Mind and body
Learning best practices from the three winners of TAFP’s Behavioral Health Integration Innovators Competition
By Jonathan Nelson
Family physicians know all too well how difficult depression can be for patients. According to the Centers for Disease Control, almost 8% of Americans ages 12 and older are estimated to suffer from depression for at least two weeks each year. Only a fraction of those receive any treatment and often the treatment is inadequate. For patients with one or more chronic conditions, depression just makes things worse.
Patients with diabetes and depression have a 50% higher mortality rate, a 30% higher likelihood of losing a limb, and significantly worse glucose control than patients with diabetes alone. Their medical costs are much higher, too. Medical expenditures for patients with diabetes and depression are more than four times higher than for patients with diabetes alone.
Behavioral health conditions like depression pose particularly frustrating problems for busy primary care physicians trying to provide the best care for their patients. David Bauer, MD, PhD, is the director of the Memorial Family Medicine Residency Program in Sugar Land, Texas, one of the winning clinics in TAFP’s Behavioral Health Integration Innovators Competition. He says behavioral health and physical health are inescapably intertwined, each affecting the other, yet medicine has traditionally separated the two.
“The question has always been, well, yeah, we know [depression] is there, but what do we do with it? Are we really trained to recognize it? Are we trained to manage it? Do we have the time to manage it?”
In the traditional model when a patient tells a family doctor they’re depressed, the physician either starts the patient on an antidepressant or refers the patient to a therapist, he says. “Then you never hear anything back and 50% of the time, they don’t even go.”
Lack of adherence to medication directions and the stigma patients may feel about seeing a therapist are major barriers to behavioral health treatment. In many communities, access to psychiatric services for referrals doesn’t even exist. Many primary care clinics around the country have found success by integrating behavioral health services into their practices and there are some excellent models and resources out there to help physicians who want to give it a try.
Basic components of a collaborative care model
Integrating behavioral health services into a primary care practice generally means bringing care managers or behavioral health consultants into the clinic to provide counseling and enhanced patient engagement. In 2017, the Centers for Medicare and Medicaid Services introduced a set of CPT codes to pay for behavioral health services in primary care through the Psychiatric Collaborative Care Model. The guidelines and requirements to use those codes constitute a good checklist for integrating behavioral health.
The Psychiatric Collaborative Care Model includes a care team consisting of:
- a treating physician or other practitioner who will bill for services;
- a behavioral health care manager who has training in social work, nursing, or psychology; and
- a psychiatric consultant who is not required to be on site.
The service components of the model include:
- an initial assessment by the physician and the health care manager complete with the administration of a validated rating scale, like the PHQ-9 (Patient Health Questionnaire) or GAD-7 (Generalized Anxiety Disorder);
- care planning by the care team and the patient, with revisions to the plan if the patient isn’t improving adequately;
- proactive and systematic follow-up by the behavioral health care manager with the patient using validated rating scales and a registry; and
- case reviews with the psychiatric consultant occurring at least weekly.
The process is more complex than this brief overview but these are the main components of the model. The Medicare Learning Network offers a booklet entitled “Behavioral Health Integration Services” that provides more detail on the roles of the care team members, the requirements of the services, and how to use the codes to bill for the monthly behavioral health fee.
Behavioral Health Integration Innovators Competition
Last year TAFP put out a call to Texas primary care practices asking them to submit their models of behavioral health integration for the chance to win $10,000. Entries were judged by the TAFP Behavioral Health Task Force, which was appointed after the Academy identified the need for greater integration of behavioral health services in primary care as a top priority in its strategic plan.
The task force members selected winners in each of three care settings: academic settings, integrated health systems, and solo and small group practices. Thirty practices entered the contest. The winners were the Memorial Hermann Medical Group Physicians at Sugar Creek and Memorial Family Medicine Residency Program of Sugar Land in the academic setting category, the Heart of Texas Community Health Center of Waco in the integrated health systems category, and the Hope Clinic of McKinney in the small group and solo practice category.
The task force also developed TAFP’s new Behavioral Health Integration Toolkit to help members provide these services to their patients. Access the toolkit at www.tafp.org.
Winner in the Academic Setting Category:
Memorial Hermann Medical Group Physicians at Sugar Creek and Memorial Family Medicine Residency Program
The Memorial Hermann Medical Group Physicians at Sugar Creek has been providing integrated behavioral health services to their patients through a collaborative care model since 2009. Their collaborative care team includes more than 50 primary care physicians ... Read more
Winner in the Integrated System Category:
Heart of Texas Community Health Center
Heart of Texas Community Health Center has developed a behavioral health program they call Integrated Health Management, which they employ to care for their 59,000 active patients in Central Texas. Headquartered in Waco, HOTCHC is a federally qualified health center with 14 clinical sites ... Read more
Winner in the Small Group and Solo Practice Category:
Hope Clinic of McKinney
Almost four years ago, a pastor in McKinney, Texas, came upon a man lying in a ditch. The man was experiencing homelessness and had mental health problems, along with other chronic health conditions. The pastor wanted to help but, in that moment, he couldn’t find any health resources aside from an emergency room ... Read more