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Strategies for Integrating Behavioral Health and Primary Care

Key Questions Mar 17, 2022
Doctor having a conversation with specialist

Draft Key Questions

  1. What are the available strategies for integrating behavioral health and primary care for children and adults with behavioral health needs.
    1. How do these strategies vary by (i) clinical focus/conditions, (ii) core components of care delivery, (iii) setting/practice type, (iv) mechanisms of care integration, (v) resources required (e.g., staff training), and (vi) business models?
  2. What is the effectiveness reported in studies of different strategies for integrating behavioral health and primary care for children and adults with behavioral health needs?
    1. Does the effectiveness of different integration strategies vary by (i) clinical focus/conditions/ patient subgroups, (ii) settings/practice type, (iii) other contexts (e.g., different payment reimbursement models), and harms?
  3. Contextual Question.  What are the barriers and facilitators to implementing and maintaining different care integration strategies? Are any of these strategies synergistic with one another?
  4. Contextual Question.  What are the best outcome metrics to monitor and evaluate care integration? Should different metrics be used as care integration matures over time? How frequently should these outcome metrics be measured?
  5. Contextual Question.  How do different care integration strategies define (or redefine) care team member roles? What training interventions may be required to facilitate integrated care team functioning?

Background

Fifty-nine million Americans, or approximately one in five adults, experienced mental illness and 17 million had a co-occurring substance use disorder in 2020. However only 46% of those struggling with these problems, cumulatively referred to as behavioral health conditions, received treatment, according to the same 2020 statistics.1 Behavioral health conditions are associated with significant morbidity and mortality. People with common mental health conditions, such as depression, are nearly twice as likely to develop cardiovascular and metabolic diseases. Behavioral health diagnoses account for one in every eight emergency department visits in the United States and are the most common cause of hospitalization for Americans under the age of 45.2 People with mental illness also face higher rates of unemployment and are more likely to experience homelessness and incarceration.

Despite these concerning statistics, behavioral health conditions are significantly undertreated in the United States. Nearly two thirds of people experiencing depression and other common mental health conditions and approximately one third of individuals with serious mental illness such as bipolar disorder and schizophrenia are treated exclusively in primary care settings. Although primary care clinicians provide the majority of mental health care for these patients, only approximately 3% of all primary care encounters are coded for primary diagnoses of depression and anxiety compared to over 40% of psychiatrists' visits.3

The historic segregation of mental health and addiction treatment and primary care has long been recognized as an important driver of the undertreatment of behavioral health conditions. As a result, numerous models for integrating general medical and behavioral health services, known as integrated care, have been proposed in recent years. While many integrated care models were shown to be effective in clinical trials, few have been widely implemented in clinical practice, largely due to difficulties with financing and a lack of certainty regarding which strategies are most appropriate for different practice settings.4 A review of the literature would characterize the existing integrated care strategies and help elucidate which practice settings and which patient populations may benefit the most from different strategies. The goal of the proposed review would be to provide healthcare systems and independent clinical practices seeking to implement integrated care services with practical guidance on selection, implementation, and ongoing assessment of integrated care within their organizations.

Draft Analytic Framework

Figure 1. Draft analytic framework for Strategies for Integrating Behavioral Health and Primary Care.

Figure 1: This figure depicts the key questions within the context of the PICOTS described below. In general, the figure illustrates how primary care practice implementation of strategies to integrate behavioral health and primary care may result in final outcomes such as health outcomes, patient satisfaction, clinician satisfaction, care utilization and process, and care access. The effectiveness of the strategies may be affected by model/patient/practice characteristics, barriers and facilitators, and team roles.  There may also be harms such as unintended consequences, including misallocation of effort, delays in care, etc.

Table 1. Questions and PICOS (population, intervention, comparator, outcome, and setting)

Population

Children (aged 0-21 years) and adults (aged ≥21 years) with behavioral health needs (e.g., diagnosed or suspected mental health conditions, SUDs, or unhealthy behaviors, stress-related physical symptoms, etc.)

Clinical focus/conditions:

  • Patients with severe mental illness
  • Patients with one or more common mental health conditions or SUDs
  • Patients with stress-linked physical symptoms (e.g., insomnia, fatigue)
  • Patients with one or more chronic medical conditions
  • Complex patients with overlapping medical conditions and psychosocial factors
  • Children with adverse childhood experiences

Intervention

Different strategies for integrating behavioral health and primary care services, with strategies being defined as both program/model components and approaches to care integration.
Examples of eligible programs/models for care integration include: Collaborative Care Model, Screening, Brief Intervention and Referral to Treatment (SBIRT) model, Chronic Care Management models, behavioral health, and primary care co-location models

Comparator

Care as usual (e.g., non-integrated behavioral health and primary care services) or use of alternative care integration strategy or strategies

Outcomes

Outcomes of interest will include, but are not limited to the following:

Health outcomes:

  • Morbidity
  • Mortality
  • Proportion of patients with improved symptoms
  • Proportion of patients who received guideline concordant screening and diagnosis
  • Proportion of patients who achieved remission/recovery at 6 or 12 months
  • Proportion of patients who are adherent to treatment

Patient satisfaction:

  • Health related quality of life
  • Functional status (including social and adaptive functioning)
  • Satisfaction with care

Clinician satisfaction

  • Clinician retention/burnout/turnover rates
  • Clinician quality of life
  • Clinician professional satisfaction

Care utilization and process:

  • Rates of emergency care utilization for behavioral health crises
  • Total care utilization rates
  • Efficiency of clinician time use

Care access:

  • Proportion of patients who report they can receive routine care as soon as they wanted (always, usually, sometimes/never)
  • Proportion of patients who report they can receive acute care as soon as they wanted (always, usually, sometimes/never)
  • Average wait time to be seen by clinician
  • Proportion of patient experiencing difficulties or delays in obtaining care
  • Proportion of patients with mental health conditions who received treatment
  • Proportion of patients with SUDs who received treatment

Population/community/clinic panel health outcomes:

  • Preventive care measures
  • Proportion of patients that received recommended screening services
  • Proportion of patients that received recommended immunizations

Care cost outcomes:

  • Cost per patient per year
  • Cost per service
  • Costs associated with care delays, fragmentation, poor coordination, redundancy, requested but not completed patient referrals

Harms (e.g.,unintended consequences, including misallocation of effort, delays in care etc.)

Setting

Health systems/hospitals and community-based primary care practices in the United States, inpatient and outpatient settings

References

  1. Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. (HHS Publication No PEP21-07-01-003, NSDUH Series H-56) Rockville, MD: Center for Behavioral Health Statistics and Quality; Substance Abuse and Mental Health Services Administration Retrieved from https://www.samhsa.gov/data/
  2. Firth J, Siddiqi N, Koyanagi A, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry. 2019 Aug;6(8):675-712. doi: https://doi.org/10.1016/s2215-0366(19)30132-4. PMID: 31324560
  3. Ramanuj P, Ferenchik E, Docherty M, et al. Evolving Models of Integrated Behavioral Health and Primary Care. Curr Psychiatry Rep. 2019 Jan 19;21(1):4. doi: https://doi.org/10.1007/s11920-019-0985-4. PMID: 30661126
  4. McGinty E, Daumit G. Integrating Mental Health and Addiction Treatment Into General Medical Care: The Role of Policy. Psychiatr Serv. 2020 Nov 1;71(11):1163-9. doi: https://doi.org/10.1176/appi.ps.202000183. PMID: 32487007

Project Timeline

Strategies for Integrating Behavioral Health and Primary Care

Mar 16, 2022
Topic Initiated
Mar 17, 2022
Key Questions
Page last reviewed March 2022
Page originally created March 2022

Internet Citation: Key Questions: Strategies for Integrating Behavioral Health and Primary Care. Content last reviewed March 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/strategies-integrating-behavioral-health/draft-comments

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