People with a major mental illness typically die between 14 and 32 years earlier than the general population. They are more likely to suffer co-morbid conditions, such as heart disease, obesity (often a consequence of the long use of psychoactive medications) and addiction related illnesses. Additionally, poverty and poor educational status impact their ability to access high quality, affordable healthcare.
The American Hospital Association published a report in January, 2012 detailing the effect that mental illness has on health. In 2007, 57 percent of U.S. adults met diagnostic behavioral health criteria and 32 percent had experienced issues within the prior 12 months. The monthly healthcare expenditure for chronic conditions in 2005 was $860 without a diagnosis of comorbid depression and $1420 with the comorbid diagnosis, a significant difference.
At the same time, cost of services is a significant barrier for 45.7 percent of adults reporting an unmet behavioral healthcare need. The report concluded that integrating behavioral and physical healthcare would improve access to care. In fact, it was shown that costs decreased significantly when patients with care management interventions were compared to those without ($5908 per year versus $6840 per year).
The Centers for Medicare and Medicaid Services (CMS) are promoting patient centered primary care, an approach to care that involves addressing a patient’s healthcare issues holistically, designed to meet the Triple Aim of improving the patient’s experience of healthcare (quality and satisfaction) and improving the health of populations, while at the same time reducing the per capita cost of healthcare.
In general, primary care is the first access point for many patients to the healthcare system. In recognition of this, CMS has issued new chronic care management codes to support the work of the primary care providers in coordinating the healthcare of their patients. Codes that address Behavioral Care Management are included in this new set of codes, which will encourage the integration of behavioral health professionals into the primary care team.
Some of the benefits would include de-stigmatization of care, rapid access to behavioral healthcare and an increased understanding by the clinicians of the physical, cognitive and behavioral challenges a patient may be experiencing. Warm hand-offs and continued collaboration amongst the team members enhance continuity of care.
CMS has detailed the duties of an integral member of the team – the Behavioral Healthcare Manager. This team member will be a clinician with formal education or specialized training in behavioral health, who provides care management services, as well as an assessment of needs, including the administration of validated rating scales, the development of a care plan, provision of brief interventions (face to face or telephonically), ongoing collaboration with the treating primary care provider and maintenance of a registry, all in consultation with a psychiatric consultant.
The integration of behavioral healthcare into the primary care setting requires education for the clinicians involved. Often, this includes the development of a clear description of the culture and vision of the team, and a delineation of roles and responsibilities for each team member.
New hires should experience inter-professional shadowing in order to gain an understanding of the roles of the various team members, and be closely mentored so that questions and concerns can be addressed in a timely fashion.
Work flow should also be addressed. This would include processes for referring a patient to the Behavioral Healthcare Manager (BHCM). Interdisciplinary communication processes should be outlined, which would include a discussion of roles and boundaries between the different levels of the team.
Documentation tends to differ between medical and behavioral clinicians, and training must be provided for the BHCM so that the notes they write will include a clear structure and easy-to-find facts. Narrative notes should be minimized. Often, the pace and rhythm of a primary care setting is vastly different to that of a behavioral healthcare setting, and adjustments to interventions will need to be made in order to maintain efficiency.
MD2U, a home based primary care practice, has been working to integrate behavioral healthcare for our particularly vulnerable patients – patients who have cognitive, behavioral or physical conditions that make it extremely difficult to access an office based practice. Increased isolation, combined with severe chronic illnesses, increases the prevalence of various mental health conditions.
Medicare determined that beneficiaries less than 65 years of age (who are primarily disabled) were 2.3 times as likely to have depression and 1.8 times as likely to have asthma, compared to aged beneficiaries. Anecdotally, we have increased patient retention, improved medication and treatment plan adherence, and reduced recurrent hospitalizations. We look forward to quantifying our success through utilization of the patient register that the chronic behavioral care management codes support.
-Ellen Thomson is senior director of Clinical Quality and Behavioral Health of MD2U in Louisville, Ky.