Program integrates physical, mental health
Patients with serious mental illness who participated in a Behavioral Health Home (BHH) program saw reductions in emergency department (ED) visits and psychiatric hospitalizations, along with more preventive screenings for diabetes, according to a study conducted by researchers at Cambridge Health Alliance and published by Psychiatric Services.
The Cambridge Health Alliance – an academic community health system in Massachusetts – implemented its BHH in 2015 in a safety-net hospital for use by adults with schizophrenia spectrum disorder or bipolar disorder.
The one-year study period compared similar patients – some enrolled in the BHH, some not. In that time, total ED visits among BHH patients decreased from 1.45 to 1.19 visits, and rose in the control group (0.99 to 1.16).
Additionally, total psychiatric hospitalizations per capita declined for the BHH patients (0.22 to 0.10); they remained stable in the control group (0.145 to 0.147). BHH patients also experienced greater metabolic monitoring than the comparison group.
Emily Wilner, Psy.D., a clinical psychologist on the BHH team, explained that BHHs are more or less the “inverse” of the movement of integrating behavioral health care into a primary care setting, by bringing a focus on medical care into a mental health or psychiatric setting.
“The goals of BHH are to provide enhanced access to medical services, care coordination between various disciplines and community providers, transitions between different levels of care, as well as psychopharmacy and individual and group therapy,” Wilner said.
Many BHH patients have comorbid medical concerns. “In addition, a lot of patients with severe mental illness are, for various reasons, hesitant to seek care outside of their psychiatric providers, with whom they are quite comfortable,” Wilner said. “The idea of going to primary care is often something that doesn’t feel as comfortable. So to be able to offer the medical piece within a psychiatric setting is a huge benefit.”
The BHH focuses on comprehensive coordinated, person-centered, holistic care and patients choose services that are in line with their individual goals. The BHH features health promotion activities like smoking cessation and healthy lifestyle groups; care coordination and peer-to-peer engagement; and a clinical paradigm shift toward integrated team-based care and chronic disease prevention and monitoring, and population health management.
By having practitioners from many different disciplines working in the same space, they are able to have joint interventions and provide supports and coordinated care.
Study co-author Alexander (Sandy) Cohen, MSW, MPH, said the researchers hope the study will advance the science of integrated care for this population while also inspiring more mental health providers to adopt elements of a BHH model.
“The Holy Grail is to improve population health and really reduce the disparities that are experienced among people with any serious mental illness, but certainly, bipolar and schizophrenia,” Cohen said. “This study gives us promising findings about the improvement and quality of care.”
A BHH engages patients through many different avenues. Some patients may not have a lot of insight into their symptoms, or perhaps don’t even identify as having a mental illness, Wilner said. “One of the great things is, we can engage a patient who does have a mental illness but we can engage them on a wellness note,” Wilner said. “We can bring people in whose goal might be to lose weight, or cut down on smoking and engage them in psychiatric care through a completely different channel.”
Added Cohen, “We’ve been surprised, even ourselves, at how interested our patients with psychiatric or bipolar disorders really are in other topics related to health.” Cohen said when the BHH began, patients received a survey at intake to identify what kind of health topics they are interested in outside of psychiatric care.
Among topics identified – sleep, smoking, physical activity, mindfulness, and stress. “I think our behavioral health clinicians have been pleasantly surprised at how willing patients are to engage in that kind of discussion,” Cohen said.
Added Wilner, “The illnesses (patients) have are so complex – the idea that one provider would really be able to intervene in a comprehensive way isn’t realistic. It makes sense to have an integrated model to serve this population most effectively and efficiently.”
“For me, one of the great things that has been a secondary outcome is that I’ve learned so much about health and wellness and psychiatry and peer support, and all of these other areas that were not necessarily part of my training as a psychologist or were introduced in more of a cursory fashion,” Wilner said. “We’re all learning from each other in a way that’s different when you aren’t so integrated. My skillset is expanding.”