Teaming up: The benefits of integrating primary care with behavioral health

Primary care and behavioral health: ©Raymond Orton - stock.adobe.com

Like many primary care doctors, family physician Sarah Nosal, M.D., FAAFP, routinely counsels patients on a variety of behavioral issues such as anxiety, attention deficit disorder and mild depression.

But Nosal, who practices at a federally qualified health center (FQHC) in New York City, has an advantage over many of her peers. When one of Nosal’s patients has a behavioral health problem she feels unable to handle, she doesn’t always have to refer them to an outside specialist. Instead, she can just walk the patient down the hall to a behavioral health therapist practicing at the same clinic.

Having a behavioral health clinician under the same roof benefits both her and the patient, Nosal says. It enables a level of holistic, collaborative care that would be nearly impossible with someone outside the practice. And it helps patients overcome any reluctance to get mental health counseling to be in familiar surroundings and knowing she remains involved with their care.

In general, patients facing behavioral health issues are helped the most by receiving a combination of medication and therapy. And although she can prescribe medications and do some counseling,
“I have access to the full breadth of what’s possible if we [the FQHC] provide both those services.”

PCPs’ growing role in behavioral health

Like Nosal, most primary care physicians (PCPs) today are trained in behavioral health counseling, and increasingly are being called on to provide it. A study in Health Affairs found that the proportion of adult primary care visits addressing mental health concerns grew by 50% between 2006 and 2017. And a 2021 position paper from the American Academy of Family Physicians (AAFP) notes that about 40% of office visits for mental health concerns are in primary care offices, and PCPs write nearly half the prescriptions treating a mental illness.

Nevertheless, there has been a growing recognition in recent years that PCPs alone cannot keep up with Americans’ mental/behavioral health needs. According to the Centers for Disease Control and Prevention more than 20% of adults live with some form of mental illness, and 5% have a serious form such as bipolar disorder and schizophrenia.

This has spawned growing support for behavioral health integration: primary care doctors and behavioral health specialists working together to add mental health and substance use counseling to the services that primary care practices have traditionally provided.

In 2022 the U.S. Department of Health and Human Services issued a “Roadmap for Behavioral Health Integration,” outlining steps it would take to “expand access to behavioral health by integrating behavioral health into primary care settings.” Among these steps was to cover services provided by clinical psychologists and social workers as part of a primary care team.

According to the American Psychological Association, behavioral health integration with primary care generally is implemented using one of two models, the collaborative care model (CoCM) or the primary care behavioral model (PCMH). CoCM uses a chronic care management approach, with services provided by a team that includes the primary care physician, a care manager and a consulting psychiatrist (who may be off-site). It is designed primarily for use with a defined group of primary care patients diagnosed with chronic mental illness — most commonly major depression.

The PCMH includes a psychologist or some other type of behavioral health professional as part of the primary care team. They develop and help implement practice-wide prevention and intervention strategies for patients of all ages and share in the responsibility and liability of patient care.

Practices thinking about incorporating behavioral health need to consider the needs and resources of the communities they serve as well as their own culture, says Mary Gabriel, M.D., lead for collaborative care at University Hospitals (UH) in Cleveland, Ohio. “Both can be successful, but it’s worth looking at these things and preparing your own practice for the kind of intervention you want to give.”

The benefits of behavioral health integration

Proponents of behavioral health integration cite a range of advantages associated with it, beginning with the financial. A 2018 research report from Milliman estimated that annual cost savings from widespread integration could range from $37.6 to $67.8 billion. And a 2021 study by the Bipartisan Policy Center (BPC) found savings at the state level ranging from $14.4 million for a Medicaid managed care program in Arizona to $178.6 million among commercial and public payers in Colorado. The BPC study also found better access to care and fewer hospitalizations among patients in integrated programs.

Even more important, experts say, are the clinical and equity benefits that integration provides. “When behavioral and primary care providers collaborate, they can identify behavioral health issues earlier,” Gabriel says. “That allows for earlier intervention and preventing an escalation of symptoms and the sequelae that come from more moderate to severe disease.”

“Most patients already are going to their primary care providers for behavioral health,” notes Celli Horstman, M.P.P., a senior research associate for delivery system reform at The Commonwealth Fund. “And integration gives those providers the skill set and opportunities to work with other providers so they can do a better job of delivering this care.”

Co-locating behavioral health services with primary care also makes them more accessible to patients in variety of ways, experts say. For patients who live in rural areas or who depend on public transportation to get to a doctor visit, it means fewer trips to get the care they need. Gabriel says that was an important consideration in UH’s decision to open an integrated primary care clinic in a Cleveland neighborhood where 90% of the residents are African American and 88% are insured by Medicaid.

“Having mental health housed in a center where they feel comfortable and is on a bus route is a huge boon to them,” she says. “It really takes down a lot of barriers to care for that population.”

Nosal agrees, citing the example of the patient population served by her FQHC, which is located in the Bronx, New York. “In communities like mine, with many black and brown people and lots of immigrants, the barriers to obtaining any kind of health care are tremendous,” she says. “So by co-locating behavioral health [services] with primary care, we’re breaking down barriers to care in an otherwise marginalized, under-resourced community.”

Normalizing mental health

Paige Gutheil, D.O., founder of Signature Primary Care and Wellness, a direct primary care practice near Columbus, Ohio that includes a licensed family therapist, says it’s helpful not to have to send patients elsewhere for the counseling the therapist provides.

“Anytime we send patients to an outside facility it gives the impression, even if it’s subconscious, of escalating care, which can scare people,” Gutheil says. “But if we can normalize behavioral or mental health care as a foundational part of overall health, then we’re able to get patients more comfortable with it as well as making it easier for them to access.”

Nosal sees that dynamic when she makes a “warm handoff” of a patient to a behavioral health counselor at her practice. “There’s nothing like the human connection to make people feel ‘oh, this isn’t actually something weird or scary, it’s just someone else who can help me and who I’ll be able to see again,’” she says.

The most common behavioral problems among Americans are anxiety, depression and attention deficit disorder, all of which PCPs usually can treat with counseling and medication. It’s generally left to PCPs themselves to decide when to seek treatment input from a behavioral health specialist.

“I see it as analogous to any other medical condition where, as a primary care physician, I know where my level of comfort lies and whether the patient would benefit from another perspective,” Gutheil explains. “In general, I’d say the patient’s level of acuity and my level of comfort in treating them are the main determinants.”

Nosal, practicing in an FQHC, has to factor an additional element into her referral decisions: time. With most visits limited to 15 or 20 minutes, “my schedule would be overflowing if I tried to provide all the behavioral health counseling that I’d like to,” she says. “So having experts right here in our clinic we can collaborate with is really beneficial.”

Then too, not every PCP is willing—or feels able—to provide behavioral counseling. “Some primary care providers feel they shouldn’t be expected to manage mental health issues,” says Gabriel. “That can really be a challenge and require a lot of hand-holding until they get comfortable with the idea.

“One of the things you absolutely need in any practice is a champion to promote this kind of care,” she adds. “Just as with any new intervention or service, if you can get an early adopter to kind of show the way, they will bring the skeptics along with them.”

Challenges to integrating behavioral health

In light of its benefits, why isn’t behavioral health integration more widespread? Experts cite a variety of reasons, the first being a shortage of mental health professionals. A 2023 government study found that 169 million Americans — more than half the population — live in a federally designated Mental Health Professional Shortage Area. In rural counties the situation is especially dire, with 69% lacking a mental health nurse practitioner and 45% being without a psychologist.

The second challenge, or set of challenges, is financial. Integrating a behavioral health professional into a primary care practice requires substantial start-up costs including salary; revamping billing, scheduling, and workflow processes; and even finding office space.

“We know that our primary care office real estate is really at a premium,” says UH’s Gabriel. “That can sometimes make it difficult to really sort of integrate into the practice.” She adds that UHHS is trying to address that problem through increased use of telehealth for behavioral services.

To Nosal—who is an AAFP board member—funding startup costs for services such as behavioral health integration demonstrates the importance of value-based payments. “There aren’t many places that can pay those kinds of expenses up front with fee-for-service payments,” she says. “It would be much easier to accomplish under a system where the payer provides the capital in advance.”

Despite these and other challenges to care integration, proponents remain cautiously optimistic that its benefits are becoming more apparent to health care policy makers and the public. “It’s such a game-changer for primary care providers to be able to connect patients directly to behavioral and mental health care,” Nosal says.

The Commonwealth Fund’s Horstman cites Medicare’s coverage of integrated health care services starting in 2017, and the Centers for Medicare & Medicaid Services’ (CMS) adoption earlier this year of the Innovation in Behavioral Health payment model, as grounds for confidence that integration will spread.

“It’s great to see CMS taking this seriously,” she says. “It’s so important to have an infrastructure in place to allow both sides [primary care and behavioral health] to help patients to the best of their abilities.”