New York State’s Path to Behavioral Health Integration
Under the leadership of Drs. Lloyd Sederer and Jay Carruthers, New York state has created a robust, large-scale implementation of evidence-based integrated care. In this month’s column, they identify factors that were critical for the program’s success and challenges they anticipate in the future. —Jürgen Unützer, M.D., M.P.H.
There is saying in Spanish that roughly translates to “the path is made by walking it.” This certainly holds true for New York state’s effort to implement behavioral health integration (BHI) into primary care—specifically the Collaborative Care Model (CoCM).
Despite compelling evidence (more than 80 randomized, controlled trials showing CoCM to be significantly more effective than treatment as usual), despite the widely acknowledged gaps in access to behavioral health services, and despite the fact that most patients prefer to receive services in a primary care setting rather than a behavioral health specialty setting, very few primary care sites were practicing CoCM in New York state (NYS) as recently as five years ago.
That changed when the NYS Office of Mental Health, in partnership with the NYS Department of Health, began the largest state-based program in the nation to fully integrate behavioral health detection and treatment into primary care settings.
The New York State Experience
The NYS BHI “walk” has had two phases. Phase I began as part of the Centers for Medicare and Medicaid Services (CMS) Hospital Medical Home Demonstration Project grant. Funded with graduate medical education monies, the portion of the grant led by the NYS Office of Mental Health was a 2.5-year implementation of CoCM for depression in 19 academic medical centers, with 32 participating primary care training sites. Our success demonstrating feasibility and clinical outcomes resulted in legislative funding for Phase II of the initiative, a Medicaid supplemental monthly payment for CoCM to further scale up the work heretofore done.
We see our success as a product of two forces: (1) unrelenting attention to performance measurement and (2) achieving sustainable financing beyond the grant.
In Phase I, we demonstrated that 84 percent of participating clinics could achieve fidelity to six significant measures of clinical performance. Moreover, depression improvement scores for approximately 6,000 participating patients improved from 14 percent to 46 percent of those diagnosed and delivered integrated primary care treatment.
When the grant expired in December 2014, the Office of Mental Health began Phase II, which we call the NYS Medicaid Collaborative Care Program. Securing what is a unique, state-funded monthly Medicaid case rate for CoCM was essential. The program now has 74 participating sites, including many Phase I grant participants, and extends beyond academic medical center sites to cover Federally Qualified Health Centers and Independent Provider Association sites. Signs of additional payer support from Medicare and commercial plans seem to be adding momentum.
Meaningful Outcomes
Attention to performance measurement has been a mainstay of the NYS BHI initiative, seeking the right balance between structure, process, and outcome measures. For Phase I, early emphasis was on structural and process measures, like behavioral health care manager training, a patient registry, and screening yield rates. Sites were held to strict reporting requirements. When they demonstrated greater implementation proficiency, our emphasis shifted to patient engagement and outcomes: Are patients getting better? If not, are their cases being reviewed, with associated changes in the treatment plan?
In Phase II, first-year data sustain the proof of the gains we had made. The Average Clinical Improvement Rate (defined as the percent of patients receiving depression care whose PHQ-9 score was reduced by 50 percent or dropped below 10 after enrollment for 12 weeks) now exceeds 50 percent, consistent with CoCM clinical trials demonstrating efficacy over usual community care. Among patients not improving, we have seen critical increases in engagement (as measured by a greater number of changes in treatment plans and case reviews by a psychiatrist, a hallmark of an effective CoCM program).
Looking Ahead
Our path ahead for BHI and the CoCM in NYS will continue to challenge practices, payers, and regulators. Because over 40 percent of all NYS practices have five primary care doctors or fewer, and hiring a FTE behavioral health specialist and finding a consulting psychiatrist is generally out of reach, we see this as a major barrier to statewide implementation. Innovative models that share care manager resources and leverage technology, like telephonic outreach and telepsychiatry, will be essential. Finally, in the rush to value-based purchasing in health care, we will have to ensure incentivizing rigorous forms of BHI, such as CoCM, which work and in which measurement-based care is the norm. ■
Biographies
Jay Carruthers, M.D., is a psychiatrist working for the New York State Office of Mental Health, where he leads behavioral health integration and the Suicide Prevention Office. He is also an assistant professor of psychiatry at Albany Medical College. Lloyd I. Sederer, M.D., is chief medical officer of the New York State Office of Mental Health, an adjunct professor at the Columbia University Mailman School of Public Health, the medical editor for mental health at The Huffington Post, and a contributing writer to U.S. News and World Report. Jürgen Unützer, M.D., M.P.H., is a professor and chair of psychiatry and behavioral sciences at the University of Washington, where he also directs the AIMS Center, dedicated to “advancing integrated mental health solutions.”
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Published online: 15 June 2017
Published in print: June 3, 2017 – June 16, 2017
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