How integrating behavioral health services into primary care could yield better clinical outcomes.
The head and the body are one connected system and should be treated as such, said Diane Powers, MA, MBA. “We know from many research studies that behavioral health conditions worsen medical conditions and vice versa,” she said. “It makes sense to treat them together.”
That is one of the chief goals of the AIMS Center, of which Powers is Co-Director. The AIMS Center was created 20 years ago to help healthcare organizations, clinicians, payers, and policymakers implement the Collaborative Care Model (CoCM) – a method of integrating behavioral health services into primary care and other medical settings using the principles of the chronic care model. Specifically, it is a patient-centered and population health approach that uses measurement-based treatment to target and evidence-based interventions to achieve significantly better patient outcomes as compared with usual care.
CoCM adds a behavioral health care manager and a psychiatric consultant to the primary care or medical team. They use a population health registry to support their work. CoCM has been proven in over 90 research studies worldwide to get more patients better faster than other approaches, even when usual care includes a co-located therapist in the primary care clinic.
“The AIMS Center has worked with hundreds of healthcare organizations and trained more than a thousand clinicians over the past 20 years and through that process we have learned quite a bit about what it takes to implement a healthcare innovation like CoCM, both what to do and what not to do,” Powers said. “We provide many resources on our website and we also provide implementation coaching, clinical training, a population health registry, and evaluation support. The AIMS Center continues to conduct research on CoCM and recent investigations include using CoCM for co-occurring opioid use disorder and mental health conditions and using text messaging as an adjunct to treatment.”
New project to scale collaborate care model
This spring, AIMS and Concert Health, a Collaborative Care Platform, announced a three year, multi-state project to facilitate mental health care for 2,700 patients with complex psychiatric disorders in primary care settings. Specifically, the project will leverage and scale a Telepsychiatry Collaborative Care Model (CoCM) to help identify and treat patients with bipolar disorder and/or post-traumatic stress disorder (PTSD).
The initiative is funded through a $2.5 million award from the Patient-Centered Outcomes Research Institute (PCORI). PCORI awarded this funding to the AIMS Center research team to implement findings from the PCORI-funded SPIRIT study, which demonstrated that telepsychiatry collaborative care significantly and substantially improved clinical outcomes for patients with bipolar disorder and PTSD living in medically underserved areas, according to a release.
“The collaboration between the AIMS Center and Concert Health stems from a research trial completed a few years ago that compared telehealth CoCM to telehealth care delivered by both a psychiatrist and psychologist for patients experiencing bipolar disorder and/or post-traumatic stress disorder (PTSD),” said Powers. That study did a direct comparison of those two treatment approaches and found that CoCM was as effective while being significantly more cost-effective and more practical considering the workforce shortages for psychiatrists and psychologists. The current project will scale CoCM for patients with bipolar disorder and/or PTSD who are being treated by Concert Health, a CoCM vendor. As a vendor, Concert Health partners with healthcare organizations to provide the behavioral health care manager, psychiatric consultant, and registry that make it possible for them to offer CoCM. The AIMS Center will train Concert Health trainers in a form of behavioral activation that was developed at the University of Washington and is designed to treat patients with bipolar disorder and PTSD.
Telepsychiatry Collaborative Care is an evidence-based model in which an integrated primary care team, including a care manager and telepsychiatrist consultant, collaboratively identify and treat patients with behavioral health conditions in primary care settings. The study also found that this model efficiently leveraged behavioral health specialist time when compared to a traditional referral approach. Published in JAMA, the findings are significant considering only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care.
Over the next three years, Concert Health and the AIMS Center will scale the findings from this research, partnering with more than 150 primary care clinics located in medically underserved areas or caring for medically underserved populations across several states. The AIMS Center will train Concert Health’s lead psychiatric trainers and lead care manager trainers in Collaborative Care management for bipolar disorder and/or PTSD. They will then train Concert Health’s expert care team, who will then partner with primary care providers to screen patients identified with a behavioral health need for bipolar disorder and/or PTSD, provide treatment to their patients with a patient-centered “treat to target approach,” and provide psychiatric consultation, making specific treatment recommendations focusing on symptom reductions. Concert Health’s care experts, who have treated nearly 100,000 patients, become an integrated part of preexisting care teams through sustained clinical partnerships.
Concert Health leverages the telepsychiatry CoCM paired with their expert behavioral health care team and technology platform. This is designed to create an extra layer of connection between each patient and their primary care team. The organization has spearheaded nine peer-reviewed studies that provide rigor around the measurement and reporting of CoCM outcomes, according to a release. Today Concert Health partners with leading health systems – including Advent Health, Mass General Brigham, Mercy, and CommonSpirit Health – independent health systems, independent medical groups, Federally Qualified Health Centers, and Rural Health Clinics. Concert Health reports it has driven strong clinical outcomes with half of its patients seeing at least a 50% decrease in anxiety or depression symptoms (PHQ9 or GAD7) in less than 90 days. Patients also express strong satisfaction with their experience – Concert Health’s care team upholds a 72 net promoter score (72) among patients.
“The goal of this project is to move the CoCM intervention for bipolar disorder and PTSD from research to practice as a first step to a more widespread dissemination through the AIMS Center,” Powers said.
All of the clinics that participated in the research trial demonstrating the effectiveness of telehealth CoCM for bipolar disorder and PTSD were federally qualified health centers that serve low-income and otherwise underserved patient populations. Some of the participating clinics were also located in rural areas. “There are other studies that have examined CoCM for common mental health conditions like depression and anxiety delivered in medically underserved areas, including one study that demonstrated that CoCM delivered via telehealth was superior, but this is the first study we are aware of that examines CoCM for bipolar disorder and PTSD, which is why it is so noteworthy,” Powers said.
Eliminating the stigma
One reason it has been difficult for U.S. healthcare providers to provide care for both physical and mental health in the same setting is stigma, Powers said. “While there have been significant gains in the past several decades in breaking down stigma, it remains a barrier to the effective integration of behavioral health services into medical settings.”
Another barrier is payment models. Until the advent of the Collaborative Care CPT codes, it was difficult to receive reimbursement for this team-based care. In many healthcare organizations, they have separate service lines for medical and behavioral healthcare, meaning they have separate budgets and sometimes separate medical records. Additionally, some health plans carve out behavioral healthcare to organizations outside the medical clinic, entrenching silos.
The CoCM approach shows promise for several reasons. Patients often prefer to receive treatment in a setting where they already have a relationship with their provider. There is also less stigma associated with receiving care at a medial clinic than at a mental health clinic, something that is particularly true in rural areas where stigma is more prevalent and where your neighbors will see where your car is parked. “In addition, CoCM has been shown in several studies to be more cost-effective than usual care, something that is important to payers and policymakers.”