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Delivery of Care

New standard of primary care: integrating behavioral health

Two new initiatives launched by the Care Transformation Collaborative to screen for behavioral health issues and identify and intervene around risky behaviors have produced promising results

Photo by Richard Asinof

From left:Dr. Pano Yeracaris, CTC chief clinical strategist; Susanne Campbell, CTC manager of the SBIRT program; Debra Hurwitz, CTC executive director; and Linda Cabral, CTC program manager.

By Richard Asinof
Posted 1/2/19
Data from two new pilot programs launched by the Care Transformation Collaborative that integrate behavioral health screening into primary care practices have shown promising results, suggesting a way to create a new standard of care.
What is the best way to share data across numerous platforms, integrating screenings for maternal depression, behavioral health issues such as anxiety and depression, and toxic stress in young infants? Is there a comprehensive platform that can link data from the diseases of despair – alcohol, suicide and drugs? If the opposite of “addiction” is “connectedness,” what kinds of interventions can create a sense of belonging and community for those in recovery? If recovery and treatment are long-term processes, what kind of institutional supports need to be created as part of primary care practices to support that kind of care?
One of the points of connection that is being developed between the work of integrating behavioral health into primary care are efforts to build relationships with health equity zones. As Debra Hurwitz, the executive director of CTC, said: “We are trying to go beyond the four walls of primary care out into the community, and we are in conversations with the HEZ. Sometimes those align nicely with the work that we are doing, and sometimes they are just in different spaces.” In South County, she continued, there is good connectivity between our community health teams and the HEZ, they share the same work space.

PROVIDENCE – The Care Transformation Collaborative continues to expand its vision on how to improve the way that primary care is delivered in Rhode Island. Data recently published from two separate pilot initiatives showed promising results during the last year, focused on ways to integrate behavioral health screening into primary care practices and to intervene around risky behaviors.

The first program, Integrated Behavioral Health in Primary Care, advanced the concept of universal screening for depression, anxiety and substance use disorders with primary care practices, coordinated with an embedded behavioral clinician.

By the second quarter of 2018, universal behavioral health screening for anxiety, depression and substance use had been conducted for more than 70 percent of patients from three different cohorts.

In addition, the medical and pharmacy costs per member per month were $100 per month less compared to PCMH practices without integrated screening during the calendar year of 2017.

Despite some initial doubts expressed by primary care practitioners about the viability of screening for behavioral health issues, now most cannot envision their primary care practice without it.

“When I say how much I love having integrated behavioral health, it is that I can’t imagine primary care without it,” said one medical provider, as quoted in a qualitative evaluation. “It just makes so much sense to me to have those resources all in the same place, because it is so important. I can’t speak highly enough of it.”

Screening, brief interventions, and referral to treatment
The second program being deployed is a screening program known as Rhode Island SBIRT, or Screening, Brief Intervention and Referral to Treatment, in order to reduce problematic use of alcohol and illicit drugs, working with community health teams in both community and clinical settings.

In its first year, from September of 2017 to September of 2018, there were 7,857 screens completed and 1,460 interventions, with 9 out of 10 people at risk receiving an intervention.

A six-month follow-up showed that 53 percent of the clients who had reported illegal drug use at intake reported no use six months later. Further, clients who received an intervention reported a significant decrease in the average number of alcohol use days after six months.

18 percent of the clients screened were Hispanic, 59 percent of the clients were female, and the average age was 47.

“Through SBIRT, there is some evidence that suggests that risky behaviors are decreasing,” said Susanne Campbell, the project manager for SBIRT and the community health team project, in a recent interview with ConvergenceRI. “I would like to attribute it to the results of the brief intervention and motivational interviewing that takes place when risky behaviors are identified through risk assessments that are being conducted.”

Training the workforce
The community health teams conducting the screenings are being trained in coordination with the Rhode Island College Department of Social Work.

“We currently have contracts in place for eight different organizations, at all different levels,” Campbell said. “We have currently about 15 screeners,” Campbell said. “These are individuals who have been trained in SBIRT. We have partnered with Rhode Island College, which has developed a six-module training course, to train individuals about substance use in general, and more specifically, for this project.”

“SBIRT is more than just screening for substance use,” Campbell said. “It is also providing brief intervention, and information and education on resources available in the community, should the individuals be at a point where they want to take advantage of this.”

Funding for the program comes in part from a grant from the Substance Abuse and Mental Health Services Administration to the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals through September of 2021.

“The idea is that we are trying to build infrastructure, and we think that a large number of patients who are identified through such screening can be handled with brief, short- to medium-term interventions, connected with primary care,” said Dr. Pano Yeracaris, the Collaborative’s chief clinical strategist.

The approach, Yeracaris continued, “is the way not only to [identify] and treat depression and anxiety, but also some of the behavioral challenges with dealing with complex, chronic medical diseases.”

Changing the culture
Debra Hurwitz, the Collaborative’s executive director, talked about the importance of changing the culture of the way care is delivered.

“We are changing the culture; you are asking everyone, so that it becomes the standard of care. Patients are asked in a non-judgmental way, using motivational interviewing. It has served as a terrific training program for medical assistants, for providers and for community health workers.”

Our vision, Hurwitz continued, “is that through primary care, there would be universal screening for all patients coming through [our doors]. For both adult and pediatric practices, there would be screens for depression, for anxiety, for substance use disorder. When there is a positive result, there would be an immediate referral to a behavioral health clinician.”

As part of the pilot program integrating behavioral health into the primary care practice, Hurwitz said, “We have a behavior health clinician embedded in the practice, so that the patient could be immediately introduced.” The clinician, she continued, is a licensed social worker, a clinical psychologist or a licensed family therapist.

Humble beginnings
The Care Transformation Collaborative began as a pilot program in 2008, with five initial practices participating in an experimental, all-payer, patient-centered medical home model of care, under the direction of then R.I. Health Commissioner Christopher Koller.

Today, more than a decade later, the Collaborative includes 106 primary practices, including internal medicine, family medicine and pediatric practices, with some 750 providers participating across the network. Perhaps equally impressive, approximately 650,000 Rhode Islanders are receiving care from one of the practices – roughly two-thirds of the entire state’s population, even if the patients may not be aware that they belong to a patient-centered medical home.

The work of the Care Transformation Collaborative is supported by investments from every health insurance plan, including private and public plans. And, all of the federal qualified community health centers participate in the collaborative.

In 2016, the Collaborative achieved a $217 million reduction in total cost of care dollars, compared to non-patient centered homes in Rhode Island, according to an analysis of date from the state’s All-Payer Claims Database.

Lessons learned, future challenges
Among the unmet or changing needs identified in the integration of behavioral health into primary care practices are that co-pays are still a barrier to treatment, billing and coding are still difficult to navigate, and workforce development remains a key part of any effort.

The Care Transformation Collaborative has suggested that there is a need to leverage legislative action to create one co-pay for primary care and behavioral health, treating screenings as preventive services.

Further, as a way to achieve sustainability over the long term, the Collaborative has suggested creating an all-payer model for the integration of behavioral health into primary care practices. In addition, the Collaborative would like to build out the workforce development program for integrated care.

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