Discussing Barriers to Closing the Behavioral Health Integration Gap

New York City – “We know that behavioral health integration is a necessary component of primary care, desired by both patients and providers. We now need to focus on what is holding us back from implementing at scale,” stated Louise Cohen, CEO of the Primary Care Development Corporation (PCDC), at the recent Primary Care Summit: Closing the Behavioral Health Integration Gap. Ms Cohen was joined by a panel of state and local speakers to address this ongoing challenge.

Need for integrated physical and behavioral health care

Ms Cohen shared the stark statistics: 1 in 5 adults in the United States experiences mental illness and 1 in 25 have serious mental illness. On average, those living with serious mental illness die 25 years earlier than their peers, largely because of treatable comorbid medical conditions such as diabetes and heart disease that are often exacerbated by poor health habits and challenges with accessing standard primary services.¹

Andrew Philip, Senior Director, Clinical & Population Health, PCDC, mentioned some of the innovations around accessibility and integration aimed at this specific population. These included the Improving Mood—Promoting Access to Collaborative Treatment (IMPACT)² intervention and the Primary Care Access Referral, and Evaluation (PCARE)³ trial. Over the past several years, funding has been available for the development of integrated health care, (eg, through the Substance Abuse and Mental Health Services Administration’s [SAMHSA’s] Primary and Behavioral Health Care Integration grants program).⁴

Case study: East New York Health Hub

Two of the guests, Robert M. Hayes, President and CEO, Community Healthcare Network (CHN), and David Woodlock, President and CEO, Institute for Community Living (ICL), discussed their organizations’ partnership in delivering integrated care. The East New York Health Hub is located in one of New York City’s poorest communities, with 30% of residents living beneath the poverty line. In addition, East New York ranks 7 out of 59 community districts in adult psychiatric hospitalizations. The project was financed by the PCDC, the Cooperative for Supportive Housing, and Deutsche Bank.

CHN runs 14 health centers throughout New York City, with staff that includes primary care providers, nurse practitioners, and dentists. According to Mr Hayes, despite increased behavioral health staff and services at the CHN locations, the needs of patients were still not being met. Aware that clients with serious mental illness are more likely to go to behavioral health sites, CHN began searching for a mental health-oriented partner, and found one in ICL. ICL maintains 110 programs that provide counseling, clinics, and community and residential support.

Mr Woodlock explained that the Health Hub’s goals include providing trauma-informed, recovery-oriented, integrated, and person-centered care to improve overall population health and reduce adverse events and emergency department visits.

No outcomes data are available since the Hub’s opening in October 2018, but Mr Woodlock said that there are already “remarkable stories.”

Barriers to behavioral health integration

Using a grant from the New York State Health Foundation, PCDC worked with ICL and CHN 
to create the following initial recommendations based on their partnership at the Hub:

• Simplify state-regulated health care facility requirements, especially for co-located primary care and behavioral health settings.
• Establish integrated systems to share patient information. This includes mutual access to electronic health record systems and streamlined reporting requirements.
• Ensure bidirectional workforce education, which acknowledges the different cultures and knowledge base among areas of practice.
• Promote a collaborative team-based approach to care, which can be as simple as a warm hand-off from one provider to another.
• Expand financing and reimbursement options for integrated care. For example, ICL staff commented that a big issue is the inability to bill for consultation time between providers.

Panelists addressed other barriers, such as billing, compensation, licensing at the individual and facility levels, success metrics, funding, and regulations.

Mr Woodlock commented, “We need to think about scale for different populations and mirror our interventional strategies to populations and individuals rather than saying here…[are] regulations that cover everyone who needs primary care.”

In addition, Thomas E Smith, Chief Medical Officer, New York State Office of Mental Health, acknowledged that barriers are reflected systemically, with separate offices dedicated to mental health, alcoholism and substance abuse services, and primary care and health systems.

Commitment to integration for the individual

While acknowledging the numerous barriers to closing the behavioral health integration gap, panelists also commented on the progress that has been made over the past decade. Patricia Lincourt, Associate Commissioner for Addiction Treatment and Recovery, NYS Office of Alcoholism and Substance Abuse Services, cited the opioid crisis as an example of successful integration. Patients interact with many sectors of care, and partnerships have formed to provide interventions like medication-assisted treatment.

In her closing remarks, Ms Cohen said, “[In] general, the agreement is that integrated health care is a very important need, if not one of the most critical things that we can do to [move] forward and help the health status of people….[We] recommend and support all the kinds of things that move us towards reduction of the barriers.”

“We have to think a lot about this issue and how much we have to measure before we’re thinking about reimbursement; how can we really pump more money into the system for integrated care,” she concluded.

The panel comprised Louise Cohen, CEO of the Primary Care Development Corporation; Robert M. Hayes, President and CEO, Community Healthcare Network; Thomas E. Smith, Chief Medical Officer, NYS Office of Mental Health (OMH) and Co-Director, NYS OMH Center for Behavioral Health Integrated Performance Measurement; David Woodlock, President and CEO, Institute for Community Living; AnnMay Hoyte-Nelson, Deputy Regional Program Director, Metropolitan Area Regional Office, Division of Hospitals and Diagnostic and Treatment Centers, NYS Department of Health; Patricia Lincourt, Associate Commissioner for Addiction Treatment and Recovery, NYS Office of Alcoholism and Substance Abuse Services; Andrew Philip, Senior Director, Clinical & Population Health, Primary Care Development Corporation; and Joan Cleary-Miron, Director, Health Care Facility Transformation Program Implementation Team and Access to Care Group, State Health Innovation Plan, Office of Primary Care and Health Systems Management, NYS Department of Health. The event was sponsored by PCDC and the New York State Health Foundation.

References

1. National Alliance on Mental Illness. Mental Health By The Numbers. https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers. Accessed June 19, 2019.
2. Administration for Community Living. IMPACT (Improving Mood—Promoting Access to Collaborative Treatment). https://acl.gov/sites/default/files/programs/2017-03/IMPACT_summary.pdf. Reviewed June 2012. Accessed June 19, 2019.
3. Druss BG, von Esenwein SA, Compton MT, Rask KJ, Zhao L, Parker RM. A randomized trial of medical care management for community mental health settings: the Primary Care Access, Referral, and Evaluation (PCARE) study. Am J Psychiatry. 2010;167(2):151-159.
4. US Department of Health and Human Services. Evaluation of the SAMSHA Primary and Behavioral Health Care Integration (PBHCI) Grant Program: Final Report. https://www.integration.samhsa.gov/integrated-care-models/RAND_Evaluation_SAMHSA_PBHCI_Grant_Program.pdf. December 2013. Accessed June 19, 2019.