Many people with serious mental illnesses have difficulty accessing primary care or do not feel comfortable in primary care settings, for a host of reasons. Often, they have experienced trauma, resulting in trust issues that impact their ability to form relationships with new providers. As a result, they use emergency services to obtain needed care, or allow health conditions to worsen to the point of requiring high-cost inpatient care. At the same time, many of these people are engaged in a behavioral health program. For this group, the natural solution is to provide physical health services within behavioral health settings, leveraging the relationships they have with existing providers with the goal of improving outcomes and reducing costs.
To encourage development of integrated services, the Substance Abuse and Mental Health Services Administration (SAMHSA) has awarded grants for Primary and Behavioral Health Care Integration (PBHCI). Analysis of data from New York State grantees has already turned up promising results. For example, New Yorkers participating in PBHCI services with at-risk blood pressure (BP) readings at baseline had average reductions of 9 points on systolic BP and 5 points on diastolic BP. Research on blood pressure medication shows that similar reductions result in a 41% reduction in stroke and a 22% reduction in coronary heart disease events such as heart attack (Law MR et al 2009. BMJ. 338:1245-1253.).
As a NYS PBHCI grantee agency, ICL has implemented primary care in two mental health clinics and in a NYS Personal Recovery Oriented Services (PROS) program. ICL has identified a number of challenges and potential solutions in the following categories, discussed below: (1) Reimbursement, (2) Health Records, (3) Physical space, (4) Staffing, and (5) Care Coordination.
Challenges and Solutions
Reimbursement: Part 599, Article 31 of NYS Mental Health Law allows state-licensed mental health clinics to bill Medicaid for health physicals, health monitoring, and complex care management. Health physicals can be billed once a year per patient. Otherwise, physical health visits with physicians, nurses, and nurse practitioners are billed as health monitoring. The health monitoring rate is about half the rate of social work clinician services for the same amount of time, making these services financially unsustainable. In addition, peer health coaching services and multi-disciplinary team meetings, both so central to the integration efforts of SAMHSA-funded agencies, are not reimbursed at all in the current structure. And while Part 599 has moved clinics forward, the NYS PROS and Assertive Community Treatment (ACT) models have not moved towards sustainable reimbursement for primary care services, even though these models often serve people with the most severe physical and mental illnesses.
Fee-for-service rates will become less important as the state Medicaid system transitions to a managed care environment for behavioral health. Under more bundled payment models including capitation, it will be vital to ensure the financial sustainability of primary care and behavioral health providers working in fully integrated, ideally co-located teams, with open and frequent communication.
Health Records: Currently, many integrated care systems use one electronic health record (EHR) for behavioral health care and another one for physical health care. This situation commonly occurs when a behavioral health agency partners with a Federally Qualified Health Center (FQHC) that provides medical services at the behavioral health site and bills for these services at the enhanced FQHC rate. While this enhanced rate encourages partnership with FQHC’s, having two agencies involved usually means two separate EHR’s. For individuals choosing to access both physical and behavioral health care in the same location, information-sharing is more integrated and efficient if both types of care can be documented in the same system. The adaptation of reimbursement structures that make it more feasible financially for behavioral health agencies to provide physical health services would be one solution to this issue. The state’s efforts to promote interagency communication via PSYCKES and the Regional Health Information Organizations help with multi-agency partnership, but where feasible, the greatest integration is still afforded by a single health care team.
However, even when a single agency provides both behavioral health and physical health services, integrating the EHR can be challenging. Behavioral health agencies in NYS often use specialty EHR’s that meet NYS Office of Mental Health (OMH) clinic regulations for treatment planning. In general, such systems can be unwieldy for medical staff members. For example, they often do not integrate physical health information such as lab results into the clinical record in useful ways, in contrast to most EHR’s oriented toward physical health care. It would be helpful for the state to facilitate EHR integration either by aligning mental health and primary care documentation requirements more closely or supporting the development of the next generation of EHR systems that are well-suited to meet both sets of requirements.
Physical Space: Clinic licensing regulations can also make it challenging to provide integrated care. Behavioral health spaces are generally designed to provide offices with a desk and two chairs. Given limited space, many behavioral health clinics have had difficulty meeting NYS Department of Health (DOH) architectural requirements for medical clinics, such as having a soiled holding room. ICL was able to obtain a waiver request stating that soiled holding is not needed for the scope of physical health services provided at its mental health clinics, since linens used are disposable and regular hazardous waste pickup is sufficient for the clinics’ needs. The consequence of the waiver request process was a substantial delay in the application for a DOH license. For many agencies, some of the requirements could be a deterrent to integrating primary care into their behavioral health programs. Given that providing physical health services in mental health settings will be an important way to increase healthcare access, we strongly promote regulatory change to make it easier to implement, while still maintaining appropriate standards.
Staffing: Integrated health staff members usually have either a physical or a mental health background, not both. Therefore, many agencies have difficulty finding employees with the flexibility and willingness to work in integrated settings. Frequently, there is high turnover in these positions. Given the growing importance of integration in healthcare, some social work, primary care, and psychiatric training programs now offer experience in integrated settings. The state can encourage more integrated care training in clinical and peer programs, via both financial support and licensing requirements
Care Coordination: An important aspect of integrated care is the use of health home care coordination services made possible by the Affordable Care Act. Unfortunately, there are limits to the level of care coordination that health homes can provide, since the care managers often do not have any medical training. They experience difficulty effectively triaging the medical needs of the individuals they serve, and at the same time, they have caseloads much larger than were carried in traditional case management programs. Many health home care managers lack access to consultation with medical clinicians such as nurses and doctors. We believe that the coming capitated care system should pay for either 1) care managers with medical training or 2) ready access to supervision or consultation from medical clinicians.
Conclusions and Recommendations: Providing physical health services in behavioral health settings is essential to improving the health of individuals with mental illness. Many NYS agencies are making efforts to move along the spectrum of levels of integration, from care coordination to co-locating services, with the final goal of true, seamless integration. Some organizations are already making changes in measurable health outcomes that are large enough to significantly decrease heart attacks and strokes.
Based on ICL’s ground-level experience integrating physical health care into behavioral health settings, we support the following:
- Revision of the Article 31 codes and rates to reimburse needed primary care services, including follow-up visits, peer health coaching, and multidisciplinary risk review, with a health monitoring rate that reflects the cost of service.
- Revision of PROS and ACT reimbursement models to include funding for primary care services.
- Requirement of managed care organizations to support fully integrated services in a bundled payment and capitated environment.
- Alignment of regulatory documentation requirements, with advocacy to strongly encourage EHR vendors to adapt systems to meet both sets of requirements.
- Adaptation of architectural standards for Article 28 clinics to reflect the reality of behavioral health clinics offering onsite primary care.
- Inclusion of integrated care competencies in training and licensing standards for social workers, physicians, nurses, and peers.
- Rates that facilitate provision of medical supervision and/or support for health home care coordinators to enhance quality of care and utility of the service.
Changes such as these will promote movement towards integrated care throughout the behavioral health system, to the benefit of thousands of New Yorkers, and with the potential to save costs related to utilization of high-end services.
Jeanie Tse, MD, is Vice President for Integrated Health at ICL, Jason Cheng, MD, is Director of Integrated Health at ICL, Marc Manseau, MD, is a Psychiatrist at NYU School of Medicine, and David Woodlock, is CEO and President of ICL.