The medical home and integrated behavioral health: advancing the policy agenda.
TL;DR: This article presents recommendations to build demonstration projects to test existing approaches of integration, develop interdisciplinary training programs to support members of the integrated care team, implement population-based strategies to improve behavioral health, eliminate behavioral health carve-outs and test innovative payment models.
Abstract: There has been a considerable expansion of the patient-centered medical home model of primary care delivery, in an effort to reduce health care costs and to improve patient experience and population health. To attain these goals, it is essential to integrate behavioral health services into the patient-centered medical home, because behavioral health problems often first present in the primary care setting, and they significantly affect physical health. At the 2013 Patient-Centered Medical Home Research Conference, an expert workgroup convened to determine policy recommendations to promote the integration of primary care and behavioral health. In this article we present these recommendations: Build demonstration projects to test existing approaches of integration, develop interdisciplinary training programs to support members of the integrated care team, implement population-based strategies to improve behavioral health, eliminate behavioral health carve-outs and test innovative payment models, and develop population-based measures to evaluate integration.
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TL;DR: The integrated care intervention was able to overcome barriers to care associated with an initial reluctance to pursue active treatment and older age and support the value of integrated medical-behavioral health care for improving rates of care.
Abstract: Objectives Depression, a chronic and disabling condition, frequently has its first onset during adolescence, underscoring the value of early effective treatment and prevention. Integrated medical-behavioral health care provides one strategy for improving treatment access for adolescents and young adults (AYA). Methods This study examined predictors of accessing treatment in a multisite randomized controlled trial evaluating an integrated collaborative care intervention aimed at improving access to evidence-based depression treatment through primary health care, compared with usual care. Results The integrated care intervention was able to overcome barriers to care associated with an initial reluctance to pursue active treatment and older age. Service use was low in both conditions among less acculturated/non-English-speaking families. Conclusions Results support the value of integrated medical-behavioral health care for improving rates of care. Findings highlight mechanisms by which integrated care may lead to improved rates of care and outcomes for AYA, an underserved and understudied group.
16 citations
Cites background from "The medical home and integrated beh..."
...This approach of improving access to behavioral health care through primary care has been emphasized in the current redesign of primary care as one strategy for achieving the triple aim of improving population health and patient experience of care while reducing costs (Ader et al., 2015)....
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...…1051 with depression, is to improve access to mental health services through integration of mental health services within general primary care (Ader et al., 2015; Asarnow, Rozenman, Wiblin, & Zeltzer, 2015a; Asarnow, Kolko, Miranda, & Kazak, 2017; Kolko & Perrin, 2014; Stancin, Perrin, &…...
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TL;DR: MCPAP enhanced PCPs' ability to deliver mental health care consistent with families' preferences, and promoting MCPAP components through outreach and tailoring guidance to PCps' scope of practice may entice greater use.
15 citations
01 Jan 2016
15 citations
Cites background from "The medical home and integrated beh..."
...…posed by FFS, CPT codes, and H&B codes, the administration of physical and behavioral health is often based in multiple state agencies , which complicates policy action on issues ranging from the elimination of “carveouts” to the promotion of innovative payment systems (Ader et al., 2015 )....
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...A number of sources have demonstrated how carve-outs have the signifi cant potential to result in more fragmented and uncoordinated healthcare (Ader et al., 2015 ; American Psychiatric Association, 2002 ; Kathol et al., 2010 ; Summer & Hoadley, 2014 )....
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...This reimbursement barrier impacts the primary care provider’s ability to focus on prevention and early intervention, and as a result, conditions are identifi ed at a much later point, where the opportunity to have the greatest impact is decreased (Ader et al., 2015 )....
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TL;DR: Psychologists are uniquely positioned to take advantage of this propitious moment and can help facilitate the integration of behavioral and primary care by developing competencies in integrated care, training a capable workforce, and advocating for integrated care as the status quo.
Abstract: Health reform, post the passing of the Patient Protection and Affordable Care Act, has highlighted the need to better address critical issues such as primary care, behavioral health, and payment reform. Much of this need is subsequent to robust data showing the seemingly uncontrollable growth of healthcare costs, and the exacerbation of these costs for patients with comorbid behavioral health and medical conditions. There is increasing recognition that incorporating behavioral health in primary care leads to improved outcomes and better care. To address these problems, primary care will play critical roles across the healthcare system, especially in the delivery of behavioral health services. Psychologists are uniquely positioned to take advantage of this propitious moment and can help facilitate the integration of behavioral and primary care by developing competencies in integrated care, training a capable workforce, and advocating for integrated care as the status quo.
14 citations
Cites background from "The medical home and integrated beh..."
...These financial practices, in part, have been one of the contributors to low rates of access to behavioral health services by patients who are identified and referred from primary care (Ader et al., 2015; Kathol et al., 2010; Miller, Talen, & Patel, 2013)....
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...…population health over individual health and decrease patient choice May incentivize ‘‘cherry picking’’ low- risk, compliant patients and firing high-risk, noncompliant patients Potential for services to be withheld (or perceived to be withheld) payment for medical benefits (Ader et al., 2015)....
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TL;DR: Despite having co-located behavioral health services at all sites, a Specialist approach to providing BI was less effectively implemented than a Generalist approach in this FQHC.
14 citations
References
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TL;DR: Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity, as shown in the recently completed US National Comorbidities Survey Replication.
Abstract: Background Little is known about the general population prevalence or severity of DSM-IV mental disorders. Objective To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication. Design and Setting Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Participants Nine thousand two hundred eighty-two English-speaking respondents 18 years and older. Main Outcome Measures Twelve-month DSM-IV disorders. Results Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%. Of 12-month cases, 22.3% were classified as serious; 37.3%, moderate; and 40.4%, mild. Fifty-five percent carried only a single diagnosis; 22%, 2 diagnoses; and 23%, 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population. Conclusion Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.
10,951 citations
TL;DR: Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.
Abstract: Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health car...
4,276 citations
University of California, Los Angeles1, University of Washington2, Indiana University3, Duke University4, Kaiser Permanente5, University of Texas Health Science Center at San Antonio6, Group Health Cooperative7, University of California, San Francisco8, Dartmouth College9, John A. Hartford Foundation10
TL;DR: The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.
Abstract: ContextFew depressed older adults receive effective treatment in primary care
settings.ObjectiveTo determine the effectiveness of the Improving Mood–Promoting
Access to Collaborative Treatment (IMPACT) collaborative care management program
for late-life depression.DesignRandomized controlled trial with recruitment from July 1999 to August
2001.SettingEighteen primary care clinics from 8 health care organizations in 5
states.ParticipantsA total of 1801 patients aged 60 years or older with major depression
(17%), dysthymic disorder (30%), or both (53%).InterventionPatients were randomly assigned to the IMPACT intervention (n = 906)
or to usual care (n = 895). Intervention patients had access for up to 12
months to a depression care manager who was supervised by a psychiatrist and
a primary care expert and who offered education, care management, and support
of antidepressant management by the patient's primary care physician or a
brief psychotherapy for depresssion, Problem Solving Treatment in Primary
Care.Main Outcome MeasuresAssessments at baseline and at 3, 6, and 12 months for depression, depression
treatments, satisfaction with care, functional impairment, and quality of
life.ResultsAt 12 months, 45% of intervention patients had a 50% or greater reduction
in depressive symptoms from baseline compared with 19% of usual care participants
(odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of
depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001),
more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group
difference, −0.4; 95% CI, −0.46 to −0.33; P<.001), less functional impairment (range, 0-10; between-group
difference, −0.91; 95% CI, −1.19 to −0.64; P<.001), and greater quality of life (range, 0-10; between-group
difference, 0.56; 95% CI, 0.32-0.79; P<.001) than
participants assigned to the usual care group.ConclusionThe IMPACT collaborative care model appears to be feasible and significantly
more effective than usual care for depression in a wide range of primary care
practices.
2,218 citations
01 Jan 2007
2,163 citations
Book•
01 Aug 2009
TL;DR: Mental, emotional, and behavioral (MEB) disorders—which include depression, conduct disorder, and substance abuse—affect large numbers of young people.
Abstract: This report builds on a highly valued predecessor, the 1994 Institute of Medicine (IOM) report entitled Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. That report provided the basis for understanding prevention science, elucidating its then-existing research base, and contemplating where it should go in the future. This report documents that an increasing number of mental, emotional, and behavioral problems in young people are in fact preventable. The proverbial ounce of prevention will indeed be worth a pound of cure: effectively applying the evidence-based prevention interventions at hand could potentially save billions of dollars in associated costs by avoiding or tempering these disorders in many individuals. Furthermore, devoting significantly greater resources to research on even more effective prevention and promotion efforts, and then reliably implementing the findings of such research, could substantially diminish the human and economic toll.
1,744 citations