When physical, behavioral health professionals team up

Public health leaders seeking a better way to offer medical care and improve patient experiences have experimented with various health care models, including one known as integrated care.

Integrated care is the coordination of physical health care and behavioral health care, which includes mental health care. When primary care physicians work closely with behavioral health professionals such as social workers and psychologists, they are, together, better able to respond to patient needs. Many Americans with mental health conditions don’t receive the care they need and the coronavirus pandemic has exacerbated the problem, according to the American Medical Association.

Research suggests that while one-third of adults can function normally during a crisis such as a pandemic, others either become immobilized or hyperactive and hypervigilant.

“The COVID-19 pandemic has exposed and magnified the flaws in our mental health system and the true burden of mental illness in our country,” AMA President Patrice A. Harris says in a statement on the AMA’s website. Behavioral health care integration can help save lives and is a proven model that has many advantages over a more divided one.”

If these physical and behavioral health care professionals also work in the same physical space, there are additional benefits — for example, patients potentially save time traveling from one health care provider’s office to another and are less likely to miss appointments.

“Because 60-80% of all primary care visits include a behavioral health component, providing integrated services in primary care is now considered a priority for health systems as they strive to meet patient needs and improve population health,” writes Erica Richman, a research analyst at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, in a new paper she authored with two other researchers.

It’s not clear how often behavioral health and general medical professionals participate in this sort of arrangement. But several studies — we spotlight them below — suggest it might have grown in popularity in recent decades and be more common in some parts of the country than others.

A number of academic articles attempt to answer the question of whether linking behavioral and physical health services can improve the health of adults and children and save money. While the results, so far, seem generally promising, some health care researchers have criticized a lack of clear results and called for higher quality studies.

A big part of the problem: Researchers have trouble comparing programs thanks to differences among them as well as the labels health care professionals give these initiatives.

“Over 175 definitions for integrated care exist, as well as different models of integrated care,” finds a 2019 research study led by Nicole Stadnick, an assistant professor and licensed psychologist at the University of California, San Diego.

Stadnick and her co-authors point out there are no established guidelines for setting up integrated care programs that are most likely to initiate positive change.

“While significant reform is often required for successful integration, there is no national or international consensus regarding the best guidelines or set of implementation strategies for integrated care efforts,” they write.

To provide a fuller understanding of integrated care programs, we’ve gathered and summarized multiple peer-reviewed studies that examine the prevalence of integrated care, its impacts and the potential cost savings. You can find that collection of research below.

We compiled the list to help with a recent episode of Tradeoffs, a new podcast about heath care policy. You can listen to the episode, “Meeting the Mental Health Need,” or read the transcript.

If you have trouble accessing some of these papers, please check out our tip sheet on seven ways journalists can access academic research for free.

—–

 

How common are integrated care programs?

Primary Care, Behavioral Health, Provider Colocation, and Rurality
Benjamin F. Miller, et al. The Journal of the American Board of Family Medicine, May 2014.

This study looks at how often primary care physician and behavioral health professionals are located within the same facility. While being in the same physical space doesn’t guarantee they collaborate on patient care, co-location is a key element of integrated care, the authors explain. This study, they write, is an indicator of potential collaboration — and where integrated care is likely not happening.

A research team led by Benjamin F. Miller, a former professor at the University of Colorado School of Medicine who’s now chief strategy officer for the Well Being Trust, geocoded the practice addresses of primary care and behavioral health providers listed in the 2010 National Plan and Provider Enumeration System, maintained by the U.S. Centers for Medicare & Medicaid Services.

Among the main takeaways: 40.2% of primary care physicians in urban areas practice in a location that also has a behavioral health provider, compared with 22.8% of primary care physicians in isolated, rural areas and 26.5% in so-called “frontier” areas, which include most of Alaska.

“The inclusion of behavioral health providers into the largest platform of health care delivery, primary care, is an essential step toward the achievement of the nation’s triple aim of decreasing overall healthcare cost, improving outcomes, and enhancing the patient experience,” Miller and his co-authors write. “Understanding their current proximity and gaps in co-location is a critical first step — one that we hope galvanizes further research to understand how such proximity affects the actual team-based integrated care delivery and population health.”

Proximity of Providers: Colocating Behavioral Health and Primary Care and the Prospects for an Integrated Workforce
Benjamin F. Miller, et al. American Psychologist, 2014.

Where in the U.S. do primary care physicians and behavioral health providers work in the same location? And how does this compare to the co-location of primary care physicians and

psychologists specifically? Miller and his colleagues try to answer those questions in this paper, published in a special issue of the American Psychologist.

The researchers find that in 2010 about 29% of primary care doctors nationwide were co-located with psychologists and that 43% were co-located with any behavioral health provider.

By examining data from the 2010 National Plan and Provider Enumeration System, they also learned that integrated care was much more common in urban areas than rural ones. When comparing them, “the percentage of primary care physicians co-located declines from 31.3 to 6.4 per 100,000 persons, more than a 75% decline,” the authors explain.

Co-location varied widely by state. “At the state level, colocation of primary care physicians with psychologists varies from 14% in South Dakota to 50% in Rhode Island; their co-location with behavioral health providers varies from 27% in New Jersey to 65% in Massachusetts,” the authors explain. “Primarily southern states such as Alabama, Louisiana, and Mississippi have both fewer psychologists and fewer behavioral health providers as well as low levels of co-location.”

Mapping Colocation: Using National Provider Identified Data to Assess Primary Care and Behavioral Health Colocation
Erica L. Richman, Brianna M. Lombardi and Lisa D. Zerden. Families, Systems, & Health, 2020.

This recent study, based on federal data from 2018, looks at how often primary care doctors in the U.S. are working in the same location as behavior health professionals. and includes physicians from a range of specialties, including pediatricians and gynecologists. In this study, behavioral health providers are limited to social workers and psychologists.

The authors estimate that, on average, physicians and behavioral health providers are co-located 44% of the time. In urban areas, the co-location rate is 46%. It’s 26% in rural parts of the country. They find that some types of doctors are more likely to work in the same physical space as behavioral health professionals.

“Pediatricians, obstetricians/gynecologists, and internal medicine physicians were more likely to be co-located than general practitioners and family medicine doctors,” write the authors, led by Erica Richman, a research analyst at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. “General practitioners and family medicine doctors, however, were also the physicians most likely to be working in rural locations, indicating that type of PCP [Primary Care Provider] and rurality may both be predictive of colocation.”

According to the analysis, which relies on 2018 data from the National Plan and Provider Enumeration System, co-location rates differed across regions on the country. Region 1 — comprising Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island and Vermont — had the highest co-location rate: 59%. Meanwhile, Region 4 — Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and Tennessee — had the lowest at 33%.

 

Access to mental health services

Beyond Parity: Primary Care Physicians’ Perspectives on Access To Mental Health Care
Peter J. Cunningham. Health Affairs, 2009.

This paper offers insights on the difficulty doctors had getting mental health services for their patients in 2004 and 2005. Peter J. Cunningham, a senior fellow at the Center for Studying Health System Change at the time, analyzed doctors’ responses to a telephone survey about the American health care system. About 6,600 practicing physicians from 60 randomly chosen communities nationwide participated in the Community Tracking Study Physician Survey, conducted from mid-2004 to mid-2005.

Some key findings:

  • Two-thirds of the primary care physicians who responded to the survey said they were unable to obtain outpatient mental health services for their patients during the past year. For 59% of these doctors, a lack of health insurance or inadequate coverage were a top reason why they had trouble.
  • Primary care providers located in counties with a large number of psychiatrists had more difficulty getting mental health services for their patients, when compared with doctors who practiced in counties with smaller numbers of psychiatrists.
  • Pediatricians were more likely than other types of doctor to say they could not get outpatient mental health services for patients. They blamed health insurance plan barriers and a shortage of behavioral health providers.
  • Doctors who saw a relatively high number of “charity-care” patients were more likely to report being unable to get outpatient mental health services for their patients than did doctors who saw none of these patients.

 

Integrated care: A case study

The White River Model of Colocated Collaborative Care: A Platform for Mental and Behavioral Health Care in the Medical Home
Andrew S. Pomerantz, et al. Families, Systems, & Health, 2010.

In this paper, researchers study the integrated care model used at White River Junction Veterans Affairs Medical Center in Vermont. Its approach had evolved over many years after its implementation in 1989 and, ultimately, became a model for the federal government’s entire Veterans Affairs system after receiving two significant awards — the American Psychiatric Association’s gold achievement award and the Secretary of Veterans Affairs Advanced Clinical Access national champion award in the early 2000s.

As of the paper’s 2010 publication date, White River Junction offered “a full spectrum of mental health care that allows 75% of referred patients to receive all of their care within the primary care clinic, thus conserving scarce specialty services for the most complex patients.”

Andrew S. Pomerantz, an associate professor of psychiatry at Dartmouth Geisel Medical School, and his co-authors describe how White River Junction’s approach to patient care changed after 1989, when a psychiatrist and psychologist were co-located within primary care. The medical center used a number of approaches over the years with promising results, which helped health care professionals expand and refine their model of care.

In 2004, the center’s “Collaborative Care Clinic,” which was primarily an access point in primary care, became the “Primary Mental Health Care Clinic.” Under this new design, many more patients who had been referred for mental health care or who had asked for a referral actually received that care. That number jumped 150%, Pomerantz and his colleagues note. Meanwhile, the number of patients entering specialized mental health care, which can be more expensive, fell by 58%. An additional benefit: The rate at which new patients failed to show up for mental health appointments fell from 38% to zero.

 

What are the benefits, drawbacks of integrated care?

Integrated Care Models and Child Health: A Meta-Analysis
Ingrid Wolfe, et al. Pediatrics, 2020.

What does the research say about integrated care for children? To find out, researchers analyzed almost two dozen studies on the topic and published the first paper to “present a systematic assessment of the effectiveness of integrated health care interventions on important outcomes for children with ongoing conditions including health, health service use, health care quality, education, and cost savings.”

A key finding: “We find that integrated care may deliver improvements in QoL [quality of life] and may offer cost savings; however, there is insufficiently strong evidence currently to make firm recommendations regarding the overall effectiveness of integrated services.”

The authors searched five research databases for studies published between 1990 and September 2018 on the topic. A total of 23 articles reporting 18 interventions met the authors’ inclusion criteria.

The authors, led by Ingrid Wolfe, a clinical senior lecturer in child public health at Kings College in London, write that the variety of interventions offered to patients “brought challenges” to their analysis. They also point out that research quality varies. Only some studies focused on mental health.

“Articles were limited in their descriptions of usual care, making comparison with control groups challenging,” the authors write. “In addition, with the available data, we could not discern which children benefited most from integrated health care. Severity of symptoms and socioeconomic background may be important determinants that influence health care outcomes. Furthermore, no conclusions could be made about the extent of integration that may be beneficial for child health or system measures because there is currently no validated measure of extent of integration.”

Research in the Integration of Behavioral Health for Adolescents and Young Adults in Primary Care Settings: A Systematic Review
Laura P. Richardson, Carolyn A. McCarty, Ana Radovic and Ahna Ballonoff Suleiman. Journal of Adolescent Health, 2017.

For this paper, researchers reviewed the academic literature on integrated care for adolescents and young adults. But they were surprised to find little research on the subject, they write.

“This limited body of literature is particularly surprising in light of the extensive array of collaborative care studies addressing these [behavioral health] conditions in adult populations,” writes lead researcher Laura Richardson, a professor of pediatrics and adolescent medicine at the University of Washington, and her co-authors.

Richardson and her colleagues note that 14% to 38% of the adolescents seen in primary care settings meet criteria for a mental health disorder. The authors’ review “revealed only three randomized controlled trial studies of integrated care models among adolescents, all of which focused on depression. We did not identify any randomized controlled trials addressing behavioral health integration for anxiety, the most prevalent disorder during adolescence, nor eating disorders among adolescents which are often medically managed in primary care.”

Integration of Behavioral Health and Primary Care: Current Knowledge and Future Directions
Mark E. Vogel, Kathryn E. Kanzler, James E. Aikens and Jeffrey L. Goodie. Journal of Behavioral Medicine, 2017.

This academic article aims to summarize what’s known to date about the integration of behavioral health and primary care. But it essentially outlines problems and shortcomings in the data and research available on the topic.

“Research to date has been promising; however, there is a significant need for more sophisticated multi-level scientific methodologies to fill in the gaps in current knowledge of integrated primary care,” write Mark Vogel, a professor of family practice and psychiatry at Michigan State University’s College of Human Medicine, and his colleagues.

They write that Integrated Primary Care (IPC) models “have evolved and spread relatively rapidly over the past two decades” and that “its continuing progress remains vexed by insufficient consensus regarding key definitions and conceptual models, the need for more sophisticated multi-level scientific methodologies, significant gaps in evidence, and a disparity in research funding relative to fields focused upon a single organ system or medical disease. Because primary healthcare needs to integrate, the cart is truly ahead of the horse. The field is challenged from within and without by confusion, resistance, and significant scientific gaps.”

Integrated Primary Care and Social Work: A Systematic Review
Mark W. Fraser, et al. Journal of the Society for Social Work & Research, Summer 2018.

Integrated primary care provided by health care teams that include social workers significantly improves the behavioral health and care of patients, this study suggests.

Evidence suggests integrated care involving social workers appears to reduce symptoms of depression and anxiety as compared with routine health services, the authors explain after analyzing 32 reports from 26 randomized controlled trials completed between January 1, 2000 and April 1, 2016.

“Patients who received integrated care from an interprofessional team that included social workers were 1.28 times as likely to experience at least a 50% decline in depressive symptoms at 6-month follow-up, compared to patients in the control conditions,” write the authors, led by Mark Fraser, a professor emeritus at the School of Social Work at the University of North Carolina at Chapel Hill.

They also learned that some models of integrated primary care involving social workers “may promote the use of less costly health services and be at least comparable in cost to usual care.”

The authors describe the roles social workers play and their impact on patient health.

“The scope of practice for social workers in integrated care entails three core functions that are often undertaken concurrently: (a) providing behavioral health care for patients with mental health problems and substance-use disorders, (b) managing the community-based care of patients with chronic physical and behavioral health conditions, and (c) engaging community resources on behalf of patients,” the authors explain.

Fraser and his colleagues write that by serving in these roles, “social workers contribute to transformational changes in health and social care that, based on findings from 26 studies, improve the behavioral health and care of patients in integrated primary care.”

Interested in more research on mental health in the U.S.? Please take a look at our write-ups of research on gaps in treatment for kids aged 6 to 17 and how infectious disease outbreaks affect mental health.