health Clinical Program. At 〈http://inter mountainhealthcare.org/about/overview/trustees/fortrustees/orientation/qual ityfocus/Pages/behavioralhealthclinicalprogram.aspx〉. Patient Health Questionnaire (PHQ-9 & PHQ-2). At 〈http://www.apa.org/pi/ about/publications/caregivers/practice-settings/assessment/tools/patienthealth.aspx〉. Bush K, et al. The audit alcohol consumption questions (audit-c): an effective brief screening test for problem drinking. Arch. Intern. Med.. 1998;158: 1789–1795. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch. Intern. Med.. 2006;166: 1092–1097.
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Into Practice
Behavioral health integration in primary care at Brigham and Women's Advanced Primary Care Associates, South Huntington Katherine Majzoub Perez a,n,1, Lydia Flier a,1, Helen D’Couto a, Meghan Rudder a, Anjali Thakker a, John Weems a, Leah Wibecan a, Zirui Song b, Asaf Bitton c, Jane Erb d, Stuart Pollack e, David Silbersweig f, Lara Sullivan g, Joseph Frolkis e,2 a
Harvard Medical School, USA Department of Medicine, Massachusetts General Hospital and Harvard Medical School, USA c Division of General Medicine, Brigham and Women's Hospital and Department of Health Policy and Center for Primary Care, Harvard Medical School, USA d Brigham Depression Center, Brigham and Women's Hospital and Harvard Medical School, USA e Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, USA f Department of Psychiatry, Brigham and Women's Hospital and Harvard Medical School, USA g Brigham and Women's Hospital, USA b
art ic l e i nf o
a b s t r a c t
Article history: Received 19 November 2013 Received in revised form 4 April 2015 Accepted 8 April 2015 Available online 20 June 2015
Of the many problems facing the US healthcare system, the shortage of behavioral health providers in outpatient settings is particularly profound. To address this issue, Boston's Brigham and Women's Hospital identified ways to incorporate behavioral health into primary care when it opened the South Huntington Primary Care clinic in August 2011. When the needs of its patients were more complex than anticipated, the clinic created assessment tools and refined care processes to identify, triage, and monitor patients with mental illness. Key insights from the South Huntington experience include:
Keywords: Mental health Primary care Behavioral health integration Medical home Team-based care Culture
Hiring for roles instead of training can decrease costs of implementation. A process for reflection, assessment, and adaptation is a critical component of innovation. Innovations must adapt to the specific needs of the local community. Innovations are most effective when they reflect the capabilities of local providers. & 2015 Elsevier Inc. All rights reserved.
1. Background The shortage of outpatient mental health services in the US has been a significant concern for over 30 years.1 According to the National Institute of Mental health, 26.8% of Americans over the age of 18 have a diagnosable mental health disorder and the US lifetime prevalence of having a psychiatric disorder is 47%.2 Anxiety disorders, major depressive disorder (the most frequent cause of disability in people between the ages of 15 and 44), and bipolar disorder are among the most common mental health diagnoses.3 Recently it has been estimated that less than one-third of Americans with a mental health problem are receiving adequate treatment.4,5 In a national survey conducted from 2004–2005, two-thirds
n Correspondence to: 260 Longwood Avenue, Holmes Society, 2nd floor, Boston, MA 02115, USA. E-mail address: [email protected] (K. Majzoub Perez). 1 Co-first authors. 2 Senior author.
http://dx.doi.org/10.1016/j.hjdsi.2015.04.002 2213-0764/& 2015 Elsevier Inc. All rights reserved.
of primary care physicians (PCPs) reported that their patients could not access adequate outpatient mental health services, primarily due to a lack of behavioral health providers.6 Similarly, a national survey of community health centers in 2006 found that there were vacancies for 22.6% of psychiatrist positions, more than any other position at health centers.7 One reason for the shortage of outpatient mental health services and psychiatrists in particular is inadequate reimbursement for behavioral health.8 As a result of this workforce shortage, PCPs are increasingly responsible for their patients' mental health needs, a job for which they have little systematic training. Recent data suggest that over a 15-year span between 1995 and 2010, PCP visits that involved prescriptions for antidepressants, antipsychotics and anxiolytics increased more than psychiatrist visits that involved such prescriptions.9 While neglecting mental health has serious implications in regard to treatment, its impacts on co-morbid chronic illnesses and subsequent health care costs are also significant.10,11 Patients with severe mental illness are two to three times more likely to have
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cardiovascular disease than are patients without mental illness.12 Similarly, diabetic patients with co-morbid depression have been found to have higher HbA1c levels and consequent complications such as diabetic retinopathy, nephropathy, and neuropathy than diabetic patients without depression.13 In addition, greater severity of depression in diabetic patients has been associated with poorer adherence to oral medications and overall physical and mental functioning.14 Research also suggests that treating mental illness can have positive impacts on the outcomes of co-morbidities. In one study, patients with major depression who received enhanced mental health services had 24% lower mortality than those receiving standard care over a two-year period.15 The shortage of mental health services in the United States is therefore a problem not just for the treatment of mental illness, but also for the management of many chronic conditions. Federal programs such as the Veterans Health Administration were among the first to adopt an integrated model of behavioral health care in the United States.16 Health maintenance organizations such as Kaiser Permanente followed suit.17 Other early leaders in the field of behavioral health integration were Intermountain Health Care in Utah and Idaho, Tennessee Cherokee Health, the DIAMOND project in Minnesota, and McMaster University.16,18 In one such case, Intermountain Health Care developed a protocol to assess whether a patient's mental illness required “low care,” “moderate care,” or “high care.” While low care patients were treated by physicians with support from a care manager, moderate care patients received consultations from an on-site psychiatrist, and high care patients were referred to external mental health specialists.16 In another example, the DIAMOND (Depression Improvement Across Minnesota – Offering a New Direction) program employed the Hartford Foundation's IMPACT model for depression care and was funded by bundled payments. The program offered patients opportunities for ongoing mental health assessments, a patient registry that facilitated teambased care, and consultations with psychiatrists.16 A 2014 report produced by the Millbank Memorial Fund at the request of the American Psychiatric Association analyzed the potential economic impact of integrating behavioral and medical health care. It predicted that the widespread integration of behavioral and medical care could save $26–48 billion in health care costs annually.19 These projected savings were attributed to patients' decreased use of emergency rooms and other hospital facilities, as well as their ability to better manage concomitant chronic medical conditions. While a study published in May 2014 found that 43% of primary care physicians in the US are co-located with a behavioral health provider, it is unclear if this physical proximity results in integration and collaboration of services.20 Regardless, there has been increased attention to behavioral health integration on a national level. In 2014, the Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) co-produced a white paper exploring how behavioral health integration would be applied to National Committee for Quality Assurance (NCQA) recognized PatientCentered Medical Homes (PCMHs).21 While the report emphasized that behavioral health integration is not a current requirement for PCMH recognition, it is possible to imagine such a scenario in the future. Aware of these models and concerned about the shortage of outpatient mental health providers, leaders in primary care and psychiatry at Brigham and Women's Hospital (BWH) in Boston identified behavioral health integration as a priority for the hospital's new primary care clinic, Advanced Primary Care Associates, South Huntington.
2. Organizational context The South Huntington clinic, which opened in August 2011, was designed to be a PCMH and received its Level 3 PCMH certification from the NCQA in April 2014.22 Its staff was organized into three care teams, each with one or two attending physicians, one or two residents, a nurse, a social worker, a physician assistant, and two medical assistants, operating in conjunction with a staff pharmacist, a RN care manager, a community resource specialist, and a nutritionist. Behavioral health integration at South Huntington was centered on the involvement of three types of medical personnel: a psychiatrist, trained PCPs and social workers. The part-time psychiatrist, Jane Erb, MD, was also the Medical Director of the Depression Center at BWH. The Department of Psychiatry supported her to spend four hours per week at South Huntington. Dr. Erb used half of these on-site hours to clinically evaluate, but not treat, complicated cases of mental illness. The remaining two hours at South Huntington were spent educating PCPs and social workers about behavioral health management, who then in turn managed less severe cases of mental illness. While PCPs often refer patients to a psychiatrist in the initial stages of mental health management, the South Huntington behavioral health integration team hypothesized that PCPs could provide more care if they were appropriately educated and coached. Expanding the role of PCPs in the management of behavioral health would allow the staff psychiatrist to see the most challenging cases, thereby significantly increasing South Huntington's capacity for providing these services. South Huntington followed the successful examples of many health care organizations when its leadership decided to hire and train social workers as behavioral health specialists.17,18 Although social workers had been involved with behavioral health care at other BWH clinics, those at South Huntington would have responsibilities that were traditionally managed by nurses in the BWH system, including assessing patients' behavioral health needs and directly providing behavioral health interventions. The leaders of South Huntington were confident that social workers would be suitable for these positions due to social workers' long history of involvement in primary care at BWH, knowledge of clinical care management, and familiarity working with patients' behavioral health issues. Because social workers would receive a lower hourly wage than the nurses who traditionally filled these roles, there was also an economic argument for this shift in responsibilities. Notably, the clinic hired a Community Resource Specialist to relieve the social workers of some of their traditional referral responsibilities such as connecting patients with legal aid and housing advocacy in anticipation of the impact of this expanded role on social workers' time.
3. Problem: The unexpected severity of patients' mental health needs Soon after integrating behavioral health into its primary care workflow, South Huntington found that its new patient population was more behaviorally complex and growing more rapidly than predicted. Many of these patients had been uninsured prior to the expansion of public insurance in Massachusetts that began in 2007, and therefore had multiple unmanaged medical problems. The staff at South Huntington had anticipated that they would be screening patients mainly for depression; instead, they were diagnosing patients with personality disorders, psychotic disorders, and bipolar disorders. Many of these patients had significant co-morbidities as well as mental illness, and had been referred directly from the inpatient floors of BWH. In addition, patients coming to South Huntington from
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the community were younger and sicker than predicted, e.g., presenting with new onset bipolar disorder and schizophrenia that South Huntington was not prepared to manage. Of the older patients with mental health needs, many were in crisis, having been without care for several years. South Huntington calculated that 27% of the clinic's population formally interacted with a member of the behavioral health team within the first year of its opening. According to South Huntington's Medical Director Dr. Stuart Pollack, this influx of patients with serious mental illness but without an established primary care physician was a symptom of a system with universal insurance coverage but insufficient access to health care services. South Huntington was identifying patients whose significant mental illnesses had previously impeded their ability to find the psychiatric services they needed. These patients were recognized at South Huntington because, unlike at most primary care clinics, clinicians were actively screening for behavioral health disorders, since they had access to social workers and a psychiatrist. Soon after opening, Dr. Erb's two referral hours per week were filled with complex cases, and her schedule had no availability for months. PCPs directly referred patients to her, and sometimes a patient would specifically request to see a psychiatrist. Social workers were also in high demand and staff members were soon requesting that the clinic's leadership hire more social workers, not more doctors. Six months after opening, the leadership team at South Huntington began discussing the need to restructure behavioral health services. One solution was to establish an expectation with BWH that South Huntington would only take five new inpatient referrals per week. This was helpful but insufficient: South Huntington needed a strategy to care for the complex behavioral health patients from the community who were presenting to the clinic.
4. Solution: Create new systems to triage mental illness In designing South Huntington, the founders had anticipated the need for self-evaluation and adaptation. From hiring staff that expressed an interest in teamwork and innovation, to a 9-day, preopening orientation for all staff that focused on motivational interviewing and the LEAN model of quality improvement, South Huntington's founders had prepared their team for rapid innovation and frequent collaboration. Examples of their intentional steps toward this culture included offices shared by whole teams, weekly all-staff meetings, and avoiding the habit of referring to staff in the possessive (i.e., “my medical assistant”). By April 2012, eight months after the clinic's opening, South Huntington was applying this culture of innovation to develop a new system of behavioral health integration. The team started by adapting and personalizing existing behavioral health integration tools, including some from the IMPACT model23 and Intermountain Health's behavioral health screening tool.24 When existing resources did not meet their needs, the team developed new materials. The result was a four-step process that included enhanced screening, employing social workers as clinicians as well as coordinators, increasing the breadth of differential assessment, and tracking patients in the electronic medical record (EMR) (Fig. 1). In the same way that teams at South Huntington huddled to discuss the identification and treatment of high blood pressure, the psychiatrist, social workers, and any other member of the care team who wished to attend would huddle on a weekly basis to discuss how to identify and treat patients with behavioral health needs.
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4.1. Step 1: Universal pre-screening and assessment The first step of the screening process used the PHQ-2 (and further tools, such as PHQ-9, AUDIT, and GAD-7 as indicated) to identify patients with mood disorders (for more information on these screening tools, see Patient Centered Health Questionnaire25, Bush et al. 26, Spitzer et al.27). 4.2. Step 2: Immediate intervention The second step was designed to discourage PCPs from prescribing a medication as soon as they identified a condition such as depression. Instead, the new protocol provided patients with less severe mental illnesses coaching and self-care strategies before offering medication. PCPs would often manage these cases independently, providing recommendations and motivational coaching when indicated. If a more intense treatment was needed, the provider would initiate a “warm handoff” to a social worker, who would follow up with supportive counseling, short behavioral health interventions such as Cognitive Behavioral Therapy, motivational counseling, and crisis intervention. The social worker would also initiate referrals for intensive treatment and emergency psychiatric evaluations, as needed. Once care had commenced, social workers would continue to monitor patients' behavioral health needs and alert the team when more intervention, including referral to outside providers, was indicated. In the most severe illnesses, such as when a patient's symptoms were interfering with basic functioning, appropriate medication would be offered at the same time as behavioral interventions. 4.3. Step 3: In-depth assessment The third step involved a 5-page packet completed by patients who screened positive for depression on the PHQ-2 and PHQ-9. The packet, which was envisioned by Dr. Erb and created by the behavioral health team, identified history of behavioral health treatment, problems with sleep, obsessive compulsive disorder, eating disorders, psychosis, history of self-harm, family history of psychiatric disturbances, alcohol or other substance abuse, and the patient's support system. The results were used to clarify the diagnosis and help determine treatment options. Despite concerns that patients would resist doing extra paperwork, staff members observed that patients seemed to appreciate being asked about these areas of their lives. The BWH psychiatry department has since adopted the packet in its outpatient practice. 4.4. Step 4: Individualized care plan The final step of the South Huntington triage program was performed at the weekly behavioral health rounds, or “huddles,” attended by the social workers, the psychiatrist, a medical assistant scribe, and any other member of the care team who wished to join. At these rounds, the psychiatrist would discuss her recommendations for the patients she had seen that week. If a patient had been seen by a social worker, she or he would present the patient's management plan. The team also reviewed patients' self-assessments, along with their online medical records and labs. The team's goal was to identify which patients were treatable at South Huntington and which patients should be directed to their associated outpatient clinic, Brigham Psychiatric Specialties. For those treatable at South Huntington, the team would create a treatment plan that might include psycho-pharmaceutical options and recommendations for nonpharmacologic treatment. Once finalized, the plan would be immedi-
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Fig. 1 South Huntington's four-step process for behavioral health assessment and intervention (credit: L. Sullivan).
ately entered into the patient's EMR in order to inform all providers involved in the patient's care. Providers at South Huntington – social workers, psychiatrist, and PCPs alike – believed that their new system of behavioral healthcare delivery was a significant improvement over their previous process. With the new model of triaging, the psychiatrist was available to see patients on much shorter notice, and felt that her time was leveraged so that face-to-face consults happened only when PCPs were unable to handle the case. Similarly, she was pleased that patients with diagnoses beyond the limits of a PCP's purview were being referred immediately to psychiatrists at the Brigham Psychiatric Specialties. Other South Huntington providers described their satisfaction with treating depression by engaging patients in a comprehensive review of organic causes of depression such as sleep, nutrition, concomitant disease, and substance abuse before they recommended medication. For example, a social worker told the story of a patient who would have been prescribed antidepressants except that the behavioral health team discovered that she was not depressed but rather distraught about not having enough food to feed her grandchildren. One of South Huntington's founders, Dr. Asaf Bitton, spoke from the perspective of a primary care physician who has learned from working closely with social workers and psychiatrists to understand more nuanced diagnoses and approaches to common behavioral health issues: “Some issues are addressable, some not, but we approach all of them with more empathic understanding.”
5. Overcoming challenges If a diagnosis was not clear or if the treatment history suggested that more information was needed before a care plan could be created, the patient was scheduled to see the psychiatrist during her reserved hours. These visits were designed for consultation, not treatment. After meeting with the patient, the psychiatrist would discuss her recommendations with the patient's PCP, who would then collaborate with the care team to determine the treatment plan. When patients were resistant to receiving mental health care, there was a discussion among providers about how to address the patients' concerns. Recommendations were recorded in the patient's EMR and immediately messaged to all clinical providers involved in the case. The team would then present the plan to the patient; if the patient disagreed, the PCP would discuss other options with the behavioral health team until consensus was reached. To ensure that the plan was followed, the behavioral health team maintained a registry to track and coordinate their services to patients and to follow up on missed appointments.
6. Unresolved questions and lessons for the field In today's predominantly fee-for-service (FFS) environment, behavioral health integration faces a distinct reimbursement
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challenge. Certain integral functions of the behavioral health team – such as telephone calls – are not billable even though they are often more efficient than an in-person appointment that would be reimbursed. While the privilege of residing within a financially stable integrated delivery system alleviates many of these problems for South Huntington, it poses challenges for dissemination and widespread adoption. If global payment systems become more popular and new billing codes are introduced that acknowledge the role of behavioral health in primary care, mental health integration could become a more realistic possibility for primary care clinics in less integrated settings. For now, however, reimbursement constraints will likely limit the ability of many primary care practices to expand their behavioral health services. Another key limitation of the South Huntington model is that despite high demand, the clinic has been able to care for fewer patients than originally anticipated. The care team attributes this to the fact that South Huntington has attracted complex patients who challenge their ability to balance efficiency in a FFS system with quality of care. As one founder put it, “[South Huntington] is not an efficient practice. It's a great practice.” As metrics for evaluating efficiency are recalibrated during the transition from FFS to a global payment model, many of South Huntington's inefficiencies may become successes as patients' co-morbidities are better managed and therefore less costly. The South Huntington leadership team presented ideas about how to improve its current model of behavioral health integration, including hiring a psychologist to expand their ability to provide non-pharmacologic therapies to patients, identifying cognitive behavioral therapy programs for stress reduction and insomnia, and developing computer-based programs and resources to aid patients in self-care management. Another focus of the clinic would be to improve relationships with the broader medical neighborhood to streamline patient referrals to outpatient mental health services. For each intervention, the leadership needs to establish sound strategies for data collection, analysis, and evaluation of success and progress. South Huntington is developing systems to track data on treatment options, referral outcomes, and whether behavioral health huddles are impacting care. These quantitative assessments will provide opportunities for critical self-reflection and when appropriate, dissemination. The significant co-morbidity associated with mental illness suggests that physical health and behavioral health cannot be separated. Primary care providers are well positioned to screen for mental illness and, with appropriate support, triage patients for treatment. The South Huntington experience of behavioral health integration offers several key lessons that are broadly applicable. While South Huntington is unique in that it was a new clinic committed to innovation, its successes were born of its “adaptive reserve,” something that existing clinics can create through training in processes such as LEAN methodology and investment in hiring individuals who value innovation, reflection, and adaptation. To date, South Huntington has been generous in sharing its experience with interested clinics: it has hosted visits from primary care practitioners coming from other sites in Boston, as well as Utah, Oregon, and Singapore. Key lessons:
Hiring for roles instead of training can decrease costs of
implementation. Although nurses have traditionally managed patients with mental health needs in the primary care setting, South Huntington found that social workers could effectively fill, and exceed, this role at lower cost. A process for reflection, assessment, and adaptation is a critical component of successful innovation. South Huntington's culture of innovation fostered the development of its
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original attempt at behavioral health integration, but it was its commitment to reflection and adaptation that ultimately enabled the clinic to adjust when patient needs were different than anticipated. Innovations must adapt to the specific needs of the local community. Providers at South Huntington anticipated that their efforts in behavioral health integration would focus on training PCPs how to treat low-severity mental illness. Instead, they found that they were diagnosing new bipolar disorder, schizophrenia, and other mental illnesses that required psychiatric expertise. Innovations are most effective when they reflect the capabilities of local providers. The revised system for behavioral health care at South Huntington triaged patients according to the three treatment options that were readily available to them: a PCP trained in managing more straightforward mental illness, an on-site psychiatrist who provided assessment but not treatment, and higher-level psychiatric care at the clinic's associated academic medical center. By triaging to these three levels of care, the clinic was able to maximize the effectiveness of its on-site psychiatrist.
South Huntington was created on the premise that practice innovations are only effective in a culture that is open to adopting them thoughtfully and effectively. As a result of their commitment to applying this culture to improve behavioral health services, South Huntington's leadership and frontline staff appear to have shortened the gap between optimal behavioral healthcare and what a primary care clinic can reasonably provide. Although quantitative analyses are still pending, South Huntington's model suggests that it may be possible for PCPs and social workers to treat a significant portion of patients with behavioral health needs, redirect those whom they cannot, and, most importantly, know how to differentiate between them.
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