Education, Policy Reforms Needed for Behavioral and Primary Care Integration Success

Primary care providers (PCPs) are often the first stop for patients when seeking behavioral health services.

Busy PCPs often lack the resources to integrate behavioral health services into their practices fully. But that may change as federal and state lawmakers advocate for more collaborative care models.

“Primary care is behavioral health,” Melissa Merrick, executive vice president of primary care services at the Southcentral Foundation, said during a Bipartisan Policy Center’s webinar last week. “So much of what comes into primary care is behavioral health-related not just your traditional mental health diagnoses, but sleep hygiene and health behavioral change.”

The Southcentral Foundation is a nonprofit health system that serves Alaska Native and American Indian people living in Anchorage and the Matanuska-Susitna Borough of Alaska.

Today, private and public entities are focusing on ways to help boost primary care and behavioral health integration, whether through provider education, innovative payment programs, or expanding the workforce.

Education around integration 

Provider education is crucial to collaborative care efforts. Still, with a provider shortage in full swing, finding the time for meaningful continuing education can be tricky unless made a priority.

“You have to create a healthcare system that reinforces those skills when people are done with their training,” Dr. Atul Grover, executive director of AAMC Research and Action Institute, said during the webinar, “otherwise we can put out 30,000 perfect physicians that work in team settings every year, but if the healthcare system itself beats that practice out of them, then we really haven’t gained any ground.”

AAMC Research and Action Institute is a think tank of the Association of American Medical Colleges. It focuses on nonpartisan policy reforms and suggestions.

This is where Health Resources and Services Administration (HRSA) grants and other training incentives could make a difference. If grants support integrating behavioral health specialists within primary care practices, this could help the movement scale faster, Grover said.

Since many providers need to balance large caseloads and provide direct training, having time and funding to implement additional instruction is key.

“It’s committing dollars to protect that time so that the training is recognized as being as important a part of someone’s job as providing care services,” Dr. Brian Baucom, co-director of Behavioral Health Innovation and Dissemination Center, University of Utah, said.

The Behavioral Health Innovation and Dissemination Center at the University of Utah provides clinical services, consultations and training programs. It also conducts clinical research focused on improving the quality of mental health care.

Although there is a new push to incorporate integrated behavioral health training programs into medical education, many providers must take on the task of educating their workforce.

“When we started, there wasn’t really anybody, myself included,” Merrick said, “who had been trained in integrated behavioral health, and so we had to develop an on-the-ground trading program that spoke to our clinic.”

Government initiatives 

Some government initiatives, like the Center for Medicare & Medicaid Services Innovation Center’s (CMMI) Primary Care Model, a 10-year program focused on ensuring value in a primary setting, are positioned to help drive whole-person care.

Still, many providers implementing primary and behavioral health integration are still in the early phases.

“The problem with integrated care is that most people doing integrated care are not rigorously doing integrated care,” Dr. Andy Keller, president and CEO of Meadows Mental Health Policy Institute, said. “They’re doing something like co-location, they’re doing something that really isn’t that effective because the things that make the evidence-based applications of integrated care effective, like collaborative care, are things like registries and the rigorous use of measurement-based care.”

Meadows Mental Health Policy Institute is an independent and nonpartisan nonprofit that works on mental health policy and programming dedicated to creating a more equitable system for people in Texas.

He noted that the language in CMMI’s Primary Care model needs to be more specific. But there are ways to make it more regulated.

The Bipartisan Policy Center recently released a Strengthening the Integrated Care Workforce report. The report recommends applications in primary care or total cost of care-oriented models are required to attribute their behavioral health integration plans.

The Bipartisan Policy Center is a nonprofit that ensures “policymakers work across party lines to craft bipartisan solutions.”

“We need to… make sure that we’re embedding not just the idea of integration, but integration with enough specificity, enough resource, enough priority to really be able to achieve outcomes,” Keller said. “I think the report lays out a pretty broad path that will allow folks to increase the rigor where they’re at, not just impose a specific model, but the move towards these common things that are associated with outcomes… [such as] a registry.”

Non-clinical staff’s role in integration  

Staff remains a major challenge despite the increased focus on adding collaborative care to medical training programs and increasing government initiatives.

While clinicians are critical to integration initiatives, non-clinical workers could be an untapped workforce that could enable these programs. For example, using peers could help boost collaborative care.

“If you include non-masters, trained professionals, such as peer counselors, then you’re talking about one million people that deliver some type of mental health care, many of which have shorter training periods than physicians or PhD psychologists,” Grover said. “So we’re also able to bump up that supply of the workforce much more quickly.”

In addition to adding to the workforce, peers have other advantages and can often be more representative of the community they serve.

“Part of the advantage that [peers] have is that lived experience and also leveraging trust and increasing access for customers. Access is trust,” Merrick said. “It’s how we build trust with our patients, and it’s how we start addressing health behavior change. I think non-clinical workers have a huge role to play in terms of quality of care, but also really expanding that workforce, and augmenting some of the services that clinical providers can be limited in how they can do work.”

While there are many ways for collaborative behavioral health care to look in the future, it will likely take a team-based approach that calls on different members of the care community.

“Every system is going to have to adapt a model a little bit to what works for their system,” Merrick said. “It’s a balancing act of keeping within fidelity to model but also what works within your system based on your care delivery, as well as your workforce.”