Why integrated behavioral health improves patient outcomes in primary care
Integrated behavioral health in primary care
Integrated behavioral health (IBH) is a whole healthcare delivery model coordinating care for physical, mental, and substance use disorders. The model typically addresses behavioral health issues that primary care providers identify during routine visits. The growing number of interventions and initiatives that providers use to integrate behavioral health into primary care has a positive impact on improved patient outcomes and cost savings .
“Providing IBH in primary care settings can help reduce the stigma patients sometimes experience when seeking behavioral health care, in turn improving patient health care access,” says David Wolfe, MD, Chief Medical Officer of the Massachusetts Behavioral Health Partnership, a Carelon Behavioral Health company. Dr. Wolfe, who maintains a faculty appointment at Harvard Medical School and Brigham and Women’s Hospital in Boston, oversees the Carelon Behavioral Health Medicaid state-direct contract for the Massachusetts market.
Better patient outcomes with less utilization
Since IBH tends to treat conditions earlier and more effectively, data indicates that IBH adoption correlates with a reduction in emergency department (ED) and office visits. In one study, emergency department visits reduced by 7%, and office visits by 6%. IBH also links to primary care practices increasing the overall volume of their services as well as the quality of the care they deliver.
“The collaborative care model, a form of IBH, is an evidence-based approach to treating conditions like depression and anxiety in a primary care setting,” says Dr. Wolfe. “The model relies upon the primary care provider working with a specialized team – including a behavioral health care manager and a consulting psychiatrist – to provide optimal care. By delivering behavioral health care in a primary care office – and by using the psychiatrist’s time only as needed, depending on the complexity of the case – this approach allows for more patients to be treated than in traditional, separate behavioral health care.”
IBH improves patient outcomes in a few key ways:
Proper diagnosing
“Behavioral health conditions are often underdiagnosed,” says Dr. Wolfe. “Many patients never see a psychiatrist or therapist and may not be routinely assessed in other medical encounters. As a result, many people continue to experience disabling, unaddressed symptoms, even though we know depression and anxiety disorders are quite common and can negatively impact physical health. To improve diagnosis, collaborative care promotes universal screening and the use of rating scales to provide measurement-based assessments to guide treatment.”
Oversight
Dr. Wolfe emphasizes how proper oversight is vital to successfully treating BH conditions. “Treatments often do not work the first time, or they may have side effects, requiring dose changes or augmentation over a period of months. The challenge can be keeping a patient engaged throughout this process, as a patient may become discouraged without close follow-up. In such complicated cases, primary care providers can benefit from consulting with a psychiatrist,” he says. “Carefully tracking patient process, keeping patients engaged in care, and treating patients to a clear goal are all ways in which the collaborative model makes a real difference.”
The collaborative model involves several shared resources. “The care team includes the primary care provider, a behavioral health care manager, a psychiatrist, and a patient registry that allows the team to track the patient’s progress. This approach allows the patient to stay in treatment, stay engaged, and receive optimal care. The clinicians can perform vital check-ins, document the process, and report the patient’s progress to the registry,” says Dr. Wolfe.
Measurement-based care
The collaborative care model provides measurement-based care by utilizing validated rating scales that track the patient’s progress to the goal of remission. “Without collaborative care, sometimes these scales are done rarely, or not at all,” says Dr. Wolfe. “The patient registry ensures clear tracking and goal measurement, with data accessible to the entire team. The recorded data can alert the behavioral health manager if patients are failing to respond, developing worse symptoms, needing changes to medications, or needing a more intensive review by the psychiatrist or primary care provider. Since the psychiatrist is not required to provide traditional, direct care to each patient enrolled in collaborative care, the model frees their time to focus on the few patients who are more complex or acute.”
The model, originally developed by the University of Washington , is effective in improving patient outcomes in patients of various ages and backgrounds.
Internal data on better patient outcomes
The Connecticut Behavioral Health Home (BHH) program , a healthcare delivery partnership with Carelon Behavioral Health, is associated with increased breast cancer and diabetes screenings. A Behavioral Health Home is a healthcare service delivery model focused on integrating primary care, mental health services, social services, and supports for adults and children experiencing mental illness.
The Connecticut BHH program is also associated with an increase in adequately controlled blood pressure for their members.
Data from one of our customer’s Employee Assistance Programs (EAPs) shows that participants in the program’s integrated, whole-health approach experienced an 80% improvement in their depression assessment.
The same customer’s Post-Discharge Management Program reduced 30-day hospital readmission rates from 9.7% to 8.9%.
Cost savings
"Care becomes more expensive when behavioral health conditions go undiagnosed,” says Dr. Wolfe. “Fortunately, we have seen more payer coverage for collaborative care in recent years, including commercial and Medicaid coverage in some states. As payers are discovering IBH models and their potential for reducing overall cost of care, we are likely to see more widespread adoption. While we typically see IBH services in larger healthcare systems, due to the upfront costs the model requires, we are also working to help support smaller practices build and operate the model.”
The upfront investment in whole-health treatment helps to save on long-term costs. “Physical and behavioral health conditions have a bidirectional effect on each other, suggesting that improving care in one, can positively affect the other. For example, an investment in depression treatment may very well yield improved outcomes – and savings – in cardiac or cancer care,” says Dr. Wolfe.
Internal data on cost savings
The Connecticut BHH model aligns with the Triple Aim of healthcare, which became part of a national strategy to address healthcare issues, seeking to reduce healthcare costs . The model improves cost-effectiveness through less usage of hospitals, emergency departments, and other costly inpatient care .
The Connecticut program’s total cost savings for 4,139 enrollees in 2020 and 2021 was $5,411,850 .
Data from one of our customer’s programs indicates that integrated whole-health treatment results in a substantial cost savings:
- Members save an average of $3,060 per year, or 16% in total costs from participating in Behavioral Health Case Management (BHCM) comanaged with medical, pharmacy, and disease management.
- An average inpatient medical savings of $1,152.
- Integrating whole health and substance use disorder support saves an average $2,493 in medical costs for employees receiving SUD treatment.
Social determinants of health
Social determinants of health (SDOH) , conditions in which people are born, live, learn, work, play, worship, and age, have an impact on IBH. “The social aspect is very interconnected with behavioral health wellbeing. For example, depression is a leading cause of disability worldwide , often linked to decreased occupational and educational productivity. Conversely, chronic social stressors such as housing insecurity, unemployment, and suboptimal nutrition can all affect not only mood, but physical health as well,” says Dr. Wolfe.
He emphasizes that while research is preliminary, evidence suggests that biological mechanisms link stress, environment, and behavioral and physical conditions. “Inflammation, for instance, presents with some types of depression, in social stress settings, and in chronic conditions such as rheumatoid arthritis or heart disease. Further research will determine whether behavioral health conditions associated with inflammation need different types of treatment than those that are not. Eventually, we need to tailor our treatments more specifically, taking physical health and social determinants into account.”
Future trends in IBH
Dr. Wolfe shares future trends that are likely in IBH. “Ultimately, we hope to refine psychiatric diagnosis by underlying mechanisms, such as inflammation, as opposed to the current state of clinical description. Moving away from descriptive diagnoses towards biomarkers found in blood tests and neuroimaging may lead to more nuanced and targeted treatments.”
He points out how the medical community is increasingly recognizing the relationship between behavioral and physical health, and how the two share processes. “Once we have a better understanding of the biological links, new treatments should hopefully be more effective and better tolerated."
Dr. Wolfe believes new biomarkers and treatments will continue to develop, eventually used in integrated care settings. “Specialists will utilize new treatment options for patients with complex behavioral health conditions that cannot be treated in a primary care setting. They will use neuromodulating therapies such as transcranial magnetic stimulation , which will refine and broaden to indications beyond depression and obsessive-compulsive disorder. We will see medications with novel treatment mechanisms, such as ketamine , which is already in use, while potential treatments such as psychedelics will continue to undergo research.”
