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Panelists of Integrating Mental Health in the Primary Care Setting: The Case in the U.S. and Abroad and GHDonline staff

Integrating Mental Health in the Primary Care Setting: The Case in the U.S. and Abroad

Posted: 11 Nov, 2013   Recommendations: 6   Replies: 41

Dear All,

Please join us for a virtual Expert Panel, from November 18 to 22, to share experience and discuss possible solutions to improving mental health services and the potential for integration into primary care.

One in four adults −approximately 61.5 million Americans− experiences mental illness in a given year. One in 17 −about 13.6 million− live with a serious mental illness such as schizophrenia, major depression or bipolar disorder. (The National Alliance on Mental Illness. March 2013. http://www.nami.org/factsheets/mentalillness_factsheet.pdf) Globally, people with mental disorders experience disproportionately higher rates of disability and mortality. Homelessness and inappropriate incarceration are far more common for people with mental disorders than for the general population, and exacerbate their marginalization and vulnerability. (World Health Organization. 2013. http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf)

Between 76% and 85% of people with severe mental disorders receive no treatment for their disorder in low-income and middle-income countries, the corresponding range for high-income countries is also high: between 35% and 50%. (WHO. 2013) In the U.S., treatment of mental illnesses has gone from an inpatient model of mental hospitals, as portrayed in the novel, and later film One Flew Over the Cuckoo's Nest, to an outpatient and community-based model. However, the US has not yet succeeded in developing an integrated community-based mental health care system reliably accessible to those in need of services. In poor and developing countries, the WHO states, mental health is completely neglected and the quality of care is poor with very few mental health professionals. There, the WHO argues, redirecting funding for mental health towards community-based services would allow access to better and more cost-effective interventions for more people.

Today, some are calling for a new model that would integrate mental health into primary care. The idea is that receiving care in an integrated model, as opposed to having to visit separate facilities and various clinicians, would be more beneficial to patients and their health. While this approach seems to achieve positive outcomes overall, the literature is less clear on benefits and identifies numerous challenges. In its 2008 evidence report on the subject, The Agency for Healthcare Research and Quality concluded that “without evidence for a clearly superior model, there is legitimate reason to worry about premature orthodoxy.” (AHRQ. October 2008. Report No.: 09-E003. http://www.ncbi.nlm.nih.gov/books/NBK38632/) But in a 2012 report, AHRQ notes that “Collaborative care interventions improved outcomes for depression and quality of life in primary care patients with multiple different medical conditions.” (AHRQ. August 2012. Report No.: 12-EHC106-EF. http://www.ncbi.nlm.nih.gov/books/NBK100652/)

We are delighted to welcome the following panelists:

- Ken Duckworth, MD, serves as the medical director for The National Alliance on Mental Illness (NAMI). He is double board certified in adult and child and adolescent psychiatry. Dr. Duckworth is an Assistant Clinical Professor at Harvard Medical School, and has served as a board member of the American Association of Community Psychiatrists.

- Allison Hamblin is Vice President at the Center for Health Care Strategies. There, she focuses on system-level strategies to promote integration of physical and behavioral health services in primary care and other settings, particularly for low-income populations.

- Giuseppe Raviola, MD MPH, is medical director of the Psychiatry Quality Program at Boston Children's Hospital, an Assistant Professor of Psychiatry and of Global Health and Social Medicine at Harvard Medical School, and is involved in a variety of mental health work in rural communities here and in abroad. He notably leads the Dr. Mario Pagenel Fellowship in Global Mental Health Delivery with mental health clinicians in Rwanda, Haiti, and in the U.S.

- Stephanie Smith, MD is a psychiatrist at the Brigham and Women’s Hospital in Boston where she is a fellow in psychosomatic medicine. She is also a fellow in global mental health delivery and implementation science in the Department of Global Health and Social Medicine at Harvard Medical School. Since 2010 she has worked in Rwanda with Partners In Health.

- Anjali Thakkar is the Co-Director of Behavioral Health at the Crimson Care Collaborative Chelsea in Boston. She has been implementing a program called IMPACT which incorporates mental health into primary care visits. She also has worked with the Institute for Healthcare Improvement on developing a tool for behavioral health organizations to assess their ability to integrate primary care services.

During our virtual Expert Panel discussion, we will address the following questions:

Day 1. What are today’s main challenges and promises to providing mental health services to people affected by mental health diseases in your setting?

Day 2. What models of integration have been used? What are the key elements of programs and payment schemes that have been implemented and sustained in large health systems but also in resource-limited settings?

Day 3. What barriers have you encountered in integration of services? How can we address these?

Day 4. What is the role of peer supporters, social workers, and patients in improving mental health services and integration? Are there any Health IT applications that show promise for self-support?

Day 5. In conclusion, how can we improve the delivery of mental health services for patients and their families? What is the role of research, policy, and advocacy?

How to Participate:

1. NCD and YP-Chronic community members: This Expert Panel is taking place in both communities. You will receive email notifications for this panel based on the email notification settings you’ve selected for these communities in your GHDonline profile. If you’d like to update your email notification settings for this Expert Panel, or any of your GHDonline communities, please log into your GHDonline account (https://www.ghdonline.org/accounts/signin/) and select « Edit Email Settings » from the « My Profile » drop down.

2. Not a member of GHDonline? Click the « Join Expert Panel » button on the right to sign up for this Expert Panel.

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve health care delivery in underserved populations in the US.

Finally, in an effort to understand the impact of our Expert Panels and how we can improve, we invite you to take a short 4-question survey before this panel begins at this link: https://www.surveymonkey.com/s/8V33NBL. Once the panel has concluded, we will invite everyone to answer a similar, short follow-up survey.

We look forward to this discussion, so join the conversation and share your thoughts!

Sincerely, Sophie

Replies

 

Sandeep Saluja Replied at 7:56 PM, 12 Nov 2013

Thanks Sophie.This is exciting and very relevant.

SOUMYADEEP MUKHERJEE Replied at 4:24 PM, 13 Nov 2013

Thanks a lot, Sophie. Looking forward to this expert panel. Very interesting and relevant topic.

Deep

Sophie Beauvais Replied at 11:02 AM, 15 Nov 2013

Dear All,

We very much look forward to the start of this virtual Expert Panel next Monday! Please remember to take our short 4-question survey before Monday: https://www.surveymonkey.com/s/8V33NBL. We sincerely appreciate your input!

Already, feel free to introduce yourself and your work, and ask questions to our panelists as we gear up for this web discussion.

Last but not least I'm delighted to share with you that the following colleagues will also join us on this discussion:

- Robyn Osrow, MD, psychiatrist, is currently a Dr. Mario Pagenel Fellow in global mental health delivery with PIH in Rwanda. Prior to her work with PIH, she has worked in nine different countries, mainly with Doctors Without Borders, as well as in various settings in the US, to provide mental health care to populations in need.

- Fils-Aime Reginald, MD, is the Director of Mental Health Services at Mirabelais Teaching Hospital in Haiti. He has been working with mental health team at PIH Haiti (Zanmi Lasante) since 2009. He provides supervision and teaching to generalist physicians as a part of the team's larger effort to integrate mental health care into primary care services.

- Rupi Legha, MD, is a psychiatrist currently working with the PIH mental health team in Haiti. As a Pagenel Fellow, Dr. Legha is supporting the team's efforts to develop mental health care systems in Haiti.

The Dr. Mario Pagenel Fellowship in Global Mental Health Delivery provides an opportunity for career development in global mental health service delivery and research for post-graduate psychiatrists. Fellows develop expertise in the field while working in Haiti or Rwanda with Partners In Health and in collaboration with the Harvard Medical School Department of Global Health and Social Medicine. (more info http://ghsm.hms.harvard.edu/education/fellowships#pagenel)

Best, Sophie

Onaiza Qureshi Replied at 1:33 AM, 18 Nov 2013

Hey, I just joined the panel for Mental health Integration, but Im new
here, and I needed some guidance as to how to go about it. That is, be part
of the discussion, is the session a webcast? Or are the discussions just in
text?
How exactly does the panel work?

Thank you,

Sophie Beauvais Replied at 9:21 AM, 18 Nov 2013

Dear All,

Welcome to this week's virtual Expert Panel on Integrating Mental Health in the Primary Care Setting: The Case in the U.S. and Abroad. To start off our discussion, we'd like to hear from all our panelists and everyone here on the question of the day:

What are today’s main challenges and promises to providing mental health services to people affected by mental health diseases in your setting?

Dear Onaiza, Dear All,

This virtual expert panel is online via text (but you can post images, files, or links of course). You can post via email if you have signed up to "Per Post" email notification (please note: no file attachment by email), or on the web when signed in directly at http://ghdonline.org/mental-health2013/discussion/integrating-mental-health-i...

The panel will last till Friday 22nd 5PM EDT (but feel free to continue the virtual discussion afterward... participants usually do!).

We look forward to reading your comments and questions.

Best, Sophie

Stephanie Smith Panelist Replied at 9:27 AM, 18 Nov 2013

I'm a psychiatrist who worked in Rwanda with Partners In Health for the past two years both clinically and programmatically at the district hospital and health center levels, working to integrate mental health into the primary care health system in Rwanda. We faced a number of challenges in those endeavors as you can imagine, but probably the largest was the significant gap between the treatment needs and the human resources available to manage those needs. We had one psychiatrist in the entire rural area of Rwanda, and just a couple of mental health staff at each district hospital (about 40 districts in Rwanda) to serve 10 million people. As we built services, the needs became more and more clear, as more and more people sought services. Our staff worked as hard as they could but the potential for burn out is large given the clinical demands. Primary care nurses face the same issues— not only are they taking care of increasing numbers of patients with mental disorders, but they are responsible for many other primary care needs of patients as well. However, in Rwanda, there are strong national efforts to improve this situation. There is commitment at the national level to decentralize and give support for these decentralization efforts, even if the budget is currently small. I think the integration of mental health into primary care is most likely to work well using strong existing systems of management and a strong policy environment, both of which are present in Rwanda, so there is a lot to build from.

Robyn Osrow Replied at 9:35 AM, 18 Nov 2013

I agree fully with Stephanie. I am currently working in Rwanda with Partners in Health, and having worked in various resource poor settings around the world trying to provide mental health care, I think that the lack of human resources to provide care is a huge issue. In general, the challenges for providing care for those with mental illness are similar to those faced by trying to provide any kind of medical care in a resource poor area - lack of trained staff, lack of appropriate medications and laboratory support, and structural barriers to care such as not having money or time to get to an appointment. But providing mental health care in a primary care setting also has particular challenges, namely overcoming the stigma associated with mental illness, the chronicity of disease that many patients face, and missed or inaccurate diagnosis.

Giuseppe Raviola Panelist Replied at 9:46 AM, 18 Nov 2013

Thanks Stephanie and Robyn. I am an adult and child psychiatrist who has worked both in the rural and urban US as well as in the Caribbean and Africa. Last week, here in the US Health and Human Services Secretary Kathleen Sebelius announced "the largest behavioral health expansion in a generation,” with health insurance companies in the US on the verge of being required to treat mental illness and addiction the same as other illnesses. A conversation about the integration of mental health care into primary care—the opportunities, and the challenges involved—could not be more a propos.

It seems that appropriately managing mental disorders in primary care will require changing health delivery systems in significant ways: reducing economic barriers to people accessing mental health care as the recent US announcement seeks to do, reducing societal stigma around mental illness, integrating quality improvement methods for mental health into health service delivery, and also finding ways to successfully integrate behavioral health/mental health and primary care as we’re discussing. This integration is still a work in progress here in the US and it’s exciting to be able to have a dialogue here from around the world on this issue.

One significant challenge from my experience is how to provide primary care physicians with the training and supervision they feel they need to support and manage problems related to mental health. Another is how to optimally foster the interdisciplinary collaboration of generalist physicians and mental health providers in a way that works best in context. Even within the mental health professions there are a range of provider roles (nurses, social workers, psychologists and psychiatrists), all with their own professional associations. This presents another interesting challenge for mental health and primary care integration, how to mobilize particular providers most effectively within a collaborative system of care.

Allison Hamblin Panelist Replied at 9:59 AM, 18 Nov 2013

Hello,
My name is Allison Hamblin and I’m pleased to participate as a panelist in this discussion. I focus on physical-behavioral health integration at a US non-profit called the Center for Health Care Strategies (CHCS). CHCS works to improve quality of care in the Medicaid program, which provides publicly-funded health insurance for low-income families and people with disabilities. Our efforts are typically concentrated at the system-level – that is, how can we design and implement policies that support higher quality, more integrated service delivery for Medicaid beneficiaries? Our work involves collaboration with government officials at the federal, state and local levels, as well as their health care delivery system partners. In the area of physical-behavioral health integration, these collaborations center on reducing fragmentation in service delivery for individuals with both physical and behavioral health needs. For example:
• How can we better align financial incentives for payors and providers to support integrated care?
• How can we increase information exchange across settings of care to improve care coordination?
• What reimbursement models can be implemented to support efforts at the practice level to integrate/coordinate care for patients?

In the US, and certainly within Medicaid which supports many individuals with behavioral health needs, the way we pay for care affects how care is delivered. Behavioral health is often covered as a separately managed benefit – with implications for who has the right incentives to support integrated service models in both primary care and behavioral health settings. The US also has strong privacy protections for behavioral health information, which can constrain some efforts to integrate care at a population level.

I look forward to hearing how these and other related issues resonate with the group in the days ahead.

Bob Franko Replied at 5:26 PM, 18 Nov 2013

Greetings from East Tennessee - My name is Bob Franko; I work for Cherokee Health Systems in Knoxville, a not-for-profit federally qualified health center and state-licensed community mental health center. For well over 30 years Cherokee has provided a primary behavioral health integrated care delivery model. We've evolved the model to what we refer to as a behaviorally-enhanced patient centered medical home now. We employ highy-skilled, well-trained behaviorists on our primary care teams - also known as Behavioral Health Consultants (BHCs). The BHCs and the primary care physicians (PCPs) are supported by a consulting psychiatrist to help with the general care of the population-based caseload, as well as to facilitate a transfer of knowledge to make for a much more informed and responsive care team. It is important to note that while our BHCs and psychiatrists are certainly well-trained and more than capable in providing traditional mental health services such as highly structured, regimented CBT - we do not provide this level of care within the context of primary care. As Allison so beautifully referred to previously, ours is a behavioral health approach that addresses both psychosocial and biopsychosocial distress that impact a patient's overall healh and wellbeing. These may include "traditional" mental health presentations such as anxiety and depression, but also symptoms, behaviors and reactions incident to a medical condition (such as maladpative behaviors that exacerbate a physical distress). The interventions provided by the BHC andcare team are brief, aperiodic and very narrowly focused on a specific goal/outcome. This model in no replaces or is meant to subvert traditional mental health care; in fact, when appropriately implemented, it seamlessly supports and interacts well with more intensive mental health interventions.

Understanding that basis, you can imagine the myriad challenges in implementing such a delivery system including 1. workforce development, 2. payer reform, and 3. just a basic understanding of the model. In terms of (1) workforce development, we have yet to find a BHC farm where well-seasoned, patient-ready BHCs can be harvested. Ours are generally home-grown through our internship program, but the need on the national level is staggering and precious few graduate and doctoral programs are responding to he demand. Not to mention the shortage of family practitioners in general, an ongoing issue for communities as our "family docs" age and are not being replenished at any effective degree. Payers (2) have generally lagged far behind in integrated approaches. Mental health carve-outs and fee-for-service models challenge providers to practice an efficient integrated model as they tend to come with many emedded qualifiers and state-specific limitations through Medicaid/MCO rules such as prohibitions on same-day billing for two services (such as medical and behavioral encounters), or the restriction of certain CPT code sets that would better encourage a blended model. And finally (3) there remains highly destructive turf battles between sectors. Some community mental health providers see primary care as the salve to their financial challenges, while some primary care providers build walls keeping mental health providers out due to perceptions of bureaucracy and restricted access. Often the sectors seek to guard their domains and populations, and fear that the other is trying to "take over" their operations - all the while losing the vision of a population-based approach that can be enhanced with collaborative support.

I look forward to more discussion, ideas and sharing of thoughts/resources as we work through this week!

Anjali Thakkar Panelist Replied at 6:54 PM, 18 Nov 2013

I am a medical student at Harvard, and am involved with our student-faculty clinic, the Crimson Care Collaborative (CCC), at the Massachusetts General Hospital, Chelsea Healthcare Center. From my experiences, one of the major challenges and opportunities for improvement in mental health is the integration of mental health services with primary care services. As Dr. Raviola mentioned above, the announcement last week by Kathleen Sebelius about the “parity” provision is a major step in the right direction, and one that is long overdue. It will be interesting to see how the implementation and enforcement of this provision unfolds.

A second challenge that I see is establishing longitudinal relationships with patients to create a safe environment (potentially most relationship in a student clinic environment). At CCC in Chelsea, we target two populations: recently incarcerated individuals, and patients who are high-utilizers of urgent care services. We have implemented a version of IMPACT, an evidence-based program for delivering behavioral health services. For our particular patient population, integrated, longitudinal care is important, both to improve outcomes and to provide patients with a safe and trusting environment which they feel comfortable accessing. It is challenging to make this commitment to patients, while also balancing the resource requirements especially in the setting of a student-faculty clinic in which student turnover is frequent.

Patrick Nakamura Replied at 7:47 PM, 18 Nov 2013

My name is Patrick Nakamura. I have done some social work jobs out in Iowa and am currently a volunteer for some non-profits based on helping people with mental illness. I myself suffer from Borderline Personality Disorder, Obsessive Compulsive Disorder, Depression, and Alcohol Addiction. I was in and out of hospitals and outpatients programs for three years before my parents sent me to the Menninger Clinic in Houston, Texas and afterwards the Houston OCD Program. The experience saved my life and gave me a second chance. I am lucky, my parents were able to afford such places even though the insurance company did not help out at all. In my prior inpatient hospitalizations, I remember getting phone calls from the insurance company asking me if I was still stable enough to enter the real world after only a couple of days of treatment.

Until my experience in Houston, my inpatient and outpatient programs did not help that much. In some, I sat around all day trapped in my own mind/coloring pictures. In others, I was forced to attend groups where they tried to teach us how to control emotions, thoughts, and feelings. It was not until Houston that I learned that somethings you just cannot control, especially in your brain. However, I learned how to appropriately react to the thoughts/feelings/emotions and what to do in a crisis or when I become to overwhelmed. My treatment process was long (I was in Houston for four months, therapy of some kind everyday from 4-8 hours) and I knew I had to continue to work on myself when I came back. It took me four months just to be able to live in the world again without ending up in the hospital every few months. The short stays in the inpatient programs and even the longer outpatient programs were ineffective and approached mental illness and addiction with outdated therapy techniques. Like me, most people that were inpatient in these hospitals had been hospitalized at least once before. You almost never left one of those places feeling better, you left because you felt imprisoned.

I started a support group for young adults with mental illness when I returned and one of the main challenges I come across for people 20-35 is that they either do not have insurance or their insurance will not cover treatment. This makes them seek help at cheaper places (usually state run) and often they do not get quality care. Also, Axis II diseases are often not covered by insurance (such as personality disorders). I have had many peers tell me that the social worker/therapist/psychologist they were seeing refused to see them anymore because they were too unstable. Imagine being thrown out by the very people that are supposed to help you. This makes many people hide their illnesses and not speak up. We once had a graduate student come to a meeting, my partner and I thought it would be beneficial if someone studying to help people with mental illness heard from the people she wanted to help. Some people in the group were put off by this and did not attend the meeting or did not say all they wanted to say in front of the “normal” person; even though that person was accepting and wanted to help.

So the main challenges I come across are having people actually take time and find a good (and affordable) therapist and a psychiatrist (instead of self-medicating with drugs, alcohol, self harm, and sex) and to help people no longer hide what is bothering them. By hiding, we create I disconnect between ourselves and those without mental illness. I never felt included or part of the group even though I have really good close friends. It was only after opening up, taking a chance and being vulnerable did I feel accepted. I want to help people with my limited experience and knowledge that I got in Houston and from my other jobs, but without a degree I cannot do much. Volunteering, writing, and being open about myself so that people can better understand mental illness is my role and I want people in the field to see what I see; people who are too scared to seek help and even if they could, often times have trouble affording it.

ken duckworth Panelist Replied at 9:00 PM, 18 Nov 2013

Hello. My vantage point comes from psychiatry and administrative work in community mental health, work on the payor side of the equation and listening to the experience of family members and persons living with psychiatric illnesses through my work at NAMI.
In my view, the history of the field is part of the problem---asylums, state involvement in payment, fear and prejudice ;towards people create great hurdles towards true integration. Our higher standards for info in mental health and substance abuse are both understandable and also represent problems in information sharing complicating efforts to have an integrated record for example. Primary care is the backbone of mental health care but needs more consistent and financially sustainable support from mental health. For people with serious mental illness the integration may need to occur through the mental health side. Finding sustainable models for this are challenging. The ACO model represents the possibility that aligning payor incentives with outcomes could advance this cause. This is one piece of the Affordable Care Act that I will be watching to see if it can make a difference in this important area.

Rupinder Legha Replied at 7:31 AM, 19 Nov 2013

Fils-Aime Reginald and Rupi Legha are both physicians working for the Zanmi Lasante Mental Health Team in Haiti. This team of psychologists, social workers, and physicians is striving to build a community-based mental health system in Haiti’s Central Plateau. They have submitted this post together.

Haiti continues to face vast inequalities in all domains, including health care, due to an enduring colonial legacy, ongoing economic disempowerment, and an under-resourced public sector. Because the vast majority of Haitians live on less than two dollars a day, accessing quality mental health care (especially in rural areas, where people must travel long distances and lose crucial wages) can be seemingly insurmountable. The challenges of poverty compound a severe human resource shortage (there are only approximately a dozen psychiatrists in the entire country), as well as a material resource shortage (such as the availability of medications).

And, yet, committed families bring their, at times, very sick children for repeat episodes of care; and determined clinicians strive to work around these seemingly insurmountable barriers to deliver quality, humane mental health care. Several examples from this past week come to mind.

On Friday, we discharged a young woman with a suspected diagnosis of bipolar. Her father had brought her into the hospital several days earlier and remained by her side throughout her hospital admission—feeding her, caring for her, and keeping a close and watchful eye. When it was time for them to leave, he affectionately touched her head and commented that she is the one usually keeping a close and watchful eye on him. He also committed to properly administering her medications and bringing her in for a follow-up appointment later this week. When he arrived at the pharmacy and could not understand how to administer the medications (he is illiterate), he immediately called the discharging physician, who carefully and supportively provided an explanation. We have no doubt he and his daughter will arrive for her next appointment. Several days ago, another member of our team hosted a meeting for our community (mental) health workers, who ensure that quality mental health care continues outside of traditional clinical settings. By offering education, support, and mentorship; and by acknowledging and airing challenges and grievances, our colleague is bolstering a growing cadre of individuals who are cultivating our developing community-based mental health system.

We have seen countless examples of families who bring their loved ones in for care—often for multiple sessions—usually traveling hours or even days a time, sometimes by foot. Family members who remain by the bedside for days on end and carefully continue treatment plans to ensure their loved ones’ path to well-being. And we have seen countless examples of dedicated community health workers and other mental health clinicians ensuring that care is continued outside of clinical facilities.

There is a Haitian saying, “vwazen se fanmi” (neighbors are family), which speaks to the power of community and solidarity in Haiti—perhaps one of the most promising aspects of the mental health work we do here. We do not in any way intend to diminish the tremendous importance of poverty and structural barriers to quality mental health care. However, we do feel strongly that community and family in Haiti are fostering the development of a sustainable community mental health model, thereby providing an important (and promising!) lesson for other health care settings, including the United States.

Sophie Beauvais Replied at 8:50 AM, 19 Nov 2013

Dear All,

Many thanks for a great conversation so far. I wanted to reflect briefly on a few comments made on Day 1 of our panel.

In Rwanda, as Stephanie Smith and Robyn Osrow note, there is a strong commitment to improve mental health services within the primary care setting. But there are significant gaps between the treatment needs and the human resources available. Structural barriers to care (e.g transportation, medication and lab support) are also a problem.

In the U.S., the Affordable Care Act is among the big promises. Panelists underscored that health insurance companies will now be required to treat mental illness and addiction the same as other illnesses, while the ACO model represents the possibility to align payor incentives with outcomes and could thus advance integration and comprehensive models of care. Payment models (e.g .Medicaid) also affect how care is delivered which can limit how care is integrated wrote Allison Hamblin. The need for PCP training and supervision and better interdisciplinary collaboration among nurses, social workers, psychologists and psychiatrists was cited as challenges for integration. Patrick Nakamura shared his personal experience and his social work, organizing peer support groups for young adults and the challenges of stigma and having the financial means, time, and opportunity to find the right provider for oneself.

Ken Duckworth noted that "Primary care is the backbone of mental health care but needs more consistent and financially sustainable support from mental health. For people with serious mental illness the integration may need to occur through the mental health side. Finding sustainable models for this are challenging." The AHRQ evidence report finds that PCPs who used evidence-based practice for depression care alone had outcomes as good as mental health practitioners, but that the primary care setting is most likely to accommodate treating mental health conditions when the treatment can be adapted to the primary care settings, while the bulk of the evidence in the integration of primary care into the mental health setting comes from the VA. AHRQ also reports that there are examples of specialty mental health adopting medical model processes of care for behavioral health concerns (e.g .for bipolar disorder).

Today we propose to discuss models of integration. What models have been used? What are the key elements of programs and payment schemes that have been implemented and sustained in large health systems but also in resource-limited settings?

Bob Franko already shared with us the example of Cherokee Health Systems of they refer to now as "behaviorally-enhanced patient centered medical home." Behavioral Health Consultants (BHCs) and the primary care physicians (PCPs) are supported by a consulting psychiatrist. However, he notes that BHCs are mostly trained by the organization as it is difficult to find well-trained ones otherwise.

What models of integration for mental health do you know about and see implemented? Looking forward to reading your experience and thoughts today.

Best, Sophie

Attached resources:

Jeannie Barbieri-Low Replied at 2:38 PM, 19 Nov 2013

Dear Panel Participants:

I'd like to add a perspective from the Global South. MEDICC Review, a peer-reviewed, English-language journal on Cuban health and medicine, devoted its October issue to Mental Health. http://www.medicc.org/mediccreview/

Cuba has a universal healthcare system that focuses on preventive, primary care, based in the community. The Family Doctor-and-Nurse Program embeds professionals in each neighborhood--with each of the country's 11,500 doctor-and-nurse offices supported by a multiservice community polyclinic, 452 throughout the country. At this level, the multidisciplinary workgroup is headed by a team leader (family physician), and incorporates a supervising nurse, internist, pediatrician, OB/GYN, statistician and psychologist.

Psychiatric services are available in all general and pediatric hospitals, 17 specialized psychiatric hospitals, and 101 community mental health centers. The goal to integrate mental health services into communities and adopt more preventive strategies led to the innovation in 1995 of "day hospitals", community-based outpatient psychiatric services where people with more severe mental disorders, not requiring hospitalization, can spend weekdays. Individualized, integrated care is provided and allows patients to live at home.

For more, see full article at "Community Mental Health Services in Cuba" at
http://www.medicc.org/mediccreview/index.php?issue=26&id=323&a=vahtml

With an estimated 450 million people worldwide suffering from mental disorders and less resources devoted to mental versus physical health, pleased to see this issue generating attention and discussion.

Bob Franko Replied at 2:43 PM, 19 Nov 2013

We're often asked to address the different models of integrated care through our training and consultation. After visiting with thousands of individuals from hundreds of organizations from 46 states in the last few years we've learned a few things about this question. I think what we've observed is that there are many approaches to integrated care, but very few are really successful. Moreover, what we define as "integrated care" has wide variation and has almost become a commoditized term that is a catch-all of these different approaches. Indeed, there are many approaches that are successful - but stop short of true integration; they are often successful co-location or preferred referral models. For example, a health center might either employ or contract with another organization to provide a mental health expert - a licensed social worker typically, or a psychiatrist rarer yet - to work within the walls of the health center. They might even become fluent in the language of integration using terms such as "warm hand-off" and "curbside consultations." But when the faceplate is lifted off and an examination of the mechanics is made, what is usually found is a case-find system where a patient is referred to a mental health provider who will often undertake a traditional "case open," full assessment, the creation of a treatment plan, and engage the patient in a structured system of appointments to work on a separate mental health issue. They might have multidisciplinary team meetings, and in more advanced co-located models even document in the same medical record. The leap to a fully integrated model from this approach wouldn't be too much of a challenge. So what's it missing?

We've found that while there are many approaches, they all seem to funnel down to one particular model that works. That model is evolving into a best practice that includes the following traits:
* Blended care team
* Shared support staff and physical space
* Well orchestrated clinical flow
* One clinical record, unified treatment plan
* Immediate communication
* Shared patient population
* Reimbursement mechanisms support the model
* Expanded, behavior-focused PCMH
* Blended and purposefully blurred professional roles
* Targeting high-risk, high-need populations
* Integration defines corporate identity and mission
* Partnership with payers
* In sync with the goals of healthcare reform and the Triple Aim

A fully integrated system is really a cultural shift; it impacts everything. I think one of the mistakes that folks make when they begin a project to integrate care is that they don't think big enough. Famed architect Daniel Burnham said it best: "Make no little plans, they have no magic to stir man's blood." The Joe Parks, MD, et al 2006 study that alerted to us to the fact that people with SMI die, on average, 25 years before their aged peers was a clear warning that our systems needed to change (Parks, J., Svendsen, D., SInger, P., Foti, Mary Ellen, Morbidity and Mortality in People with Serious Mental Illness. NASMHPD, Alexandria, VA, October, 2006). That report certainly brought people to the integrated care table; but they often came too narrowly focused. A best practice integrated care approach is a population-based approach; not one that is keyed on a specific diagnostic spectrum. This is for several reasons, the most practical being that an integrated model is expensive, complicated to code and bill, and has to be sustainable - and to overcome those challenges volume and patient flow are necessary. Beyond that, an integrated approach with its generalist orientation is die-cast for whole population care.

Sandeep Saluja Replied at 7:43 PM, 19 Nov 2013

In very remote and resource limited settings,there is no insurance cover for any illness.The critical issue there is the motivation of the clinician to provide holistic care and going beyond his formal training.

Allison Hamblin Panelist Replied at 9:30 PM, 19 Nov 2013

First, thank you to Bob for that invaluable list of critical factors to support truly integrated care. While this may be a far reach (albeit a worthy one) for most clinical settings today, the good news from my vantage point is that so many practice sites – whether in primary care or mental health settings – are attempting to integrate care at some level. The amount of activity is heartening, and even if many of the models fall short of achieving the full promise of integration, the traditional boundaries between medical and behavioral health care are being chiseled away to one degree or another.

In terms of models that work at a system-level, Pennsylvania has achieved some impressive outcomes in its efforts to improve integration of services for individuals with serious mental illness. As mentioned yesterday, fragmented financing models can present formidable barriers to integrated care – in terms of who pays for what, who has the right incentives to support care coordination efforts, and what information can be shared with whom for what purpose. To address these barriers within its own “carve-out” model, Pennsylvania sponsored two regional pilots that aimed to create new incentives for payors to support integrated care. Specifically, managed care plans (both those managing physical and those managing behavioral health services) were eligible for performance incentives based on their joint efforts to identify individuals who could benefit from intensive care coordination, development of integrated care plans, real-time notification of hospitalizations across systems, and medication management. The local pilots used this framework to build out new models of integrated care – for example, embedding nurse “navigators” in community mental health clinics to work on wellness goals and coordinate individuals’ medical care. A plethora of models flourished, and in total, as demonstrated through a rigorous external evaluation, the pilots demonstrated statistically significant reductions in mental health hospitalizations, all-cause readmissions, and emergency department visits. Consumer surveys also revealed substantial increases in quality of life. One of the most exciting things about this study is the proof of concept that integrated care is good business – which is critical to wide-scale implementation and sustainability.

Attached resource:

Patrick Nakamura Replied at 9:58 PM, 19 Nov 2013

I really agree with what Mr. Franko said. Many places often simplify their mental health integration models and while they may be ‘adequate’, they are mostly designed to get people in and out as quickly as possible. As Mr. Franko points out, a really good system is complicated and expensive. To overcome these problems, raising awareness will help people see that mental health is real and it affects many people. Raising awareness can do many things; including ending the negative stigma, increasing fundraising, better education, a growth in people who go into the mental health field. (I know I am no expert on funding and all that goes into the costs and financials of quality care but raising awareness is very important I think)

As a peer, the most helpful integrated model includes a milieu that is supportive, where bonds are formed that seemingly cannot be formed outside the treatment setting. This method is easier said than done and the bigger the group, the harder it is. You can never have a “perfect” milieu; but one where everyone seems to have at least one person they can confide in that is a peer and not part of the staff is great. Opening up to a peer can help them for the real world when they talk about their illnesses to others. Staff members can encourage bonding and being with peers by having more groups that put people in social situations where interaction is more likely to occur. These connections help people realize they are not alone and so different from everyone in the world.

Loneliness is a problem that many people overlook. In their book, "Loneliness: Human Nature and the Need for Social Connection", by John T. Cacioppo and William Patrick, the authors talk about their twenty odd years of research and how social connection is essentially needed in order to survive. Many with mental illness feel so outcast, so different from others that they end up feeling isolated even when among friends and family. Meeting people with similar problems, the same mental illnesses, the same feelings; it helped me connect to the world and I lost that sense of loneliness I had felt my whole life.

Stephanie Smith Panelist Replied at 2:13 AM, 20 Nov 2013

Thanks for the great comments everyone. Bob—I really appreciated your outlining your experiential evidence on what you have found to be the most important pieces of an integrated care model. In Rwanda, as mental health services are decentralized, there is an important opportunity to integrate within primary care from the beginning. Although I think there are many challenges in a resource limited setting, there are a number of opportunities to capitalize on as well—such as the national health insurance scheme which gives parity to mental health care, shared staff, physical space and record keeping, community based health centers and patient populations, and a strong policy environment highlighting the need for integration of mental health care. By necessity, there are also blended roles within primary care, as the health centers take all comers. In this way, there may be some similarities to the Cuban model of care described by Jeannie.

In the Partners In Health supported districts of Rwanda, our mental health team has developed a system of supported supervision currently being implemented by district mental health staff. Primary care nurses at health centers care for patients with mental disorders, with close and careful supervision by psychiatric nurses, who are district based and provide referral services for complicated patients. There is also a focus on continuous clinical and systems based quality improvement. The program is geared towards both common and severe mental disorders. However, severe mental disorders probably make up the majority of the patients currently, along with epilepsy (considered part of mental health programming in Rwanda, like many other African countries).

Both Bob and Ken mentioned severe mental illness as one area which clearly needs to be addressed within primary care but perhaps is less adequately covered, maybe because of the high needs of the population. I look forward to hearing about any successes you have had integrating care for this patient population within primary care, and what you imagine the key elements of the program’s success to be.

Robyn Osrow Replied at 3:33 AM, 20 Nov 2013

Thanks Stephanie, for your post. You have well described some key tenets of the program in Rwanda, and have shortened my post! And I really appreciate the previous posts - I am learning a lot about care within the US. It is clear that similar issues are faced around the world, and that similar principles for a coherent integrated system (which Bob has detailed) are going to apply no matter what the specifics of the setting.

I would like to come back to an important topic. I think that the issue of payment is a huge one, and a positive I have noted in many developing countries is that parity is not an issue. The rate limiting step may be lack of personnel, medications, etc, but mental health is not “discriminated” against in the payment system as it is in the US. Countries such as Kenya, which is moving towards a system of national health insurance like Rwanda, include mental health in the system, and generally where public or subsidized health care is provided, mental health care is included if there is available treating practitioners, medications, etc. It is worth noting here too that in much of the EU, mental health is seen as part of essential medical care and as a public health issue, is covered by the national health insurance, and is better integrated into primary care. We in the US should learn from these other systems of care.

Sophie Beauvais Replied at 10:35 AM, 20 Nov 2013

Many thanks Patrick for highlighting the need for peer support and advocacy in any model of integration of care.

And many thanks to Bob, Allison, Stephanie and Robyn for sharing examples of models of integration and thoughts on the barriers that exist.

Clearly financial and structural barriers are a big problem. How can these be addressed? Any examples of how organizations work to overcome these? Would love to hear from everyone on this.

Food for thought from AHRQ (October 2008. Report No.: 09-E003.):

"Efforts to implement integrated care will have to address financial barriers."

"No reimbursement system has been subjected to experiment; no evidence exists as to which reimbursement system may most effectively support integrated care."

Thank you, Sophie

Bob Franko Replied at 2:15 PM, 20 Nov 2013

"Yeah, but how do you pay for it?"
Think we ever get that question? Ha.
Or...
"Well, Tennessee is unique; we can't do the integration because our state is different."
I suppose that was true to some extent a decade ago, but as Angela pointed out in in her example of what's happening in Pennsylvania, more and more states are coming around to the idea of integrated care, but there is still much debate on how to actually pay for it. Essentially there are but a handful of funding mechanisms that we've seen:
* Fee-for-service
* Case rates
* Capitation
* Blended Capitation
* Incentive Pools/Shared Savings
* Percent of Premium
Notice I left out grant funding as that is not really what we're talking about here in terms of sustainable methods.
I think we've made the case this week already about the challenges of fee-for-service payer structures, especially when married to a behavioral health carve out. CPT guidelines say that Evaluation & Management (E&M) codes should not be billed on the same day as the behavioral health intervention (CPT 96150-55). Other issues include when a claim is rejected because of an invalid diagnosis usually attributed to a behaviorist using a medical diagnosis, or when MCOs don't credential behavioral providers.

A highly functioning, best-practices integrated care model when supported by a fee-for-service model is also fraught with a number of "almost billable" services such as the hallway and phone consultations outside of the presence of the patient, the weekly multidisciplinary team meetings, and the real-time access to providers such as through telepsychiatry. We often think about a few things in terms of the "building blocks" to fund integrated care:
* Same day billing (efficiencies for both the patient and payer)
* Health and Behavioral Assessment/intervention CPT Codes (96150-55)
* Placing a value on consultation and case coordination
* Per-member/per-month (PMPM) care management rates
* Global funding streams
We don't mind - and in fact, prefer - being at-risk for the populations we serve. We've had several of these types of contracts with payers and they've worked out well for the patient, payer and us. We've seen data from one payer that when compared to our safety net provider colleagues in the state that we produce 68% fewer ER visits, 42% fewer referrals to specialty care, 37% few hospital admissions and an overall 22% reduction in overall costs - all the while producing 17% MORE primary care visits. It's a good leverage basis to be able to prove that we can deliver over a 20% cost reduction. It makes for discussions about shared saving models and PMPM arrangements easier to have. Of course, you have to have the model in place before you can have those discussions. In fact, more data is forthcoming that continually shows the overall medical cost savings of integrated models to be in the neighborhood of 20-30% (Strosahl & Sobel, 1996).

One thing to consider as we move into a post-reform world where the contracts we develop as individual organizations with our MCO partners is that we all have to become highly-skilled negotiators and more adept contract readers. Most administrators feel that they have no options and simply have to sign any contract that comes across their desk, and have never had to go toe-to-toe with a managed care organization under the bright lights of a tough negotiation tussle. The more education and support we can find for administrators in contract review and negotiation, the better options we can provide for our patients.

Allison Hamblin Panelist Replied at 10:04 PM, 20 Nov 2013

On the subject of “how do we pay for it”…
One of the lesser talked about features of “Obamacare” is the broad array of payment and delivery system reforms it has catalyzed – most of which have an explicit link to improving integration of service delivery. For example, in Medicaid, states can now pay for some of those very important and previously hard to bill for services like care management, care coordination, and telephonic contacts. This is possible through a new option to create “health homes” – which aim to extend the patient-centered medical home concept to include behavioral health providers, and to increase the focus beyond medical care to include behavioral health and other social support services. For example, states like Iowa, Missouri and Maine are using this model to bring behavioral health professionals into primary care settings to provide care management/care coordination – an important step toward the ultimate goal of truly integrated care delivery. While payment models vary, most entail some form of “per member per month” capitated payment.

Another large effort is called the State Innovation Model initiative – through which dozens of states across the country are working to design more integrated models of care for their entire state population, regardless of payer. Payment reforms that provide better incentives for integrated care are a core part of these efforts, and we should see these models coming to light over the next two years.

There is a whole body of work focused on integrating care for individuals dually-eligible for Medicare and Medicaid – many of whom have behavioral health needs of one form or another, and who have the added complications associated with having two sets of insurance that each pay for different things.

I could go on and on, but suffice it to say we appear to be a tipping point on these issues in the US. I’ll end with specifics on a very interesting new model in Massachusetts, where primary care providers have a new option to take on any one of three levels of responsibility for behavioral health integration. Options range from taking on new care coordination responsibility, to providing a limited array of brief behavioral health interventions, to providing onsite psychiatric support. Participating primary care practices receive a bundled payment, based on which level of integration they support. The initiative rolled out earlier this year, and many are watching closely to learn from its experience.

ken duckworth Panelist Replied at 7:08 AM, 21 Nov 2013

Allison makes some great points about the models of integration. In my work as a policy maker and student, I have been impressed at how challenging it can be to study the effects of policies to inform best practices. Budgets are often short term, data sets are often conflicting, leadership is often in flux. Developing an understanding of what models gets better outcomes in a affordable manner is the promise of these initiatives. It will be a challenge. Ken

Sophie Beauvais Replied at 11:36 AM, 21 Nov 2013

Great point on studies. I was just looking at the AHRQ 2008 review on this and they commonly found these limitations:
- Studies conducted under atypical circumstances
- Using additional personnel covered by external resources
- Addressing depression uncomplicated by other mental health co-morbidities such as alcoholism or anxiety

It might be of interest to people here to see a list of studies done in Europe on this topic as well as AHRQ’s future research recommendations so adding these to our discussion.

Last, does integration call for more non-physician workforce? "With the decline in production of primary care physicians, other ways will be needed to produce this vital service. One answer may be greater use of nurse practitioners/specialists in mental health and more medically trained social workers. If so, they will need training." (AHRQ 2008). To that, I would add peer supporters and caretakers, like relatives, who are not always recognized by the system. Can this be supported?
And that may be trivial but what of Health IT applications? Are there any that show promise for self-support?

Best, Sophie

Attached resources:

Bob Franko Replied at 12:21 PM, 21 Nov 2013

Great questions today, Sophie. First, I'll touch on the workforce, and then circle back to technology - and the two are even related in some aspects.

You're exactly right about the need for a more diversified workforce in an integrated setting. Not only due to the shortage of family physicians entering the field, but also because of the unique demands an integrated system creates. Well-trained advanced practice nurses in both general med and psychiatry are wonderful resources in integrated settings, especially in places where physicians and psychiatrists are hard to find. I know in many parts of Appalachia and in much of our service area in East Tennessee this to be the case, as it is in many of the frontier regions of the Plains states, and throughout the south and southwest. Beyond that obvious extension though is the need for highly qualified and well-trained behaviorists who can function in the fast-paced, highly unpredictable world of primary care. These are clinicians that have to function much like primary care providers and have a wide generalist orientation to serve a diverse caseload. Not all Ph.D.s or social workers are cut out - nor do many want - to do this type of work. Next, it is imperative to find a consulting psychiatrist (or a psychiatric APRN) who functions much more as a consultant to primary care and sharer of knowledge rather than a catch-all referral agent. So, yes, workforce development is very important in the continuing acceptance and evolution of an integrated approach.

You also mentioned IT. Given the demands of instant communication, shared information, and data collection/reporting, we find it very difficult (not impossible though) for an integrated approach without a decent electronic medical record system. An integrated approach is all about access and the sharing of information across a multidisciplinary team - most of which will be done in person - but it is still vital that the information is collected in a centralized accessible document. I'm sure I need not sell anyone on the benefits of an EMR at this point. Other technology that is as equally helpful in an integrated model are smart phones and telehealth systems. Being able to extend a consulting psychiatrist or perhaps even a BHC across vast service regions is important, especially when we circle back to the workforce issue. The technology to do telepsychiatry, telehealth, and even telepharmacy improves all the time. More states every year recognize the immense cost savings and complete lack of a drop-off of quality with these types of electronic services and allow for these to be billed.

I would imagine our colleagues from Rwanda and other places around the globe have similar experiences in the development of IT and other technical aspects to extend services.

Sophie Beauvais Replied at 1:39 PM, 21 Nov 2013

Many thanks Bob. Indeed, IT has many potential. I was reading a bit about the IMPACT model which Anjali Thakkar said was used at the Crimson Care Collaborative Chelsea Healthcare Center at MGH and found that University of Washington (IMPACT is a program of the University of Washington, Department of Psychiatry & Behavioral Sciences) offers a free 13 module online training program (it’s $50 if you complete it and want credit). http://impact-uw.org/training/web.html

They also share an annotated bibliography, job descriptions, videos, team building tools, and other resources here: http://impact-uw.org/tools/

To those of you who are not familiar with IMPACT: “In one of the largest treatment trials for depression to date, a team of researchers led by Dr. Jürgen Unützer followed 1,801 depressed, older adults from 18 diverse primary care clinics across the United States for two years. The 18 participating clinics were associated with eight health care organizations in Washington, California, Texas, Indiana and North Carolina. The clinics included several Health Maintenance Organizations (HMOs), traditional fee-for-service clinics, an Independent Provider Association (IPA), an inner-city public health clinic and two Veteran's Administration clinics.” I’ve invited a few folks from there to discuss with us.

Would love to hear from others re: workforce and IT, Sophie

Giuseppe Raviola Panelist Replied at 2:06 PM, 21 Nov 2013

Thanks Bob and Sophie. Use of IT could potentially be a critical tool for the delivery of mental health services in less resourced settings. Where we work in Haiti with Partners In Health we plan to pilot a cell-phone based interface for helping community health workers refer and track outcomes in their work. However, this is very early stage work, which follows the initial task of working to successfully engage and support community health workers in the identification and delivery of care for mental disorders. We have also sought to apply some of the core principles embodied by IMPACT—systematic diagnosis and outcomes tracking, and a stepped-care approach that shares tasks across provider roles—in our work.

There is the technological. There is the organizational. There is the financing aspect. And there is the simple fact of limited human resources. Commonly there are few specialists, or specialist-training programs for that matter, and much of the delivery of mental health care will necessarily have to happen in the community thought non-specialists. In 2011 WHO developed the mhGAP Intervention Guide for nonspecialist providers, to support the need for “skill-package based planning”. Others are also thinking about the fact that such packages of care need to be adapted and integrated into existing health care systems, and they need to be operationalized. I’ve included a link to the mhGAP materials in various languages as well as an article from Patel et al (including Un ützer of IMPACT) from PLOS Medicine (2013) describing some of the current thinking on integration of mental health in less resourced contexts. This article is part of a 5-part series in PLOS Medicine examining mental health integration.

Looking at the literature there are case examples from all over the world on efforts to integrate mental health care into primary care. But as we are discussing there is much to learn yet from this work. Are there others for whom methods of “task sharing” across provider roles have been helpful, or for whom IT has been successfully implemented to provide greater access?

Attached resources:

Stephanie Smith Panelist Replied at 5:05 PM, 21 Nov 2013

Thanks all. I completely agree with Bepi that IT has the potential to contribute immensely to systems development in resource limited settings, especially where specialists are few. For example, our primary care integration program in Rwanda has the potential to be sustained by a system of tele-supervision within the country, enabling specialists to supervise a significant number of health centers or districts. Bob also pointed out that technology is useful in the USA as well for managing workforce shortages in mental health. Yet as others have mentioned, the creation of quality integrated services through "task sharing" (including adequate training and supervision of non-specialists, case finding, follow up and outcome measurement at all levels), as well as managing structural barriers (such as a lack of reliable electricity at many health centers) must occur prior to, and simultaneous with, IT interventions. These are some of the major challenges of system building. I look forward to others' continuing responses about how the use of task sharing or IT interventions have helped create higher quality services in their experience.

Giuseppe Raviola Panelist Replied at 5:42 PM, 21 Nov 2013

Just one more background document from AHRQ: Establishing the Research Agenda for Collaborative Care:

"This collection of three research papers represents the fruits of the AHRQ-funded Collaborative Care Research Network Research Development Conference in Denver in October 2009. At the meeting, participants took steps toward establishing a research agenda for collaborative care among primary care and mental health clinicians."

Attached resource:

Allison Hamblin Panelist Replied at 9:21 PM, 21 Nov 2013

Great discussion today. One of my favorite health care innovations comes to mind in this discussion: Project ECHO. Project ECHO is an amazing evidence-based approach to building workforce capacity leveraging technology. It was developed at the University of New Mexico and has since been replicated in many sites across the US (including Harvard) and internationally. Its goal is to build the capacity of primary care teams to treat a more complex array of conditions in the primary care setting, thereby increasing access to specialty care for underserved populations. Here's how it works: groups of primary care clinicians from disperse geographies join regularly-scheduled telehealth clinics (say, Tuesdays at noon) that are focused on a particular specialty/clinical topic (say, behavioral health). They are joined in this virtual clinic by a multi-disciplinary team of specialists from an academic medical center, with everyone joining via videoconference. A subset of the participating PCPs each present a case for consultation by the specialist team, each of whom weighs in with treatment recommendations as warranted. All of the PCPs who join the virtual clinic (not just those who present each week) learn from these unidentified case conferences, just as they would during grand rounds during their medical training. Over time, through ongoing regular participation, the PCPs build their own permanent capacity to treat these conditions -- with a broad array of benefits: 1) increased access to specialty care for patients, particularly those who often have difficulty accessing specialists; 2) broad and rapid dissemination of best practices -- for example, as new treatment modalities/better evidence emerges, these clinics provide a channel for rapid dissemination of new knowledge; 3) effective triage mechanisms for specialists -- when more patients who can be treated in primary care settings are (with appropriate supervision), this frees up specialty time to treat the more complex cases who require that level of expertise.

Project ECHO has been shown to produce clinical outcomes in the community that are equivalent to those achieved by academic medical centers. I'll attach one of the studies here for reference and would encourage you to visit the link below to learn more. In New Mexico, it's been used to dramatically expand access to buprenorphine, has trained a workforce of 500 community health workers, increased access to hepatitis c treatment... the list goes on and on. And apropos of this discussions, there is currently a large effort underway to use it specifically around behavioral health in primary care.

Attached resources:

Anjali Thakkar Panelist Replied at 10:17 PM, 21 Nov 2013

Thank you, Sophie, for bringing up IMPACT. As you mentioned, we have implemented a version of IMPACT at our clinic. The Crimson Care Collaborative at MGH Chelsea predominantly serves two patient populations: 1) recently incarcerated individuals who are at high risk of death upon release from incarceration, esp. in the first 2 weeks following release, and 2) patients who have been unable to establish routine primary care and are high utilizers of urgent care services. After conducting a comprehensive needs assessment, we found that some of the primary causes of depression in our population were substance abuse and intimate partner violence. Thus, we have adapted the IMPACT model to address the needs of our particular community, and we use screening tools such as the PHQ-2/9, DAST, AUDIT/AUDIT-C, etc. Our model employs interdisciplinary collaboration between MD and NP students to provide a healthcare model suited toward an interdisciplinary model approach. In addition, student clinicians are mentored by a Psychiatry resident. Primary care is incorporated with behavioral health to ensure holistic healthcare, and the IMPACT model ensures longitudinal care which decreases referrals and wait times, increases patient turnover and compliance.

The resources that you pointed out are terrific. We use a lot of the training module videos for our training sessions, in addition to a live interactive training session hosted by Dr. Alex Keuroghlian and Dr. Trina Chang (both at MGH). I'd be happy to share more information including our workflow with anyone interested.

Giuseppe Raviola Panelist Replied at 7:35 AM, 22 Nov 2013

Thank you very much Anjali and Allison. Both Project ECHO in New Mexico ((USA) and IMPACT in Washington state (USA) are shining lights that are teaching us important lessons. Wonderful to hear about the Crimson Care Collaborative in Boston (USA). Is anyone else out there aware of other exciting or innovative initiatives integrating behavioral health and primary care that would be of interest to the discussion? It would be great to hear of other initiatives from around the world, either ongoing or nascent, that integrate behavioral health and primary care, and that people are feeling hold meaningful potential to increase access and/or quality care to populations that have previously lacked access. There is significant commitment coming from WHO exemplified for example by the mhGAP initiative. There is the PRIME consortium to improve evidence on scaling of mental health care. There are significant research efforts around the world (just a few examples include Ricardo Araya and colleagues in Chile, Vikram Patel and colleagues in India, and Atif Rahman and colleagues in Pakistan--just some of many exciting examples that come to mind for me) teaching us about effective models of care for mental health that are integrated within existing health delivery infrastructures. There is much happening in this area and it would be great to hear about other interesting or exciting examples people have in mind from which we might learn.

Attached resource:

Sophie Beauvais Replied at 3:44 PM, 22 Nov 2013

Dear All,

Many thanks for sharing these examples for integrated care. You might also be interested in reading this white paper about the DIAMOND Initiative (Depression Improvement Across Minnesota, Offering a New Direction): http://www.integration.samhsa.gov/images/res/DIAMONDWhitePaper200807211.pdf

And the SAMHSA-HRSA Center for Integrated Health Solutions (Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration) has put together a great list of models, webinars and videos here: http://www.integration.samhsa.gov/integrated-care-models/behavioral-health-in...

Now that we’ve discussed many challenges and models for integration, on this last day of our panel I was hoping we could conclude with some thoughts on how we can improve the provision of mental health services for patients and families and what is the role of research, policy, and advocacy? Any other closing thoughts?

Many thanks, Sophie

Allison Hamblin Panelist Replied at 5:45 PM, 22 Nov 2013

In response to Sophie's great wrap-up question, I'd say the IMPACT model is a great case study of the important roles that research, policy and advocacy play in the case of improving access to mental health services and integration of care overall. As the model of integration with the most robust research behind it (at least for integrating mental health in primary care settings in the US), it is currently among the models of greatest interest to policymakers -- who are now more than ever interested in supporting the implementation and scaling of evidence-based models of integrated care. And why are they interested? In part, because the advocacy community has helped make the case that solutions are needed to address lack of access to quality care among individuals with behavioral health needs. This is of course oversimplified... the relationship between research, policy and advocacy is a virtuous circle with mutual reinforcement. But regardless of the starting point, we are currently in a highly opportune moment when these three streams have come together -- and the years ahead hold substantial promise for increased access to mental health services and decreased fragmentation of care across the system.

Sandeep Saluja Replied at 7:27 PM, 22 Nov 2013

A small suggestion for whosoever may like to take it up--Could we have a panel of volunteer mental health experts who may be available to doctors working in remote and resource limited settings for interaction on cases through email?

Robyn Osrow Replied at 10:07 AM, 23 Nov 2013

Hi everyone. I wanted to first say thanks to all for the discussion. A few last thoughts I had reading thru the last entrees. IT will become increasingly important, especially as internet access improves in resource poor areas around the world. And certainly task sharing is already an important and essential part of integration. One (relatively) small improvement which I think could have big benefits in this area of task sharing/shifting would be a greater incorporation of mental health training into the basic curriculum of general nursing and medical students, and into the general training for nurses and medical doctors. This is significantly lacking in many resource poor settings where I have worked internationally, and it makes the goal of integration much harder to achieve in many ways. I think that this is an area advocacy should not ignore.

I was also much impressed by Bob’s earlier description of the 20% cost reduction as well as significant reductions in ER visits and inpatient hospitalizations his program realized. As we work to find the models of care that are able to provide the very best care for our patients, we must also have more research on the economic aspects of this issue both in the US and certainly in resource poor settings around the world.

Sophie Beauvais Replied at 7:48 AM, 25 Nov 2013

Dear All,

Thank you to all our panelists and participants for taking part in this
virtual Expert Panel on mental health and the potential for integration in
the primary care setting. We will be sharing some lessons learned in a
Discussion Brief to be published here in the coming weeks. Note that this
discussion will always be available and open to new comments so feel free
to discuss your experiences.

To Sandeep Saluja's question: If people are interested in the idea of
volunteer mental health experts doing tele-consultation for doctors in
remote and resource-limited settings, either via email or other option we
could think of here at GHDonline, please let us know in this discussion.

Starting today until Monday, December 2nd, 9AM EDT, we would like to invite
you to take a short follow-up survey at this link:
https://www.surveymonkey.com/s/YMLMPKQ
Results from this survey will help us understand the impact of our Expert
Panels and how we can improve.

Best, Sophie

Sophie Beauvais Replied at 8:58 AM, 17 Feb 2014

Dear All,

Thank you again to everyone who participated in our virtual Expert Panel, "Integrating Mental Health in the Primary Care Setting: The Case in the U.S. and Abroad", last November.

Starting today until Monday, February 24 at 9AM EDT, we invite you to take a final short 5-question follow-up survey at this link: https://www.surveymonkey.com/s/Y32ZZD7
Results from this survey will help us understand the impact of our Expert Panels 3 months later and how we can improve.

You can also now access a peer-reviewed Discussion Brief of this panel that summarizes key lessons learned and references exchanged. You can view, download and share it at this link: http://www.ghdonline.org/mental-health2013/discussion/integrating-mental-heal...

Best, Sophie

This Expert Panel is Archived.

While this Expert Panel is no longer active, we invite you to review and recommend past replies and resources. Membership for this Expert Panel is closed, but we hope you'll review the Discussion Brief or join us in one of the many communities on GHDonline.

Panelists of Integrating Mental Health in the Primary Care Setting: The Case in the U.S. and Abroad and GHDonline staff