How Intermountain, Geisinger and M Health Fairview Are Integrating Behavioral Health into Primary Care

In the U.S., it can often take individuals months to get appropriate behavioral health care. As a result, emergency departments across the country are seeing a massive uptick in patients seeking these types of services.

Some health systems – Intermountain Health, Geisinger Health and M Health Fairview among them – are combatting this issue by tackling behavioral health challenges upstream and addressing issues in the primary care setting.

“So often, by the time someone is saying to themselves, ‘I really should get some help,’ or someone in their life is saying, ‘you need some help,’ [the problem has] been going on for quite some time,” Lewis Zeidner, M Health Fairview’s system director for clinical triage and transition services, told Behavioral Health Business. “Many people see their primary care provider regularly, and if challenges were intervened earlier, oftentimes, they could get access quicker.”

While many health systems are looking to implement these upstream approaches to addressing behavioral health issues, there is no one-size-fits-all approach.

Some health systems are co-locating mental health professionals in primary care offices, while others are using technology to help flag mental health concerns.

BHB caught up with leaders from the three aforementioned health systems for an inside look at their strategies.

 Intermountain: A collaborative care model

Intermountain uses a collaborative care approach to address behavioral health concerns in a primary care setting.

Salt Lake City-based Intermountain is an integrated health system with hospitals, medical groups and community services. It also has a payer organization with over 1 million members. Additionally, it has a population health organization called Castel.

Having both a payer and provider point of view allows Intermountain to think about population health from a broader lens rather than just billable services, Tammer Attallah, clinical program system executive clinical director at Intermountain, told BHB. And this, in turn, allows it to prioritize collaborative care.

Specifically, the system has an electronic process to identify patients who may have behavioral health concerns. This system allows medical assistants to notify the physician ahead of a visit.

If appropriate, a patient can be referred to a collaborative care model with a virtual behavioral health provider.

“We use very targeted, specific support. When a patient then enrolls in the program, [they] get a collaborative care manager, who’s also a mental health therapist that provides short-term therapy, generally and virtually,” Attallah said. “They have high flexibility; they can call, have a conversation or visit for 10, 15, 20 minutes.”

This model also helps support PCPs prescribing behavioral health medications. In particular, the system includes a psychiatrist who never actually touches the patient but can provide consultations through the registry to the PCP, specifically around recommendations for psychotropic medications.

Patients are also asked to consent to provide ongoing measurement-based goals like the PHQ-9 or the GAD-7 to help monitor progress.

The registry is highly monitored, Attallah said, and it allows psychiatrists to see 10 times the number of patients they otherwise would because they are not interfacing with them directly.

For more complex patients, Intermountain also overlays care. In this model, providers can assess patients in person and then triage them to determine if they have mild, moderate, or complex behavioral health needs. If they are identified as having a mild or moderate need, they are typically cared for in the clinic, and if they have complex needs, they are moved on to the navigation services.

But not all patients with behavioral health challenges need to be in a clinic. Intermountain has also explored digital services to help engage patients.

“Another opportunity is for them to be referred, for example, to a vendor that we partner with that provides behavioral health coaching and asynchronous coaching, through texting,” Attallah said. “We want to provide a myriad of options and that upstream opportunity to engage them with the expectation that all of that work needs to be measured. We need that measurement-based care, and we need to focus on whether they’re improving.”

M Health Fairview: Applying co-location to behavioral health 

M Health Fairview Health takes a co-locating approach to behavioral health and primary care integration. Master’s and doctorate-level mental health clinicians sit in the same “pod” as primary care practitioners, making them highly visible for a PCP to find.

“So when your primary care clinician identifies you may struggle with anxiety, sadness, or other challenges,” Zeidner said. “They can say, … ‘Down the hall is a professional. Why don’t we spend some time with you?’”

M Health Fairview is a partnership between the University of Minnesota, University of Minnesota Physicians and Fairview Health Services. The health system includes 10 hospitals and 60 clinics.

This strategy enables patients to have a warm handoff to a behavioral health professional and can alleviate some of the stressors, according to Chris Beamish, VP of integrated and outpatient mental health and addiction services at M Health Fairview.

Similar to Intermountain, M Health Fairview also uses a “schedule scrub,” which looks daily at PCPs’ schedules and why each patient comes into the clinic.

“We might have a list of all the patients coming into a clinic for the day, and we want to have their PHQ-9 score to know what their depression ratings have been recently,” Beamish said. “And then we would talk to primary care providers and say, ‘Your patients are coming in for X, but maybe we can also help them [with Y]. Let’s see.’”

Additionally, knowing where to find the appropriate level of care can be difficult for patients and can lead to a backup in the emergency department. This is another area that M Health Fairview has worked to address.

“Our primary care providers also don’t always understand the full continuum of mental health care, but they know the patient needs help,” Beamish said. “And so we’ve created an easy button for them to push in their referral. They can press some electronic medical record referral to assess and evaluate the team.”

That team is made up of master’s level mental health professionals, doctoral psychologists and clinical health assessors that look at every referral. Their mission: to help determine who is the right provider to see the patient within 24 to 48 hours, and to help patients with wayfinding.

“They do an assessment, and they get them to the right place to get an assessment to determine what level of care is right for them,” Beamish said. “That’s a nice way to help with that navigation. And not require primary care to understand every facet of our care continuum.”

Piloting SUD Innovation: Geisinger

Geisinger is moving to further integrate addiction treatment care into primary care with a new $2.8 million grant from the U.S. Health Resource and Service Administration.

Geisinger will use the new funds to develop fellowship programs that train advanced practitioners to provide SUD care in a primary care setting.

“Our goal for this program is to foster robust clinical training and augment expertise among clinicians, who will see patients that accept points of care and provide mental health and addiction prevention, treatment and recovery,” Tracy Rockefeller, a nurse practitioner specialized in addiction medicine at Geisinger, told BHB. “That’s our basic goal for what we’re doing. And the way we’re going to do that is we’re going to train eight advanced practitioners, they can be nurse practitioners or physician assistants, as well as eight social workers into the program, so that we can actually put them out into the communities.”

Danville, PA-based Geisinger includes 10 hospital campuses, a health plan and a research institute. It has more than 25,000 employees.

Geisinger is currently developing the curriculum and training for these practitioners. The goal is to train these clinicians in addiction prevention, treatment and recovery and then insert them into the primary care setting, including settings that serve the pediatric population.

Integrating behavioral health teams into a primary care setting can also help educate PCPs about SUD care options.

For example, the X-waiver, which required prescribers to have additional certifications to prescribe medication-assisted treatment for individuals with opioid use disorder (OUD), was eliminated earlier this year. This opens the door for advanced practitioners and physicians to prescribe MAT.

But this could be a prime opportunity for clinicians with training in SUD care to help educate PCPs on prescribing MAT.

“We just keep giving more and more education and being there to hold hands and say, ‘We can do this together,’” Rockefeller said. “And if you’re uncomfortable, we can do it for you, so that we make sure that patients have access.”