This article examines the concept of the Patient-Centered Medical Home (PCMH) as it applies to children and adolescents, emphasizing care for behavioral health conditions, the role of psychology and psychological science, and next steps for developing evidence-informed models for the Pediatric-PCMH. The PCMH concept for pediatric populations offers unique opportunities for psychological science to inform and enhance the transformation of the United States health care system and improve health in our nation. Available evidence on the outcomes of PCMH implementation for pediatric populations is limited, underscoring the need for additional research evaluating Pediatric-PCMH models and concepts. While behavioral health has only recently been emphasized as a formal part of the PCMH, accumulating evidence supports the effectiveness of some approaches for providing behavioral health care through pediatric primary care. These approaches suggest that a comprehensive Pediatric-PCMH model that includes behavioral health care has the potential to optimize the availability, quality, benefits, and cost-effectiveness of behavioral health services. This could ultimately enhance youth health and behavioral health, with effects potentially extending through the adult years. Rigorous research and demonstration projects are needed to guide further development of optimal strategies for improving health and behavioral health in pediatric populations and advancing the public health impact of behavioral health care services. (PsycINFO Database Record

The Pediatric Patient-Centered Medical Home: Innovative models for improving behavioral health.

This article examines the past, present and future of primary care and teamwork. It begins with a definition and description of primary care-its uniqueness, diversity and complexity, including the historical role of teams within primary care. The article then reviews the emergence of innovative primary care teams, including those grounded in new processes such as the Patient-Centered Medical Home and interprofessional teams that include new types of health professionals, particularly psychologists and other integrated behavioral health clinicians. The article describes key factors that support or hinder primary care teamwork, as well as evidence of the impact of these team-based models on patient outcomes, costs, and team members. It also discusses the role of primary care teams within multiteam systems (or 'teams of teams'), which are organized around the needs of patients and families, and the unique challenges these systems pose to coordinating care. The article concludes with recommendations for advancing teams in primary care, including changes in payment, descriptions of team competencies, models for primary care team training, and research necessary to inform the gaps in scientific knowledge. (PsycINFO Database Record

The complexity, diversity, and science of primary care teams.

With persisting health disparities contributing to a disproportionate impact on the health and well-being of socially disenfranchised and medically underserved populations, the emerging patient-centered medical home (PCMH) model offers promise in bridging the health disparities divide. Because behavioral health care is an important component of the PCMH, psychologists have significant opportunity to contribute to the development and implementation of PCMH services in settings that primarily serve medically underserved communities. In this article, after briefly defining the PCMH model and its role in clinical settings for medically underserved populations for whom health disparities are present, roles of psychologists as interprofessional collaborators on PCMH medical care teams are explored. Next, the constellation of competencies that position psychologists as behavioral health specialists to contribute to PCMH care teams for medically underserved groups are characterized. The article concludes with reflections on the prospects for psychologists to make tangible contributions as health care team members toward reducing health disparities and promoting health equity in patients served in the PCMH. (PsycINFO Database Record

Psychology in patient-centered medical homes: Reducing health disparities and promoting health equity.

Never before has so much been asked of primary care. Primary care providers are increasingly encountering heavy workloads, serving a large volume of patients in shorter visit times. At the same time, there is a growing emphasis on healthcare delivery models that meet the “triple aim” (patient satisfaction, improvedhealthoutcomes,andlower cost).Inthe context of these demands, patient complexity in the primary care setting is high, with roughly one in four primary care patients presenting with multi-morbidity 1 and up to half meeting criteria for a psychiatric disorder. 2 As such, emerging primary care models must address the significant impact of behavioral health complications on both the complexity and intensity of care. Integrating behavioral health providers (e.g., psychiatrists, psychologists, social workers) into primary care teams can enhance provider responsiveness to patients with complex clinical presentations and improve patient/family outcomes and satisfaction. This approach may also lower stress and increase professional quality of life for primary care physicians, associated specialty care providers, physician’s assistants, nurse practitioners, nurses, and other members of the healthcare team. A key role for behavioral health providers in the primary care setting is to identify and treat psychiatric conditions. Because primary care providers typically have little training in assessing and managing psychiatric conditions, they understandably may experience discomfort in working with some patients with psychiatric comorbidities. In addition to the challenges associated with treatment of psychiatric disorders, unidentified or untreated mental illness can impact overall care, and may be associated with multiple visits for medically unexplained, yet debilitating, somatic symptoms. Such visits can be frustrating for both patients and their care teams, and provider-rated “difficult” encounters are more likely to occur both with patients who have mental health diagnoses and with patients describing multiple somatic complaints. 3 Behavioral health providers can support their primary care colleagues in managing the behavioral complications of mental health conditions to optimize provider- patient relationships, patient and family engagement in care, and treatment outcomes. They can offer accessible and prompt follow-up treatment when psychiatric conditions are identified, either within the primary care setting itself or via facilitated referral to specialty behavioral health treatment resources outside the primary care practice. They can also provide telephone sessions or utilize telemedicine for patients with limited transportation access to clinic offices. Behavioral health providers can also support the efforts of the primary care team to facilitate health-enhancing behaviors, address behaviors associated with health risk, and improve pain management and pain-related outcomes by focusing on non-pharmacologic coping strategies. Primary care providers spend a significant portion of their clinical time managing chronic medical conditions, largely through pharmacotherapy.

https://link.springer.com/content/pdf/10.1007%2Fs11606-015-3499-8.pdf

The Role of Behavioral Health in Optimizing Care for Complex Patients in the Primary Care Setting

Financially supporting and sustaining behavioral health services integrated into primary care settings remains a major barrier to widespread implementation. Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) was a demonstration project designed to prospectively examine the cost savings associated with utilizing an alternative payment methodology to support behavioral health services in primary care practices with integrated behavioral health services. Six primary care practices in Colorado participated in this project. Each practice had at least one on-site behavioral health clinician providing integrated behavioral health services. Three practices received non-fee-for-service payments (i.e., SHAPE payment) to support provision of behavioral health services for 18 months. Three practices did not receive the SHAPE payment and served as control practices for comparison purposes. Assignment to condition was nonrandom. Patient claims data were collected for 9 months before the start of the SHAPE demonstration project (pre-period) and for 18 months during the SHAPE project (post-period) to evaluate cost savings. During the 18-month post-period, analysis of the practices' claims data demonstrated that practices receiving the SHAPE payment generated approximately $1.08 million in net cost savings for their public payer population (i.e., Medicare, Medicaid, and Dual Eligible; N = 9,042). The cost savings were primarily achieved through reduction in downstream utilization (e.g., hospitalizations). The SHAPE demonstration project found that non-fee-for-service payments for behavioral health integrated into primary care may be associated with significant cost savings for public payers, which could have implications on future delivery and payment work in public programs (e.g., Medicaid).

Cost savings associated with an alternative payment model for integrating behavioral health in primary care.

The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. As defined by the Agency for Healthcare Research and Quality, the PCMH framework has 5 attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Evidence increasingly demonstrates that for the PCMH to best achieve the Triple Aim (improved outcomes, decreased cost, and enhanced patient experience), treatment for behavioral health (including mental health, substance use, and life stressors) must be integrated as a central tenet. However, challenges to implementing the PCMH framework are compounded for real-world practitioners because payment reform rarely happens concurrently. Nowhere is this more evident than in attempts to integrate behavioral health clinicians into primary care. As behavioral health clinicians find opportunities to work in integrated settings, a comprehensive understanding of payment models is integral to the dialogue. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy. (PsycINFO Database Record

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Patrick D Gordon

Papers

Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care.

Cost savings associated with an alternative payment model for integrating behavioral health in primary care.