Hospitals, Health IT

How healthcare organizations are fusing primary care and behavioral health

Montefiore in New York is equipping primary care patients with Valera’s behavioral health app, while Cherokee Health Systems in Tennessee utilizes an integrated care model that involves a behavioral health consultant and a primary care doctor working on the same team.

Human brain is made of multi-colored wooden blocks. Creative medical or business concept.

Despite the correlation between physical and mental health, primary care and behavioral health have long been siloed within the world of medicine. Now, however, there’s an increasing push to integrate the two concepts, particularly as some patients are heading to their primary care doctor’s office for mental health-related visits.

How are healthcare providers finding ways to integrate behavioral health into the care continuum? To find out, we talked to two health systems serving different patient populations. One in New York is integrating technology into the workflow, while a Kentucky-based organization has a model involving a behavioral health consultant and primary care physician working together.

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About four years ago, Montefiore Health System in New York received a grant from the CMS Innovation Center to develop a financially sustainable way to integrate behavioral care and primary care. A commonly used model in today’s healthcare landscape is called the Collaborative Care Model. It essentially involves a care manager and psychiatrist working with the primary care provider.

“That model is very labor intensive,” Dr. Henry Chung, senior medical director of Montefiore’s Care Management Organization, explained in a phone interview.

Patients aren’t always available for follow-up appointments or don’t respond in a timely manner to calls. It ends in a lot of phone tag and wasted time from everybody’s perspective.

“That’s when we realized trying to keep the patient engaged with traditional phone-based methods was not working,” Chung said.

Eventually, Montefiore tapped into Valera Health, a startup based in New York City. In a phone interview, Valera’s co-founder and CEO Dr. Tom Tsang said its HIPAA-compliant tech tool uses secure messaging among other things to allow care managers to monitor patients.

In addition to secure messaging with patients, managers can use the app to send educational materials. Patients can use it to complete self-assessments and receive appointment and medication reminders. If the patient opts in, the app can also collect passive data, such as their geolocation and activity. If the patient is inactive or remains at home for a long period of time, the tool can alert the care team. Valera Health’s customers include health systems and payers in four states: New York, Wisconsin, Texas and Florida.

Montefiore initially started using the Valera app through a pilot study that began in July 2016. In total, the organization has had more than 2,000 patients use the tool across 20 different sites in primary care, behavioral health specialty clinics and Medicaid health home care management. The health system has found that the tool has helped give patients more context about their care. It’s also helped with no-shows.

“Patients engaged with the app start showing better appointment adherence,” said Michelle Blackmore, project director for behavioral health integration at Montefiore Health System’s Care Management Organization, in a phone interview.

Additionally, a study of Valera’s app at Montefiore found depression and anxiety scores and remission rates showed improvement. The implementation and use of the app by its patients also helped to disprove a challenge Blackmore fully expected: She expected patients wouldn’t necessarily feel comfortable using the technology or wouldn’t have smartphones. However, she noted that Montefiore hasn’t seen much of that and that if anything, it has experienced high patient satisfaction rates.

Chung declined to discuss the cost of the program. As for quantifying the value of the technology, Chung noted that through care management fees and treatment codes, the app can support billable work. For instance, the New York State Office of Mental Health has a Collaborative Care Medicaid Program that allows PCPs to receive reimbursement for collaborative care.

But has it lowered costs associated with taking care of these patients?

“We do not have statistical power to assess costs at this time, but we know that it improves patient adherence and patient outcomes, which may improve our ability to achieve quality incentives,” Chung said.

Infusing technology into the care journey isn’t the only way to align behavioral health and primary care. A federally qualified health center, which is also a community mental health center based in Knoxville, Tennessee, is taking an alternative approach through its integrated care model.

Cherokee Health Systems operates more than 20 clinics in both urban and rural areas of Tennessee. It serves the migrant farm work population, patients with opioid addictions and those who live in public housing, among others.

Cherokee’s integrated care approach involves a behavioral health consultant (often a psychologist) and a primary care doctor working on the same team.

At the start of an appointment, the patient answers typical questions about vital signs as well as a few behavioral health queries. Next, the primary care physician sees the patient and conducts the visit. If the patient answered affirmatively to the behavioral health questions, the PCP will ask the behavioral health consultant to talk to the patient as well. Rather than a long and drawn out psychotherapy session, the intent of the behavioral intervention at Cherokee is to help the patient with the presenting issue. By the end of the visit, the PCP and behavioral health consultant will reach a consensus about the patient’s care plan going forward.

To support this model, the PCP and behavioral health consultant also share an electronic health record. This ensures they both know what’s going on with the patient. In a phone interview, Cherokee CEO Dr. Dennis Freeman explained that his organization bought an EHR for primary care and wrote its own behavioral health templates.

Cherokee also employs nurses, psychiatrists, community health workers and dentists, who can help with the patient’s care.

Freeman noted that the approach brings a unique model to the rural areas Cherokee serves, where there’s a shortage of behavioral health providers. Overall, he said patients like Cherokee’s model because they don’t have to get referred out to see a behavioral health specialist. Primary care providers, who often don’t have time to attend to behavioral health or substance use disorders, find it comforting to know there’s a behavioral health consultant, Freeman said.

Still, there have been hurdles to using this blended approach. The work requires a unique skill set, so hiring the appropriate employees can be a challenge. Cherokee offers various educational opportunities relating to its work, such as a psychology internship and a practicum experience for master’s and doctoral students. The practicum allows social work, clinical psychology and counseling psychology students to work with and learn from Cherokee healthcare professionals.

There’s also the issue of reimbursement. Freeman noted that although there are specialty billing codes that exist for the work Cherokee does, “it often takes some time to educate a health plan … [on] what this work is really like and make sure you’ve got these codes in the contract.” Cherokee has used different types of value-based payments, he added.

Undoubtedly, bringing together behavioral health and physical health presents its own set of challenges, particularly as it relates to finances. But Montefiore and Cherokee are proving that it’s possible — and beneficial to patients — to intertwine primary care and mental health instead of treating them as separate issues.

Correction: This article previously used the incorrect title for Dr. Chung. Additionally, an earlier version of the article inaccurately referenced what Blackmore said when discussing a challenge she expected with patients using the Valera app.

Picture: Radachynskyi, Getty Images