Integrating mental health care into primary care

Imagine a visit to your primary care doctor that did as much to assess and treat your mental health as it did your physical health. How would such an encounter differ from the ones most of us are accustomed to? Your doctor would ask about your mental wellbeing along with questions about your diet, exercise, lifestyle choices and social behaviors such as smoking. He or she would integrate behavioral health counseling into your physical health care, providing guidance so you can self-manage your medication, nutrition and exercise.

Under this scenario, a physician's primary care practice would be fluent in behavioral health clinical guidelines and standards of care, confident in clinical decisions, and deeply familiar with the community social supports available to patients.

Sounds great, doesn't it? A growing body of research gives us good reason to think it would be. Unfortunately, making this scene a reality for primary care patients across the country is much more complicated than adding a few questions to physicians' typical script. For example, while patients interact directly with a practice's reception staff, physicians and other health care providers during their visit, there is a whole back-end infrastructure that patients may not be aware of that enables the practice to function - from billing and coding protocols to electronic medical records systems to care management platforms - that often isn't built to support behavioral health care integration.

Still, I know that the integration of mental health care into primary care is possible, in part because we're making strides in this direction in New York at both the state and city levels, and in part because it's a health industry-wide goal that's too important to give up on.

In my roles as a public health leader, practitioner, professor and researcher, I have focused on reconceptualizing and transforming community-based health care delivery systems. Plenty of primary care physicians are reluctant to change how they operate in order to integrate behavioral health care into their practices. This is understandable; doing so would involve developing a familiarity with new assessments, medications, diagnoses and treatment styles - a new way of practicing the craft that they have honed for decades. The overhead for accommodating these changes, in addition to the backend system changes mentioned above, is significant and often prohibitive. What will catalyze such systems-level seismic shifts in motion?

Policy has a role to play. As our country's health care system - and especially legislation regarding its financing - continues to evolve at the federal, state and local levels, incentives to integrate mental health care into primary care must be baked into health care financing structures. New York is demonstrating how this might be done. The state's Office of Mental

Health is building incentive structures to encourage primary care providers to adopt the Collaborative Care Model, or the integration of behavioral health services into the primary care setting. The Collaborative Care Medicaid Program, launched in the state in 2015, offers primary care providers a method of financial sustainability to integrate behavioral health care into the primary care setting through supplemental monthly payments at a specified case rate.

There are still restrictions on health care practices that qualify for and maintain participation in the program; for example, practices must demonstrate achievement of quality metrics and ongoing use of patient registries to continue receiving the full case rate. Additionally, the upfront start-up costs of establishing the necessary infrastructure can be a heavy lift for many independent primary care practices.

Policy changes are not enough. Beyond changing financial incentive structures at the health care system level, we must empower primary care providers to see for themselves how integrating behavioral health care into their practices truly benefits patients and improves health outcomes. In New York City, this education is a critical part of the Department of Health and Mental Hygiene's mandate to provide ongoing technical assistance to primary care providers to help them understand how offering behavioral health services will support their success in a value-based purchasing landscape.

Health departments across the country should make it part of their mission to convey the significance that behavioral health integration may have to the primary care providers they serve. Not only is what we're doing in New York City replicable elsewhere, but it's also highly adaptable to the unique socioeconomic characteristics and needs of other cities that can tailor the model in a culturally humble and accessible manner.

I hope that we in the health care field won't stop there. Let's continue to expand our goals, think broader, reach wider, and acknowledge that beyond the primary care environment, there are many other settings that would benefit from more focus on behavioral health. Consider hemodialysis centers, where people with chronic kidney failure undertake weekly dialysis. Or bring to mind oncology, hematology, palliative care and other community-based settings and the significant occurrence of anxiety, depression, mood disorders and other mental health conditions in these contexts. These are optimal environments to drive behavioral health integration beyond just the primary care setting.

We also must keep in mind that the integration of mental health care into primary care settings is a journey, with each step a milestone. It is part of a broader strategy towards embracing population health as an ideology, not just a model clinical outcome towards which we strive. Whether it starts with enabling a private practice behavioral health clinician to co-locate within a partnering primary care facility.