Integrated practices: Moving toward comprehensive health care

The Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration report that some primary care offices are becoming a “gateway” for individuals who have a combination of behavioral and physical health needs. The growing prevalence of co-existing physical and behavioral challenges is prompting a closer look at integrated practices.

Corey D. Smith, director of behavioral health training at the Maine-Dartmouth Family Medicine Residency Program, which trains medical doctors and nurses in collaboration with the University of New England (UNE) College of Medicine and UNE’s College of Pharmacy, pointed out that few medical conditions present without a behavioral component.

“The classic example is diabetes,” he said, noting that these patients must juggle nutritional needs, exercise and daily living activities. “If you look at the research, a patient with diabetes will, at some point, have depression. Integrated care shows good patient outcomes specific to medical conditions.”

Additionally, Smith notes that a “limiting stigma with mental health treatment” still exists. He indicated that patients are more likely to see their primary doctor and mention a cluster of symptoms that could be depression or some other behavioral condition rather than seek counseling from a mental health provider.

“Mental and medical health often butt heads. By providing access at the point of care, we can catch a number of patients who wouldn’t know to consider behavioral health therapy,” he said.

States like Maine, whose population is scattered over a wide geographic area, can be especially well served with an integrated practice. Smith said. “It serves as a one-stop shop. It’s difficult to find a physician [in rural areas] and it’s likely as difficult to find a psychologist. It’s a nice catch for the patient to find a psychologist and physician in the same clinic.”

In an integrated setting, the medical provider can do a “warm hand-off” to a professional who is qualified, skilled and ready to address the behavioral issue, according to Smith. “This allows the physician to stay on schedule and meet the needs of the other patients.”

Smith works side-by-side with physicians at the Family Medicine Institute where he sees patients in half-hour blocks. “The 30-minute visit is a structural way to facilitate focus on distinct behavioral and cognitive changes, rather than getting too far into history,” he said. “Also, the integrated setting is short-term so patients learn skills they can use in traditional therapy. There could well be benefits for the rest of the patient’s life. He can benefit from knowing how to calm himself down.”

For the last four years, John Todaro, Ph.D., co-owner and director, Providence Behavioral Associates, has also served as a consulting and clinical health psychologist at Coastal Medical, a physician-owned network of medical practices in Rhode Island.

He reported that this co-location where psychologists were placed into the practice has evolved into a fully integrated behavioral health model. “This means we’re part of the clinical team of physicians, pharmacists, nurses and social workers. We actually work together in the joint care of the patient. It’s a team-based approach as opposed to individual providers working in silos,” he said.

Todaro works in primary care, pulmonology and cardiology services and is helping Coastal evolve its behavioral health services and identify individual ways to integrate behavioral health more fully into clinical services.

In spite of the patient benefits, reimbursement continues to present one of the biggest barriers to integrated practices, according to Todaro.

“We’re looking at business models that allow psychologists and physicians to partner together financially. I think if the healthcare system moved away from fee-for-service to alternate payment models, the revenues we generate from bundled payments, for example, shared savings agreements, may make it financially attractive for both groups to form joint ventures,” he said.

“There’s no question that it makes clinical sense to integrate clinical health into behavioral care, but now we have to demonstrate that it makes financial sense. That’s the next phase, refining the business model that allows integration not just to initiate a program but to sustain it over time.”

Traci Cipriano, Ph.D., JD, Connecticut Psychological Association director of professional affairs and a private practitioner in Woodbridge, Conn., explained that determining which billing codes will work on the medical side, especially for short-term therapy or intervention, is part of the problem.

However, hospitals and professional organizations are conducting research and collecting data to solve the issue.

“Hartford Hospital is doing a lot of grant work that involves gathering pilot data,” she said, noting that figuring out how to manage the 50-minute hour in a medical setting is the challenge. “But physicians are interested, especially with the opioid crisis and pain management. You can’t just give pills to people. You need to learn ways to manage the pain.”

The American Psychological Association is also exploring the viability of integrated practices. Cipriano reported that in 2016, the Centers for Medicare and Medicaid Services awarded a three-year, $2 million grant to the APA to place psychologists into medical practices to gather data.

The CMS Transforming Clinical Practice Initiative Support and Alignment Network, which issued the grant, is intended to enhance patient care quality and find ways to better use health care dollars. As part of the grant, the APA plans to offer education, training and workforce development to more than 5,000 psychologists to qualify to participate in integrated care programs.

Although some physicians and psychologists involved in integrated care report good outcomes, Cipriano pointed out that robust data would reinforce the need for integrated practices and help secure funding to support them.

“When you are asking for funding, you need data, not just anecdotal evidence,” she said.

Todaro said that this work can be beneficial for patients and also fulfilling for psychologists who enjoy the fast pace and multi-disciplinary nature of the work.

“You have to have a lot of internal interest and enthusiasm to do this kind of work,” he said. “We like feeling our behavioral contributions enhance the overall medical care the patient is getting with the physician, pharmacist and nurse.”