Cambridge Health Alliance Primary Care Behavioral Health Integration Program

Program Description

CHA implemented a model for primary care behavioral health integration (PCBHI) for adult patients between 2013 and 2017. CHA based its model closely on the Improving Mood- Providing Access to Collaborative Treatment (IMPACT) model for collaborative depression care management, and the Screening, Brief Intervention, and Referral for Treatment (SBIRT) model for unhealthy alcohol and substance use. The program consists of several key elements: annual screening for high prevalence mental health conditions (depression, unhealthy alcohol use and illicit substance use) using an integrated screening tool and systematic follow-up; training of primary care teams in depression and addictions care; integration of behavioral health providers (therapists and psychiatrists) who provide patient care and team consultation at each site; development of a new unlicensed Mental Health Care Partner role to perform population-based functions (patient navigation and proactive outreach), behavioral health coaching and care planning; usage of a depression registry for population management and team-based care; establishment of a tele-psychiatry consultation service; establishment of a central and site-based leadership structure for management of the initiative; establishment of an IT system for routine documentation and monitoring of quality outcomes; and completion of periodic site PCBHI self-assessments and comprehensive work plans for implementation.

Creativity

Other models typically employ licensed “behavioral care managers” responsible for brief therapy screening, population management and patient follow-up. We split this role into licensed therapists, performing brief therapy, and mental health care partners (MHCP). MHCP have the cultural competence, training, and flexibility to ally with patients in multiple ways, including as guides, coaches, care coordinators and educators for team members. They meet with patients during the visit and provide telephonic support. To better support patients, CHA conducted a patient-informed process to identify free, reliable, safe and accessible eHealth tools appropriate for use in the primary care setting. MHCP introduce these tools to patients through an engaging process established by CHA. These innovations allow CHA therapists to ‘work at the tops of their licenses’ while allowing patients to get help where and when they need it – whether in the clinic, at home, or via an eHealth tool.

Leadership

CHA is sharing this innovative program through several mechanisms including dissemination at conferences, academic literature and as part of collaboratives. For example, CHA presented on “innovative approaches to integrating behavioral health and primary care,” specifically focusing on the care partner role at the IHI 28th Annual National Forum on Quality Improvement, and participates actively in similar forums. A manuscript describing program impact on primary care providers’ experience is under review at a peer-reviewed journal. CHA participates in collaboratives through the Harvard Medical School where they have shared experiences with other providers. Perhaps one of the most critical ways in which CHA is leading the field is by sharing its model regularly with state government entities such as the Massachusetts State Health Policy Commission and MA Executive Office for Health and Human Services. In these ongoing relationships, CHA has had the opportunity to influence state and national policies and programs.

Sustainability

In addition to clinical best practice, health reform is a major impetus for this work. CHA is an essential part of the Massachusetts health care delivery system for low-income vulnerable patients. CHA has played a pivotal role in the success of the state’s coverage expansions and is a long-term partner in Massachusetts’ ongoing health reform efforts. CHA partnered with MassHealth through the Primary Care Payment Reform Initiative and through the CMS Medicaid Waiver, in order to gain initial experience in global payment initiatives and Patient Centered Medical Home transformation. In recognition of the ongoing critical role that the CHA PCBHI program plays, CMS is in the process of approving CHA’s Medicaid Waiver for FY2018-FY2023, which will have substantial focus on key quality metrics of PCBHI. In addition, the MA Health Policy Commission recently awarded the PCMH PRIME Certification to all 12 CHA practices, officially recognizing the PCBHI program.

Replicability

CHA built its program using evidence based models that have been adapted in other settings. As it advances beyond these models, CHA is taking care to document lessons learned from its innovations. For example, CHA has conducted time-tracking studies to quantify how integrated mental health staff spend their time. This information will help other organizations understand the tasks performed by these roles, and therefore how to sustainably support the work. Similarly, CHA is interviewing providers and nurses to better understand which aspects of the program support success and how, and which challenges remain and why. CHA has also implemented an annual site self-assessment process using validated tools to determine the extent of mental health integration at each of the 12 sites. By combining an evidence based model with high replicability and careful examination of its innovation, CHA is creating a model that could be replicated in other settings.

Results/Outcomes

This program has succeeded in increasing access to care through a robust screening and follow up system. Roughly 70% of patients -are screened annually for high prevalence mental health conditions, including depression, alcohol & drug use – receive Depression Screening and Follow-Up (NQF O418) -receive Preventing Screening and Counseling for Unhealthy Alcohol Use (NQF 2152) Early data demonstrates improvement in patient outcomes and provider experience: -Growing improvement on depression response, moving from 25% of depressed patients with symptom improvement (NQF 1884) to 32% over a ten-month period in the sites with fully integrated mental health care partners, and this continues to rise across sites. -Significant improvement in primary care provider’s subjective experience of knowledge and confidence in managing mental health conditions, as indicated by annual workforce survey data.