IssueBrief
March 2015
Building paths, demolishing walls
The challenge and necessity of integrating behavioral
health and primary care
I
ntegrated care involves a whole-person, patientcentered approach that engages patients in the full
range of physical, psychological and social aspects of
care. That does not describe the status quo: Behavioral
and physical health operate in their own silos, to the
detriment of patients, the health care system and society.
Such an approach makes no sense, says Benjamin F. Miller,
PsyD, director, Eugene S. Farley, Jr. Health Policy Center, and
assistant professor, department of family medicine, University
of Colorado Denver School of Medicine.
Mental and physical health are profoundly interrelated.
Medical conditions may lead to psychological problems,
and psychological problems can impair physical health.1,2
1
Patten SB. “Long-term medical conditions and major depression
in a Canadian population study at waves 1 and 2.” Journal of Affective
Disorders, vol. 63, no. 1–3, 2001.
2
Patten SB, et al. “Major depression as a risk factor for chronic disease
incidence: Longitudinal analyses in a general population cohort.”
General Hospital Psychiatry. vol. 30, no. 5, 2008.
Integrated care results from a practice team
of primary care and behavioral health
clinicians, working together with patients
and families, using a systematic and
cost-effective approach to provide patientcentered care for a defined population.
This care may address mental health,
substance abuse conditions, health
behaviors (including their contribution to
chronic medical illnesses), life stressors and
crises, stress-related physical symptoms,
ineffective patterns of health care utilization.
— Lexicon for Behavioral Health
and Primary Care Integration,
Agency for Healthcare Research
and Quality
For example, people with
conditions such as diabetes
and heart disease are more
prone to depression and anxiety.3
Depression and anxiety can
contribute to worsening health
problems—even increased
mortality.4
“We have an opportunity to do something quite profound when it
comes to addressing the needs of the whole person. If the goal is
to improve individual health, lower health care costs and improve
the health of communities, it is imperative to understand that
behavioral health is integral to physical health, and vice versa.”
When mental and medical
conditions co-occur—which they
do frequently—it leads to worse
symptoms, functional impairment,
decreased length and quality
of life, and increased costs.5,6
The evidence has long shown
that human behavior directly
affects the way we deal with
illness, manage chronic conditions
and adhere to a care plan,
Miller says. The current system
isn’t addressing this, and it’s c
ostly. A 1996 Institute of Medicine
report concluded that mental
health and primary care are
inseparable, and attempts to
separate them lead to inferior,
more expensive, care.7
“We have the business case—
these individuals cost more,” says
Katon W, et al. “Integrating depression
and chronic disease care among patients
with diabetes and/or coronary heart
disease: the design of the TEAMcare
study.” Contemp Clin Trials. 2010 Jul.
3
Frasure-Smith N, et al.“Depression
following myocardial infarction: Impact
on 6-month survival.” JAMA, October 20, 1993.
4
5
Goddell S, Druss B, Reisinger Walker E.
Mental Disorders and Medical Comorbidity,
Robert Wood Johnson Foundation, Policy
Brief, 2011.
6
Miller B, et al. The importance of time
in treating mental health in primary care.
Families, Systems, & Health, Vol 29(2),
Jun 2011.
Donaldson M, et al., (Eds.), Primary
Care: America’s Health in a New Era. Washington, D.C.: Institute of Medicine. 1996.
7
— BENJAMIN F. MILLER, PSYD, DIRECTOR, EUGENE S. FARLEY,
JR. HEALTH POLICY CENTER, ASSISTANT PROFESSOR,
UNIVERSITY OF COLORADO DENVER SCHOOL OF MEDICINE
Miller. Integrated care addresses
this by offering better access to
treatment and improved health
outcomes.8,9,10
Identification and
assessment
The inseparability of mental health
from physical health is no longer
at issue. The question, he says, is
this: How will we change the
health care delivery system to
acknowledge that? “We have
an opportunity to do something
quite profound when it comes to
addressing the needs of the whole
person,” Miller says. “If the goal is
to improve individual health, lower
health care costs and improve the
health of communities, it is imperative to understand that behavioral
Butler M, Kane RL, et al. “Integration of
Mental Health/Substance Abuse and Primary Care.” No. 173. AHRQ Publication No.
09-E003. Rockville, MD. Agency for Healthcare Research and Quality. October 2008.
8
9
Goddell S, 2011 op. cit.
Kathol RG, et al. “Barriers to Physical
and Mental Condition Integrated Service
Delivery.” Psychosomatic Medicine. July/
August 2010.
10
2
health is integral to physical
health, and vice versa.”
More individuals with a diagnosable mental health condition are
seen in primary care than any
other setting, he says. So it makes
no sense for the health delivery
system to continue to silo them.
A wide range of behavioral health
interventions can be offered by
behavioral health providers in
the primary care setting. Miller
provided five categories.
Addressing psychosocial
barriers to care.
Addressing evidenced-based
interventions for lifestyle
changes to improve
physical health.
Addressing mental health
and substance use problems.
This is the most common
intervention.
Addressing the needs of
patients with multiple chronic
conditions, both mental health
and physical health concerns.
Addressing the needs of
persons with severe mental
illness (e.g., schizophrenia,
bipolar disorder). Case managers may prove especially
helpful in bridging the care
gaps for these patients.
But primary care providers have
not been encouraged to consult
or collaborate with their behavioral health colleagues because
of the current system’s design.
They aren’t even equipped to
make a diagnosis: In particular,
depression remains undiagnosed
among more than half of primary
care patients.11
How a practice may identify those
with behavioral health needs can
vary. Maybe the front desk staff
administers a screener, or maybe,
as at Bon Secours, it’s part of
rooming protocol. Miller offered
a list of commonly used nonproprietary instruments for
assessing behavioral health needs
in primary care (see Figure 1).
Although they do take some time
to administer, most require very
little effort to interpret.
Simply identifying need isn’t
enough. Having the resources
to interpret the results is also
essential. That requires professionals with clinical judgment;
professional case managers
can take on this role. (See
sidebar on page 4 for an
example of how a Bon Secours
pilot is accomplishing this.)
Among the other issues:
Who is responsible for following
up with the patient?
Who retains the data from the
assessment tool (and where)?
Where will risk stratification
come into play?
How is the screening tool used
Mitchell et al. “Clinical diagnosis
of depression in primary care: a metaanalysis.” The Lancet, 2009; 374:609-619.
11
to monitor treatment?
This last question is an important
one: Screening tools aren’t merely
for identifying patients who need
behavioral health interventions.
Just as a clinician uses the A1c as
a measure of how well a patient
with diabetes is doing, the
PHQ-9 depression screen can
be used repeatedly to assess
the effectiveness of behavioral
health interventions.
But there is a catch, and in the
current fee-for-service environment,
it’s a big one: time. No matter how
effective the screening tool, it will
meet resistance from providers and
 Figure 1
Issue
Name of Measure
Number Items Score for Positive Screen
Depression
PHQ-9
9
6-10 moderate
10-15 moderately severe
16+ severe
Alcohol Abuse
AUDIT
3
7 or more for women
8 or more for men
Generalized
Anxiety
GAD-7
7
6-10 moderate
10-15 moderately severe
16+ severe
Bipolar Disorder
Mood Disorder Questionnaire
5
Yes to 7+ items in question 1 AND Yes to question
2 AND moderate to serious to question 3
PTSD
PC-PTSD
4
Yes to one or more items
Cognitive Function
Montreal Cognitive Assessment Tool MOCA
12
>26 (out of 30) Normal
3
ON THE GROUND:
Bon Secours/UMFS pilot
B
on Secours Medical Group is in the early stages
of a pilot to put the principles of behavioral
health integration into practice. Working with
United Methodist Family Services (UMFS) in Richmond,
Virginia, the initiative focuses on adolescent behavioral
health. The site is a large family practice —11 doctors
and three embedded RN case managers (referred to
as “navigators”). Behavioral health specialists are
co-located three days a week; the nurse navigators
are there full time, explains Robert Fortini, PNP,
chief clinical officer, Bon Secours Medical Group.
•Workflow must be adapted: Rooming protocol,
assessment, treatment algorithm, EHR workflows
and access, credentialing with different payers,
coding—all workflow aspects must be examined
in the context of integrated care.
What’s been missing from the traditional referral
approach is systematic, routine depression screening;
it’s at the core of this pilot. The rooming protocol calls
for each patient to be screened. The rooming staff asks
the first two questions on the PHQ-9. If the patient
scores 3 or higher, the navigator takes over and asks
the other seven questions. For those with moderate
depression, the navigator opens a new case management file. Those with severe depression are assigned
to a behavioral health specialist.
•Clinician buy-in isn’t enough: Getting the C-suite
to embrace such a program can prove difficult,
he says. And before anything can get underway,
legal and compliance officers must sign off.
One of the biggest hurdles is the fee-for-service environment. But that will change, he says, and organizations
working on integration will be well-positioned for the
new value-based models.
The program is still working through growing pains.
“Including behavioral health on the team has been an
interesting experience,” says Fortini, who designed and
championed implementation of the pilot. He shared
some observations from the program’s first 60 days.
That is the direction health care is headed. Penalties
for increased utilization, coupled with the lure of shared
savings in accountable models, make an integrated
approach more attractive, says Fortini. And he’s
already able to make the business case: The RN case
manager and the behavioral health professional are
invaluable in improving quality metrics and reducing
gaps in care—especially in ACO-like contracts with
commercial payers. “It’s huge. The case managers
earn their salaries right there alone, just by plugging
gaps in care.” And there’s the biggest benefit of all,
he says—improved patient outcomes.
•Expect initial resistance: There was pushback
from rooming staff and providers about the
amount of time required to complete the depression
screening and the accompanying documentation.
•Training matters: “As we train the rooming
staff, rehearse scripts and simplify documentation
tools and training, they are becoming more
comfortable.” Likewise, as United Methodist
provides more training, the navigators are
more comfortable with triage.
“Inevitably, inexorably, we’re moving
to a value-based model.”
4
staff because of the time involved,
warn Miller and Robert Fortini, PNP,
chief clinical officer, Bon Secours
Medical Group. Time is one of the
many casualties of a fee-for-service
approach to health care delivery.
Changing the system
The task, then, is to integrate care
delivery in ways that meet the
patients’ needs. That includes providing interventions and assistance
in that moment when they need
it the most, Miller says—and not
making them wait weeks for a
referral appointment. There’s a
“huge role” for individuals such as
case managers to identify and
help assess patients. “When we can
detect depression in primary care,
we can step up and do something,” he says.
The mind and the body are
indeed connected. How we
deliver and pay for their care is
not. Miller identified four areas
for change to make true integration happen.
Delivery: Only 2 percent of
patients are screened for
depression in family practices,
only 5 percent in internal medicine.12 But simply identifying
patients with mental health
issues isn’t the answer. More
screening is meaningless without the proper staff support.
“Once depression—or another
condition—is identified, we
need to step up and do
something. That’s where the
12
Phillips, R., Miller B. et. al. “Better Integration of Mental Health Care Improves
Depression Screening and Treatment in
Primary Care,” Am Fam Physician. 2011 Nov
professional case manager
can play an important role,”
he says.
Financing: Similarly, behavioral
health and physical health
each has a “different pot of
money,” Miller says, making it
difficult to collaborate as a
team.“We often do not pay for
the team, but rather for the individual service. In doing so, we
perpetuate that false dichotomy. Every time we see them,
we tell them they need to go
somewhere else to have their
have their needs taken care of.”
Community expectations:
Patients have come to expect
that if they have a mental
health complaint, there is a
different path to care than for
physical health.
Training and education:
Training for health care professionals must begin to focus on
the whole person, not just the
parts. It teaches providers to
operate in their respective
silos; it should instead focus
on the team.
Making it happen
The Agency for Healthcare
Research and Quality’s13 Lexicon
for Behavioral Health and Primary
Care Integration describes three
stages of the integration continuum: coordinated, co-located and
integrated. It’s a simplified way to
address the pathway, Miller says,
but it’s nonetheless helpful.
Coordinated: The first step is
coordination of care. This is
referral-based and relationship-driven. Clinical information exchange protocols are
required so mental health
clinicians and primary
care professionals can be
knowledgeable about all
the patient’s health issues.
Coordination of care around
mental health is necessary,
but far from sufficient.
It’s just the first step.
Co-located: Embedding
It’s no surprise, then, that most individuals with a behavioral health
disorder remain untreated, Miller
says. Meaningful change requires
addressing the situation on all four
fronts: “We have to address each
one of these areas simultaneously.”
Case managers can play a significant role in the overall integration
of care.
Coordination of care around
mental health is necessary, but far
from sufficient. It’s just the first step.
5
external specialty mental
health services in the practice
is the next step. It’s farther
along the path toward
integration, but it’s still referralbased and there are separate
behavioral health and
medical treatment plans.
13
Agency for Healthcare Research and
Quality, better known as AHRQ, is a federal
agency. Its mission is to produce evidence
to make health care safer, higher quality,
more accessible, equitable, and
affordable.
Identify your vision. It needs
“Recognition that cost and quality must be part of the equation
means the demand for board-certified case managers will
continue to increase.”
— PATRICE SMINKEY, CHIEF EXECUTIVE OFFICER,
COMMISSION FOR CASE MANAGER CERTIFICATION
to be based on a consistent
definitional framework, such as
that identified in the Lexicon,
but it must also be rooted in
your institutional vision.
Design the model to meet the
needs of the population you
serve. That means knowing
who those people are.
Integrated: Integration is the
goal. This approach provides
instantaneous, seamless
access to the care the patient
needs, be it physical or behavioral. It includes management
of psychosocial aspects of
chronic and acute diseases
along with co-management
of treatment of mental disorders and psychosocial issues.
Practices working towards
integrated behavioral health
are at various stages. “Find out
what role you can play to move
them toward better integration,”
Miller tells professional case
managers.
Efforts to enhance coordination
of primary and behavioral care
are expanding, but they are rarely
sustainable. Reimbursement and
billing challenges posed by feefor-service medicine are the greatest barrier to creating and maintaining integrated care practice—
specifically, physical and mental
health reimbursement,14,15 say Miller
and Fortini. It follows, then, that the
way to make integration efforts
14
Kathol, Psychosomatic Medicine op. cit.
15
Smith, C. “Beyond a Fad: How Integrated Care Can Swim to the Mainstream,
Collaborative Family Healthcare Association blog, April 21, 2011
sustainable is to change the
fee-for-service model.
That will happen, says Patrice
Sminkey, CEO of the Commission
for Case Manager Certification®.
She notes that the Department
of Health and Human Services
announced that by 2018, half of
Medicare’s direct payments will be
value-based to align with the Triple
Aim of better care, better health
and lower costs.16 That’s just one
example, she says.“Recognition
that cost and quality must be
part of the equation means the
demand for board-certified case
managers will continue to increase.”
Changes won’t happen overnight,
but one milestone on that path is
team-based care—a sweet spot
for the professional case manager.
If anyone understands the continuum of care and how patients
can get lost in the system—and
can figure out how to help them—
it’s case managers, says Fortini.
Miller offers a few tips to case
managers who want to advocate
a more integrated approach.
16
Developed by the Institute for
Healthcare Improvement
6
Work to get buy-in from
organizational leadership.
Too often, he warns, there’s
no top-down support.
Advocate for retraining in
behavioral health skills.
Think about logistical consider-
ations. Are there places for
team meetings, or for private,
spontaneous meetings
with patients other than an
exam room? Ask for staff
recommendations to solve for
this: “Sometimes, the people
who know the best are the
MAs and the front desk staff.”
"If anyone understands the
continuum of care and
how patients can get lost
in the system—and can
figure out how to help
them—it’s case managers."
— ROBERT FORTINI, PNP
VICE PRESIDENT AND CHIEF
CLINICAL OFFICER. BON SECOURS
MEDICAL GROUP
Decide how you are going to
implement and measure. You
can use that data to make
the case for your integration
efforts.
to optimize healing, paying special
attention to the emotional, social,
financial and health needs of our
clients. Initiatives such as these
that champion integrated
behavioral health and total care
management are the heart of
our continuing evolution toward
more patient-centered, effective,
cost-efficient care.” 
Finally, he says, keep your goal in
sight. “The end goal is the Triple
Aim. If what you’re doing doesn’t
touch on this, it probably won’t
last for long.”
Patients are walking a different
path than the one paved by the
health care delivery system, Miller
says. It’s time to meet patients
where they are. “We have an
opportunity to create a more
patient-centered solution by integrating care, by creating a system
that addresses the whole person.”
“We have an opportunity to create a more patient-centered solution
by integrating care, by creating a system that addresses the
whole person.”
Integrated, connected care dovetails into what board-certified
case managers do, says Sminkey.
“As case managers, we know how
— BENJAMIN F. MILLER, PSYD, DIRECTOR, EUGENE S. FARLEY, JR. HEALTH POLICY CENTER,
ASSISTANT PROFESSOR, UNIVERSITY OF COLORADO DENVER SCHOOL OF MEDICINE
About the Experts
Patrice Sminkey, Chief Executive
Officer, The Commission for
Case Manager Certification
As chief executive officer, Sminkey oversees
the management of all activities related to the
Commission’s operations, including all programs,
products and services; and the provision of quality
services to and by the Commission. She is a direct
liaison to the Commission’s Executive Committee.
She works with CCMC’s volunteer leadership to
evaluate and develop potential new products for
implementation by CCMC, and she establishes
and maintains communication and working
relationships with other organizations, agencies,
groups, corporations and individuals.
Sminkey comes to the Commission
from URAC, where she most recently
served as senior director of sales. Prior to that, she was
senior vice president, operations and client management, Patient Infosystems in Rochester, N.Y. She brings
a proven track record in operations management in
small and large operations, multilevel services and
cross-functional teams. She has extensive experience
in client management and coordination, including
marked improvement in client retention, timely and
fiscally sound program implementation and an
expanding book of business.
She holds a diploma of nursing from the Chester
County School of Nursing.
7
About the Experts
Benjamin F. Miller, PsyD
Director, Eugene S. Farley, Jr.
Health Policy Center;
assistant professor, University
of Colorado Denver School
of Medicine.
Miller is an assistant professor in the Department of
Family Medicine at the University of Colorado Denver
School of Medicine where he is also the director of the
Eugene S. Farley, Jr. Health Policy Center. He is a principal investigator on several federal and foundation
grants, as well as state contracts related to comprehensive primary care and mental health, behavioral
health, and substance use integration. He leads the
Academy for Integrating Behavioral and Primary Care
project for the Agency for Healthcare Research and
Quality (AHRQ), as well as the Sustaining Healthcare
Across Integrated Primary Care Efforts (SHAPE) project.
He has published extensively in the area of integrated
behavioral health and primary care.
He received his doctorate in clinical psychology
from Spalding University in Louisville, Kentucky.
He completed his predoctoral internship at the
University of Colorado Health Sciences Center,
where he trained in primary care psychology.
Miller is the co-creator of the National Research
Network’s Collaborative Care Research Network, and
has written and published on enhancing the evidentiary support for integrated care. He is the section
editor for Health and Policy for Families, Systems and
Health and reviews for several academic journals.
Miller is a technical expert panelist on the AHRQ
Innovations Exchange and on the International
Advisory Board of the British Journal of General
Practice. Miller is a past president of the Collaborative
Family Healthcare Association and is faculty for the
Institute for Healthcare Improvement.
Robert Fortini, PNP
vice president and
chief clinical officer
Bon Secours Medical Group
Fortini is vice president and chief clinical officer for
Bon Secours Medical Group in Richmond, Virginia.
He is responsible for facilitating provider adoption
of EMR, coordinating clinical transformation to a
patient-centered medical home care delivery
model, and facilitating participation in available
pay-for-performance initiatives as well as physician
advocacy and affairs. He has extensive experience
in operations and clinical policy development, and
experience in workflow re-engineering and CQI in
ambulatory care. Before coming to Bon Secours, he
served as the chief medical affairs officer at Queens
Long Island Medical Group, engaged in quality and
health IT adoption. He successfully applied for the
first Level 3 NCQA-recognized PCMH in New York
state. Prior to that, at Community Care Physicians
Medical Group, Fortini participated in the successful
launch of the Bridges to Excellence Collaborative in
upstate New York. He has 30 years of experience in
health care. He is a graduate of Fordham University
and the State University of New York College of
Health Professions at Upstate Medical Center
in Syracuse.
Commission for Case Manager Certification
1120 Route 73, Suite 200 • Mount Laurel, NJ 08054 • (856) 380-6836
[email protected] • www.ccmcertification.org
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