March 15, 2016

Integrating behavioral health into primary care: The time has come



Dr. Ed Wagner offers guidance for care teams as they begin to treat mental health, substance abuse, and behavioral disorders

By Ed Wagner, MD, MPH, director emeritus of Group Health Research Institute’s MacColl Center for Health Care Innovation.

The patient-centered medical home (PCMH) transformation in America has inspired a re-examination of an old defining characteristic of primary care: comprehensiveness. Historically, comprehensiveness meant that primary care should have the capability to diagnose and treat the common illnesses that occur among the population that it serves. We now know that common in almost every population are mental health issues, substance abuse, and behavioral disorders. There’s now an expectation that primary care should be able to manage a significant percentage of patients that suffer from mental health issues. I think that it’s now clear that behavioral integration has to be considered part and parcel of comprehensive primary care.

One of the great frustrations about practicing primary care historically has been the inability to address common psychiatric issues in a meaningful, concerted way. From the perspective of a typical patient suffering with a mental health condition, primary care was supposed to be the place they went first. Discovering that primary care not only wasn’t equipped to deal with these conditions but also wasn’t especially welcoming was frustrating and very unpleasant for patients.

Change is underway

The good news is that this is all changing. Here at Group Health, an initiative is underway to integrate behavioral health into routine primary care, and researchers from Group Health Research Institute (GHRI) are studying important aspects of that effort. Practices nationwide also have a lot of advice on how to go about doing this. GHRI in partnership with the University of Washington developed TEAMcare, a primary care clinic-ready model for managing medical and behavioral conditions that is used nationally for PCMH and Accountable Care Organization programs. On a national level, through our work with the LEAP project and a one-year collaborative with the Institute for Healthcare Improvement, we’re seeing primary care add behavioral health specialists to practice teams at a very rapid rate.

Effective behavioral health integration is an enormous relief to a primary care provider and makes a huge difference for patients. It’s now possible to have everything taken care of either in primary care or by people who are working closely with and in communication with primary care. Comprehensive, well coordinated care reassures patients and their families and helps lessen suffering.

So how does the average primary care practice get started? There’s helpful guidance from the Substance Abuse and Mental Health Services Administration-Health Resources and Services Administration as to what real behavioral health integration looks like. This organization emphasizes the very important distinction between just having someone on-site, and having someone who’s an active collaborating member of the primary care team. If the behavioral health specialist is an active member of the practice team, real integration of the care becomes possible even as the complexity of peoples’ illnesses increases.

Here at GHRI’s MacColl Center, our work with a project called LEAP: Learning from Effective Ambulatory Practices has produced an implementation guide, which includes a planning worksheet. We also offer the online Primary Care Team Guide, which includes tools and resources.

In addition, there is now a powerful body of evidence showing that with an effective team, common behavioral health conditions such as depression can be very effectively managed in primary care. There are online resources that provide step-by-step guidance on how a practice can start to really integrate behavioral health into their care, and into their team. There’s even advice about how to make this produce a reasonable return on investment.

Now that we know how primary care practices can truly address the comprehensive needs of people seeking care in a patient-centered medical home, the time has come to meet those needs.