Integration with primary health care remains an urgent challenge to improve outcomes in behavioral care. During a recent webinar, physician leaders from Penn Medicine and the Department of Veterans Affairs spoke about the impact of integration efforts in their organizations.

The June 21 webinar was hosted by the American Medical Association (AMA) which, in collaboration with Manatt Health, developed report to formulate opportunities and challenges associated with the introduction of virtual care (telemedicine) and other digital tools to accelerate the implementation of behavioral health integration.

Matthew Press, MD, is the Executive Physician of Penn Primary Care and Medical Director of the Primary Care Line at Penn Medicine. In these roles, he helps lead clinical operations, practice transformation, and community health management across a network of 90 primary care practices across the University of Pennsylvania Health System.

Prior to Penn Medicine, Press was a member of the senior leadership team at the Center for Medicare and Medicaid Innovation at CMS, where he helped develop and implement several new payment and care models, including ACO, bundled payments, and integrated mental health. and medical houses. He also worked with the Healthcare Payment Learning and Action Network, a national public-private partnership working on healthcare payment reform.

The press began by calling Behavioral Health Integration (BHI) the number one issue we need to address in the American healthcare system due to the high prevalence of mental health problems, the impact that mental disorders have on both quality and cost. medical care in the USA. United States, as well as the lack of access to high-quality and affordable mental health care throughout the country.

“When I was at CMS, we were looking for ways to support integrated mental health and I was introduced to the collaborative care model. This is an evidence-based model for integrating mental health into primary health care that has been around for decades,” Press explained. “There are over 80 randomized controlled trials that show its impact, especially on mental health outcomes, as well as evidence of an impact on improving comorbid disease outcomes as well as reducing the overall cost of care.”

The press has been involved in creating billing codes for the shared care model in CMS. “Then when I came to Penn Medicine with the responsibility of leading the transformation of primary care and community health management, I felt that we would never succeed in the world of community health management and cost-based payment without a truly effective, integrated mental health program. . Therefore, our first priority was to launch a comprehensive mental health program based almost entirely on the collaborative care model. I would refer those who are unfamiliar with the collaborative care model to the AIMS Center at the University of Washington, which pioneered the model.”

Press said that in his primary health practice, he has a Behavioral Medicine Manager, a key new role that works very closely with him. “This person and I are supported behind the scenes by a consulting psychiatrist, so you are taking a really scarce resource of a psychiatrist and extending it to a much wider population using a primary care physician and a behavioral health manager who work with primary health care. doctors. Patients prefer to receive primary care due to low stigma and easy access.”

According to Press, many patients with mild to moderate depression, anxiety, and/or substance use disorder can be effectively treated and have all their mental health needs met in a primary care setting with this model, which is based on actual data. He noted that one of the features is that they centralize the admission process, but otherwise their model looks exactly like the collaborative care model described in the AIM Center.

They use co-treatment billing codes to fund the program after some initial upfront investment. “This allowed us to create a sustainable business model for continued growth,” Press said. “We launched each of our practices in the City of Philadelphia in 2018. At the moment we have about 20 practices. We’ve added 12 or so outside of Philadelphia. We have over 100 practices in our primary health care network, and our goal in the next year or two is to bring collaborative care into all of these practices.”

The press was followed by Edward Post, MD, PhD, who is Senior Advisor to the Director of Primary Health Care Operations for the Veterans Primary Health Care Administration and co-chair of the Virginia Electronic Health Record Ambulatory Council. Modernization. From 2007 to 2020, he served as National Director of Primary Health Care for VA Primary Health Care.

Post said that VA has taken an approach that is more of a hybrid of a collaborative model with some shared resources.

“Ultimately we’re starting with a population-based approach where we screen veterans for behavioral illnesses annually,” he said. “We often have a hot transmission, even if we have a care manager, it’s always great for them to put a name in the face, even before the pandemic, although the use of video, telephone and remote technologies for assistance has increased markedly. increased during the pandemic. The care management community was often telephone or video based. However, warm transmissions can be key, and they take center stage in our more collaborative component that really focuses on crises and also when the need for diagnostic evaluation arises.”

The VA has a mental health integration staff under the Primary Care Medical Home model, a patient-activated care team. “For those veterans with less acute behavioral health needs, we have digital support options that existed not only for patient-care provider interactions before COVID,” he said, “but also for community health and other aspects. fully integrated model. But now most of our behavioral health visits through our care management program are being conducted virtually.”

In the VA model, nearly 95 percent of veterans are regularly screened for various mental health conditions. These include depression, post-traumatic stress disorder, alcohol use disorder, and the more recent concept of suicidal tendencies.

Screening in primary health care is usually performed by a medical assistant or licensed practical nurse. “We made the decision early on that the experience and the need to observe a collaborative care model would really lead us to focus on nurses, social workers, or even clinical pharmacists as care managers within an integrated mental health team,” Post said.

When a positive screening result is found, primary care physicians can in some cases use counseling dialogues for brief alcohol use interventions within the clinical reminder system in the electronic health record, Post said, and they can conduct this brief intervention. Then, depending on additional needs, and even for other conditions besides alcohol use, the attending physician has the prerogative to either take care and follow-up depending on the condition, or involve a mental health integration team, which in many cases is close to the place. provision of primary health care. With difficult patients, they can refer them directly to specialized mental health care. “So there is a whole continuum of mental health, of which the least intensive aspect of our mental health system is, in fact, deployed into primary health care.”

The AMA report on this topic aims to:

  1. Identify the opportunities and limitations of technology adoption to promote BHI.
  2. Identify practical solutions that stakeholders can use to promote digitally enabled BHI.
  3. Demonstrate how to use the AMA Return on Health framework to measure the value of BHI digital models.

These efforts build on the AMA’s ongoing efforts to promote the implementation of BHI in medical practice, as well as its concept of “Reclaiming Health”, which defines the various ways in which virtual care programs can create value.

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