Laying the foundation for behavioral health integration

According to the World Health Organization (WHO), the disease burden and costs of behavioral health conditions are staggering: 1 in every 8 people in the world lives with a mental disorder.¹

As a result of the COVID-19 pandemic, there has been a considerable increase in anxiety and depressive disorders: The WHO estimates a 26% jump in the former and a 28% rise in the latter.² A 2020 study of 21 million commercially insured individuals showed that those who have been diagnosed with a behavioral health condition experienced costs between 2.8 to 6.2 times higher than average annual costs for those individuals who did not have a behavioral health condition.³

In 2019, depression was the second-leading cause of disability globally, with anxiety ranking eighth — the two most common types of mental health disorders.⁴ Patients’ medical conditions are often impacted by their mental health and behavioral choices. As such, there is an opportunity to integrate behavioral health care with existing expertise in medical practices.

As noted by the Agency for Healthcare Research and Quality (AHRQ) Academy, integrated behavioral healthcare (IBHC) “is an emerging field within the wider practice of high-quality, coordinated health care. In the broadest use of the term, ‘integrated behavioral healthcare’ can describe any situation in which behavioral health and medical providers work together.”⁵

The AHRQ Academy adds that the “care may address mental health and substance use conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”⁶

Patient-centered care is at the heart of behavioral health integration (BHI). By adding behavioral health expertise to a practice, providers can better meet their patients’ needs and preferences, particularly when providers are already treating mental health disorders such as depression, anxiety and substance abuse.

Historical barriers

From a historical perspective, there have been several impediments to BHI. In a recent Alliance for Health Policy webinar, Harold Pincus, MD, professor, Department of Psychiatry, Columbia University, focused on three in particular. The first dates back to a belief espoused by Hippocrates and Descartes. “We have had this mind-body dualism that thinks of mental health and general healthcare as being two entirely separate things. Mind and body are split,” Pincus asserts.

The second long-standing barrier Pincus points to is the stigma associated with behavioral health conditions — both toward individuals with those conditions and self-stigma.

The third deep-rooted barrier is fragmentation, which has many layers. Pincus uses the metaphor of grain storage, where general healthcare, mental health, and substance use are housed in distant silos. However, Pincus adds that there are additional contributing factors. “There are other silos that have to do with the settings where people are or social determinants of health (SDoH) that might include criminal justice, educational systems for children, social service systems, etc.,” he says.

Due to these contributing factors, Pincus says BHI is best explained through the use of the family farm model. “You have a team working together to make sure the work gets done properly and in a coordinated and effective way,” he says.

Working on the family farm

An example of the family farm model in practice is Magnolia Place Obstetrics, Gynecology & Wellness, in Greenville, N.C. The practice opened its doors in October 2021 and is a self-designed hybrid model of care established by Magnolia Place’s physicians, Marie Stormi Rowe, MD, FACOG, and Ransom Witt Loftis, MD, MPH. It is membership based and is different than concierge in that insurance is accepted. Membership helps patients afford services not covered by insurance, and it also provides an affordable option for those patients who don’t have insurance or have high-deductible plans. 

“We try to do full health and wellness for our patients,” says Practice Success Administrator Carrilee Andreu-Neel, CMPE. “All-in-one care and anything patients could need, we provide it for them here first, including some primary care services.” She adds that the providers refer patients to specialists if the care is outside the providers’ scope.

The practice has two OB/GYNs, two family nurse practitioners (NPs), two licensed clinical mental health counselors, a nutritionist, a yoga instructor, two massage therapists and 12 staff. For the physicians at Magnolia Place, BHI dovetailed perfectly with OB/GYN. “A lot of people don’t realize that OB/GYNs are obligated at times to practice a lot of psychiatric therapy. … because that field is often underserved in women’s health,” according to Rowe. 

Rowe adds that the practice also offers primary care because many female patients will only see their OB/GYN doctor for care. This is a fundamental part of Magnolia Place’s mission and vision — providing as much care as possible in one location. The providers do this by continuously educating themselves and recommending helpful resources to their patients.

Although Rowe has seen an uptick in patients with anxiety and other behavioral health concerns since the start of the pandemic, she notes that the stigma has lessened over time. “I feel like over the past 10 years people are more open to talk about it, especially in the realm of feeling anxious and irritable and describing their feelings a lot easier,” she says.

A crucial step for Magnolia Place was to get the word out regarding its behavioral health services. “We really put a lot of effort into our social media platform and its design … to engage from a community standpoint,” Rowe says. “That part has been very successful.”

For existing patients, the practice began offering screening to measure their levels of anxiety and other behavioral health conditions. “Every patient gets [generalized anxiety disorder] (GAD) screening, [patient health questionnaire] (PHQ) and [Edinburgh Postnatal Depression Scale] EPDS if they’re postpartum, so that is a sounding board,” Rowe says.

She notes that she’s had some patients save their responses and keep journals to monitor their progress. For example, Rowe pointed to one patient whose answers improved over time. Even though she had been Rowe’s patient for eight years, the screenings and journal allowed Rowe to learn more about her than she had in all her years as the patient’s physician. “We gleaned a lot of things that I never knew about her, that she never expressed … how she feels day to day,” Rowe says. “So that’s been very successful.”

Key challenges when integrating behavioral health care

While Medicare payment historically has been a challenge, the four issues that stand out the most are changing cultures, developing sustainable payments models, establishing quality measurements and benchmarks, and addressing workforce needs.

Changing cultures

Even though some progress has been made in reducing the stigma regarding mental health, institutional, self- and public stigma remain embedded in society. For example, an Oct. 2019 CBS News poll showed that 86% of Americans believe those with mental health disorders experience “a lot” or “some” stigmas and discrimination.⁷

Magnolia Place’s colocation of behavioral care within specialty care offices helps to alleviate this stigma. “You’re not walking into a mental health office; it’s a women’s health office and we do a lot of different things here,” Rowe says. “I think that definitely has helped remove the stigma. … Patients are already comfortable being here for their women’s health needs.”

In comparison, the primary care practice where Magnolia Place’s Mental Health Director Jennifer Harrup, MS, LCMHCS, LCAS, MAC, CCS, also works has a much higher no-show rate for patients, whereas Magnolia Place has created what Rowe calls a “familiar safe haven” for patients.

Beyond mind/body dualism, healthcare organizations must also address the culture ingrained in federal, state and private institutions. “For almost 200 years, treating behavioral health conditions was almost exclusively a state responsibility,” Pincus notes. “It was only through the advent of … the Community Mental Health Act” in 1963 “that made resources available at the community level.”

Developing sustainable payment models

Pincus points out that even with the sea change created by the Community Mental Health Act, “there was very little direct support of behavioral healthcare through insurance.” He emphasizes that it’s important to incentivize organizations to integrate behavioral health due to the cost of implementation.

A larger issue may be the lack of investment in behavioral health. “We are actually spending less than 5% on behavioral healthcare as a proportion of the total cost of healthcare,” he says.

Rowe echoes Pincus in that, for her practice, it always comes back to finances when attempting to integrate behavioral health. A big piece of this is the lack of integration of insurance coverage. “If patients knew it was already built into their plan, I think they would more readily use it,” she says. Unfortunately, for many patients, the behavioral health piece is often separate from their primary coverage. “Patients will have different copays that they have to pay for mental health, so that is a deterrent for some,” Rowe adds.

To help confront this, Rowe contends that Magnolia Place strives to make behavioral health services more affordable. “If insurance does not cover mental health, we try to negotiate preferred pricing with therapists that’s even lower than the average pricing in the area to entice patients and encourage them to follow through with it,” she says.

Establishing quality measurements and benchmarks

According to Pincus, it’s imperative to establish uniform benchmarks and quality metrics when integrating behavioral health. “That means building a quality measurement infrastructure that requires stewardship of organizations and leadership at the federal and private level for developing these measures and testing them,” he expresses.

The same holds true on an organizational level. Like most practices new to BHI, Magnolia Place has not yet established benchmarks to measure success. However, Rowe notes the practice is focusing on sustainability and consistency, much like it would with a vaccine drive. For Rowe, it raises a key question: “Can we break the mold for patients and get them to see mental health as necessary and view it similar to a screening or any regular visit?”

She adds that there should be no age restrictions on who receives screening, citing the U.S. Preventive Services Task Force (USPSTF) recommendation in September that only those 65 and under should be screened for anxiety. 

Without a playbook, Magnolia Place has had to look for resources that help with sustainability. To that end, they have been selected to participate in a BHI program.

BHI immersion program

Magnolia Place is taking part in the Behavioral Health Integration Immersion Program created by the Behavioral Health Integration Collaborative. The Collaborative was established by the American Medical Association (AMA) in October 2020 and is also composed of the American Academy of Child & Adolescent Psychiatry, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association.  

Magnolia Place is one of only 20 practices nationwide participating in the industry-expert-led yearlong program, launched in November 2022. “Our first immersion experience we had to do virtually, but we found that everyone that was chosen to participate in this program were in very similar situations, experiencing very similar frustrations and challenges,” says Rowe of their experience with the first module.

Each practice receives enhanced technical assistance, primarily through a virtual learning platform, on how to effectively integrate behavioral health in their practices. Per the Collaborative, there are eight BHI building blocks:

1. Behavioral health as a routine part of care.
2. An integrated care team
3. Accessibility and sharing of patient information
4. Practice access to specialty services
5. Workflows to support population-based care
6. Evidenced-based tracking and treatment
7. Patient involvement in care
8. Data for quality improvement.

At the conclusion of the program, practices will complete an assessment to determine the impact of their participation in the pilot. For more on the Collaborative, visit bit.ly/3VpjXR5.

Addressing workforce needs

As with most clinical positions, there is clear need for more behavioral health professionals. “We need to develop some new models for training and education and look at the roles of peers and community health workers and care managers in terms of how we can standardize training,” Pincus insists.

Per Rowe, Magnolia Place’s two licensed clinical mental health counselors were part of the practice’s mission from the start. Although they spend part of their time working at other facilities, Rowe says that she has had discussions with them about working at Magnolia Place full time.

“They function independently, and then we collaborate from the medical side when it’s necessary for the patient,” Rowe says. “Anyone who requests therapy, we offer them the opportunity to see our therapists versus referral out in the community.”

As they designed the practice with BHI top of mind, the team discussed how they wanted to deliver that care. “A prime example was the group therapy classes,” Rowe says. “They don’t really exist in our area and people don’t readily come to them.”

The group therapy class was the first of what Rowe hopes to be many practice and community initiatives. Another initiative was brought forth by a master’s student at East Carolina University who was working under one of the practice’s clinical mental health counselors. The student developed an LGBTQ support group for students designed to meet at the clinical mental health counselor’s other office. 

Since the group has had a difficult time getting off the ground, Rowe believes it might garner more of a following at Magnolia Place. “If you have the group meet in a collaborative setting like the medical office, people would be more apt to come because our patients feel as though they are part of a community,” Rowe says. “They speak freely about what challenges them in the medical setting when they are in the office.”

Outcome improvement

Even though Magnolia Place has only been open for a little more than a year, Rowe says patients have already seen the benefits spurred by BHI. “I can give you testimonials of patients who said, ‘I felt this way for years and I finally feel less anxious for the first time in a long time, just after one visit with one of our therapists,’” she says.

Rowe cites two examples in particular. One younger patient had been experiencing family dynamic issues, and Rowe pointed out that she didn’t feel confident enough to bring them up during her OB/GYN visits. When she started seeing one of the practice’s clinical mental health counselors, she felt much different after just two visits. Rowe says that when she saw the patient again, the patient mentioned that it “really changed her perspective on how she felt. She felt like a veil had been lifted, talking about the dynamics that she lived.” Rowe adds that “those are the victory stories that keep us trying to hone in on what works and what we can keep doing.”

The second patient was highly non-compliant, according to Rowe. The patient’s mother said that she had been unable to get through to her about taking care of herself. However, since the patient has been to therapy, Rowe notes that she’s turned her life around. “She just messaged me not long ago and said that she’s feeling great,” Rowe says. “She’s doing everything she’s supposed to in terms of her medications. … It was a victory story.”

Rowe has also witnessed a noticeable difference in physical health outcomes, noting that they often go hand in hand with improved mental health outcomes. Patients will “come in asking about hormone testing and I try to explain to them that how they feel mentally and emotionally is another hormone that needs to be talked about in terms of our neuroendocrine system,” she says. “Getting them to realize that how they feel and function [are] really interconnected.”

For that reason, educating patients on basic physiology has helped patients consider different care plans. For example, Rowe notes that yoga has been one of the practice’s biggest successes. “I was just talking with a patient who had never done yoga before, and she was thanking me,” Rowe says. “She said, ‘I love it. … I never realized how beneficial it could be.’” For Rowe and Magnolia Place, it’s just another form of complementary BHI that has led to better health outcomes.

Notes:

1. Institute of Health Metrics and Evaluation (IHME). “Global Health Data Exchange (GHDx).” Available from: bit.ly/3tX6SCA.
2. “Mental Health and COVID-19: Early evidence of the pandemic’s impact.” Geneva: World Health Organization; 2022. Available from: bit.ly/3i2lLAV.
3. Davenport S, Gray TJ, Melek S. “How do individuals with behavioral health conditions contribute to physical and total healthcare spending?” Milliman Research Report. Available from: bit.ly/3tX5QXe.
4. IHME.
5. AHRQ. “What is integrated behavioral health care (IBHC)?” Available from: bit.ly/3tTr48r.
6. Ibid.
7. De Pinto J, Backus F. “Most Americans think there is a stigma associated with mental illness.” CBS News. Oct. 23, 2019. Available from: cbsn.ws/2PdHyFi.