Which Flavor of Integrated Care?

The buzz about integrated behavioral health care is everywhere; almost every meeting and publication in our field is addressing this delivery model. Mental health providers have discovered how satisfying it can be to work closely with our primary care colleagues using a biopsychosocial approach to care for the “whole patient.” Creative and caring practitioners and researchers have taken up the challenge of improving behavioral health services in primary care and we have seen the development of integrated care models shaped by the professional and practice cultures we work in.

At the University of Washington, we have conducted more than 20 years of research on an approach called collaborative care (CC). Based on principles of effective chronic illness care, CC focuses on defined patient populations tracked in a registry, measurement-based practice and treatment to target. Trained primary care providers and embedded behavioral health professionals provide evidence-based medication or psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for patients who are not improving as expected. CC originated in a research culture and has now been tested in more than 80 randomized, controlled trials in the United States and abroad. Several recent meta-analyses make it clear that CC consistently improves on care as usual. It leads to better patient outcomes and functioning, better patient and provider satisfaction, and reductions in health care costs, achieving the “Triple Aim” of health care reform.

One of the early limitations of the CC model was its emphasis on specific disorders such as depression. However, research has demonstrated that CC is effective for a broader range of mental health problems including anxiety disorders, PTSD, and ADHD. Large-scale practice implementations show that CC can serve patients with a wide range of behavioral health problems—from mood and anxiety disorders to substance abuse and chronic pain.

Another prominent approach is the behavioral health consultant (BHC) model, which is solidly grounded in a clinical practice culture. The BHC model emphasizes a generalist behavioral health provider embedded in a primary care clinic who provides rapid access to behavioral health intervention, often addressing a wide range of health, mental health, and substance abuse problems. A major strength of this model is that it meets patients and primary care providers where they are, usually the same day a patient presents in clinic. When this works well, primary care providers have immediate support and distressed patients receive quick relief. This emphasis on rapid access also comes with some potential limitations. Patients are often limited to brief interventions typically consisting of one to three sessions with a BHC. Such brief interventions may work well for patients who present with emotional distress, but even the most talented clinicians cannot fix serious mental health or substance use problems in one to three sessions. We have limited evidence that this approach is more effective than typical primary care for patients with common mental disorders such as major depression, PTSD, or substance abuse.

In a recent post, Alexander Blount, Ed.D., director of the Center for Integrated Primary Care at the University of Massachusetts and one of the leading experts in the BHC model, wrote, “[T]he need is too great to be waiting for a protocol for every illness before we stir BHCs into the Primary Care soup.” He further wrote: “Outcomes [are] not reported in changes in scores on screening measures but in the number of babies who could safely go home with their mothers after their birth. Ask them why they don’t write this up, get a grant, and launch a big research study, and I suspect they would say that research studies are not their mission. Their mission is to provide the best possible care anywhere to the folks in their area whom no one else serves.”

This sentiment, based in a strong clinical culture, appeals to us as clinicians, especially those of us caring for underserved patient populations with little access to specialty mental health care. As researchers, we are reminded to think not only about the “numerator,” the patients who come to see us, but also the “denominator,” those who do not engage in care or fall through the cracks. Without a denominator and without routine measurement of clinical outcomes, we won’t know how many mothers are at risk or how many of the moms we have identified are actually getting better. We like to assume things are O.K., but research and a careful look at real-world practice tell us that this is often not the case.

These two models (CC and BHC) come from different cultures (research and clinical practice). They also address somewhat different clinical needs. In my experience, they are quite compatible and they are, in fact, converging clinically. Some locations offer BHC-style rapid access to behavioral health interventions for all patients and follow-up with more systematic CC for those patients who are not improving as expected or who are at high risk for relapse, often those with more persistent mental health and substance use problems.

In the end, it is clear that one size does not fit all. Practices will need to create local solutions that make the best use of available resources and meet the needs of their unique patient populations. Effective integrated care teams use a range of behavioral health providers with complementary skills and engage patients, family members, and caregivers in care. Technology can also help. Telephone and televideo technologies, web-based registry tools, and phone apps can help leverage limited mental health specialists and improve access even in remote locations.

After more than 20 years of working in integrated care, I have become less concerned about the right approach to integrated care and more concerned about making sure the patients we serve actually get better. Whatever approach we choose, we need to make sure it gets the job done for individual patients and the populations we serve. Health care reform and payers are pushing us in the direction of accountable care. This involves a commitment to (1) measurement-based practice and treatment to target, making treatment adjustments until each patient is improved, and (2) population-based care in which we track all patients in a registry to make sure no one falls through the cracks. Well-implemented integrated care programs that follow these principles can help the millions of patients who present in primary care with behavioral health problems every year. ■