Fall QCLC - Integrating Mental Health into Advanced Primary Care – Why and How?

In early July, Dr. Neil Korsen presented practical strategies for integrating mental health into primary care during a Quality Counts and Maine Practice Improvement Network webinar.  Dr. Korsen, a technical advisor to the Patient Centered Medical Home Pilot, is a family physician and geriatrician with 18 years of practice experience in Maine. He serves MaineHealth in a variety of roles, including the Medical Director of the Mental Health Integration Program, the Senior Director for Program Evaluation for the Center for Quality and Safety, and the Principal Investigator for a grant-funded pilot program in Shared Decision Making.  For practices participating in the PCMH Pilot, Dr. Korsen provides support to assist in meeting their core expectations of integrated behavioral and physical health care.  This article contains information presented by Dr. Korsen, including the rationale, approach, and considerations for integration.

Over the past two decades, evidence for integrated care continues to build.  Most people with poor mental health, estimated at 25% of the primary care patient population (Spitzer, JAMA 1999; Kessler, Arch Gen Psych 2005), receive most of their care in the primary care office (Petterson et al, American Family Physician 2008), including more than 50% of people with depression (Katon, Arch Gen Psych 1996).  Because of the high level of co-morbidity of common mental health conditions in populations with chronic illnesses such as diabetes and heart disease, the need for primary care teams to effectively identify and treat mental health is critical.

Screening and Assessment: Routinely identifying your population of patients living with mental health problems is the starting point to provide integrated care.  Dr. Korsen recommended practical steps for practices – 1) Choose a high-risk population to screen (such as patients living with diabetes and/or heart disease), 2) Identify one or more conditions to screen for (such as depression, anxiety or substance abuse), and 3) Implement a routine process to screen patients and to act on the results of screening.  The screening process should include clear assignments to members of the practice teams, and protocols for action steps for patients who screen positive.

Screening for Depression: Use of the PHQ-9 will be one measure publicly reported underAdvanced Primary Care .  Dr. Korsen provided an overview of the PHQ-9 tool, interpreting results, and follow up activities.  The PHQ-9 is a validated tool for screening and diagnosing major and minor depression and for following the results of treatment.  Ninety-six percent of patients with depression will respond affirmatively to one of the first 2 questions on the PHQ-9 (scoring a level 2 or 3).  The full PHQ-9 can then be administered to patients who screen positive.  As a follow up tool, the PHQ-9 should be administered monthly for 6 months, or until patients reach a remission score; every three months for patients on active treatment, and annually for patients with a history of depression who are no longer on treatment.

Improving Communication and Coordination with Mental Health Specialists: To improve coordination and referral to mental health specialists, Dr. Korsen suggested 1) Identify and meet with mental health specialists who provide care for many of your primary care patients, 2) Develop templates for communications with specialists, and 3) Improve tracking of patients referred for mental health care, ideally incorporating routine sharing of treatment results and care plans.

Strengthening the Integrated Team: Integrated care may be coordinated through communication and tracking with off-site specialists, or with specialists co-located in the primary care setting.  Regardless of physical location, strategies to improve the overall cohesion and functioning of the integrated team are essential.  Strategies to advance team functioning include: Regular team meetings, brief morning huddles for onsite teams to plan for the day, and ‘warm-handoffs’ between physical and behavioral health providers.

Even though integration makes sense from a clinical perspective, current reimbursement rules make it challenging to sustain integration financially. It is possible to be financially successful, but attention must be paid to important details of the integrated service in order to be reimbursed appropriately for the work that is done. Essential questions Dr. Korsen recommended addressing include:

–        Who will be delivering the service (what type of mental health clinician)?

–        What service will be delivered and what codes will be used?

–        Where will the service be delivered?

–        What is the “facility”? Under what license?

–        Who will “employ” staff?

–        Who will do the billing?

–        How will the reimbursement work? Which insurance will be billed? What are the rules for that insurer?

To access slides from Dr. Korsen’s presentation, please visit the link “Integrating Mental Health into Advanced Primary Care v7.18.11”