Integrating mental health care into primary care settings to improve patient care and staff support

From the 2018 HVPAA National Conference

Jin Hui Joo (Johns Hopkins University), Scott Feeser (Johns Hopkins University), Phoebe Rostov (Johns Hopkins University), Arielle Alvaro (Johns Hopkins Health Care), Daniel Meltzer (Johns Hopkins Health Care), Lindsay Hebert (Johns Hopkins Health Care), Robert Findling (Johns Hopkins University), Scott Berkowitz (Johns Hopkins University), Constantine Lyketsos (Johns Hopkins University)

Background

Mental health conditions such as depression occur in at least 20% of persons undergoing treatment for medical conditions; yet patients with depression in primary care settings are underdiagnosed and undertreated with negative consequences such as worsening of medical conditions, decreased quality of life, and increased mortality.

Objectives

Our goal was to design and implement a behavioral health program in community-based primary care clinics, part of the Johns Hopkins Medicine Alliance for Patients (JMAP) Accountable Care Organization.

Methods

Implementation steps included: 1) definition of the model using a collaborative care approach, 2) identification of primary care sites for clinician embedding and of regional sites as well as stakeholder buy-in, 3) development of EMR tools and reporting mechanisms, and 4) development of program evaluation measures. Information regarding volume of patients served, behavioral health conditions addressed, and services provided, was extracted from the EMR and analyzed. Primary care providers, behavioral health providers and practice administrators provided perspectives about the program.

Results

Teams of Health Behavior Specialists (HBS) and psychiatrists were recruited, trained and embedded in 8 primary care clinics and served approximately 20 regional primary care clinics. Each HBS was the hub of the behavioral health program and provided mental health counseling, referral to community mental health resources, and care management. The psychiatrist provided case consultation and reviewed patients being served with the HBS. The psychiatrist also provided in-person evaluation and consultation to primary care providers. Available to the team was a community health worker who addressed social determinants of health as needed. Initially, referrals were made solely by the primary care team, but later drew from a claims-based list of patients at high risk of hospitalization. Since inception in 2015, approximately 1,200 patients (mean of 5 visits per patient) have received behavioral health services in the program with mood disorders such as depression and anxiety (74%) being most common, frequently comorbid with other behavioral health conditions. Substance use disorders and smoking (6%) as well as stress, grief and non-adherence to medications were also addressed. HBS services included assessment and counseling (>50%) or care updates (29%). Psychiatrists provided in-person patient assessments (>50%) and support to HBS and primary care providers. We initially experienced, but were able to overcome, challenges with HBS recruitment and retention, slowness of clinic engagement, and rates of referrals.

Conclusion

A behavioral health model was successfully implemented in multiple primary care settings as part of JMAP. Deployment of HBS-psychiatrist teams was challenged by geography, integration into local clinic team workflows, and workforce issues that were successfully addressed. Patients and primary care providers valued having access on site to behavioral services.

Implications for the Patient

Patients often receive suboptimal care and suffer negative health consequences due to barriers in accessing behavioral health services. Provision of services in primary care settings is convenient for patients and facilitates receipt of behavioral health care.