Integrated Behavioral Health Services in Primary Care - Improving Patient Access and Outcomes

Abstract

Introduction: Approximately one-third of children and adolescents will experience a behavioral health disorder in their lifetime, but the majority will not receive behavioral health treatment. Primary care pediatricians PCPs are most often the first and only health professionals to identify and treat behavioral health disorders, despite lacking time and appropriate training to do so effectively 1. Insufficient access to behavior health services is problematic given that inadequate treatment of behavioral health problems is strongly associated with poorer long-term health outcomes and greater health care cost 2. Practice change: Michigan Medicine’s Integrated Behavioral Health IBH program integrates psychologists directly within the pediatric primary care setting using a co-located model. PCPs consult IBH psychologists for management of behavioral health concerns and refer them patients for treatment which occurs on-site. Aim and theory of change: Research indicates patients referred for behavioral health treatment are 2 to 4 times more likely to initiate treatment in an integrated clinic than those referred externally. The overarching purpose of the IBH initiative is to improve pediatric patient access to high-quality i.e., evidence-based behavioral health services. Targeted population and stakeholders: Michigan Medicine serviced 52,188 patients 29% Medicaid in its pediatric primary care clinics in 2016 alone. Timeline: The IBH program was established at Michigan Medicine in 2012 and is employed in 4 of its 9 pediatric primary care clinics. Several universal screening and skills training initiatives are currently being implemented to improve management of behavioral health issues. Highlights: Improved Access to Treatment: Over 80% of patients referred to IBH psychologists presented for treatment. Enhanced Assessment: Nearly all patients diagnosed with ADHD 96% in clinics with IBH received an assessment that met American Academy of Pediatrics’ practice guidelines. Reduced Medication Use. Since 2012, prescriptions for psychotropic medications has decreased from 16% to 4%. Improved Clinical Outcomes: Overall, patients rated IBH services as effective in 3-4 sessions. Sustainability: IBH psychologists bill directly for services and maintain a full clinical caseload. Expansion of the IBH program to the remaining five clinics is supported by institutional leadership and is expected at a pace of one clinic per year. The program also incorporates a full-scale training program with fellows, interns, and practicum students. Transferability: Start-up costs for an IBH program are low given shared space. The model has empirical support for private practice and adult populations as well. Conclusions and Discussions: PCPs have essentially become “de facto” mental health providers in the United States due to care access problems, and patient health outcomes suffer as a result. Adoption of an integrated behavioral health model in primary care is an empirically-validated solution that can be implemented with minimal effort. Lessons learned: Both patients and providers benefit from the IBH model. PCPs are permitted to focus primarily on medical issues while maintaining assurance their patients will have access to effective behavioral health treatment. Psychologists can anticipate patients will follow-up with appointments and promote population health changes. The integrated setting facilitates collaboration between providers, thereby improving quality of care.