6 Steps to a Virtual Behavioral Health Integration
October 11, 2018
Mental health originated as a medical focus around 750 CE when the first psychiatric hospital opened in Baghdad – and was named “psychiatry” in the early 1800s and studied individuals who were placed in asylums and deemed unfit for living in society. Primary care has been assessing the human physical condition since the 5th century CE. This is how long these two fields of medicine have been siloed.
Behavioral health integration (BHI) seeks to remedy the disparity between these two medical fields. By incorporating mental health services into primary care, patients receive full, comprehensive medical care addressing the mental and physical maladies of the body. BHI makes significant strides towards the goal of addressing the interconnected nature of the human body.
If you’re reading this, you may be seeking a way to better serve patients presenting with a mental health diagnosis, needing a way to improve outcomes among patients with chronic conditions, or wanting to grow your practice. Between an influx of patients with mental health issues, growing populations with mental health comorbidity, or mental health patients consistently visiting Emergency Departments (EDs) – the siloed approach to mental healthcare is no longer working. Behavioral health integration is the modality recognized as the leading solution by The Centers for Medicaid and Medicare (CMS), the World Health Organization (WHO), and other leaders in healthcare.
Regardless if you are in the initial steps of researching BHI, or you want to go virtual and never look back – this guide is for you. At VisuWell, we understand the dilemmas and the benefits of BHI implementation. We want to share our knowledge with you and get you back to caring for patients, more comprehensively and efficiently.
Step 1: Understanding Behavioral Health Integration
BHI is an integration of behavioral healthcare into primary care and its assessment and treatment of patients, with the goal of changing the standard of care. In its simplest form, primary care physicians assess the physical symptoms of their patients alongside their mental well-being. The Centers for Medicaid and Medicare and others are promoting a form of BHI under the umbrella of the Psychological Collaborative Care Model (CoCM). It combines the expertise of mental health providers and primary care clinicians through a team-based approach to care that engages patients and their caregivers as part of the treatment process.
Under the CoCM approach the behavioral care manager “acts as part of the primary care team whose function is to deliver brief interventions and other behavioral health services in consultation with the clinician leading the care team and a psychiatric consultant” (PCPI). Primary care BHI initiatives in particular increase access to behavioral care, resulting in happier and healthier populations. Broad-scale implementation of BHI has been proven to decrease the demand for expensive alternatives, such as emergency departments while improving the overall health of patients with chronic conditions. The net impact is an overall reduction in the cost of care for providers, patients, health insurance companies, and those that underpin insurance payment systems, including employers and taxpayers.
What Problems Can BHI Solve
According to the National Association on Mental Illness, approximately 1 in 5 adults in the U.S. experience mental illness each year. That’s 43.8 million people or 18.5% of the US population. Contrastly, 56.5% of the affected population is not getting treated. The demand for behavioral care is clearly present; however, mental health providers are notably separated from the institutions that serve as the traditional point of care, including hospitals, emergency departments, urgent care centers, and primary care physicians. In most cases, these points of care are ill-equipped to serve mental health needs, either through lack of training, or a lack of behavioral staff.
The occurrence of patients presenting with mental health illnesses in primary care offices is not rare. A study conducted in Belgium found that out of 2,316 patients, only 5.4% initially presented for mental health issues, but 42.5% had mental health issues detected, highlighting the value of providing access to behavioral services in primary care (PubMed.gov, 2004).
While most individuals don’t visit a mental health professional each year, 85% of patients visit their primary care doctor. Primary care physicians assess the physical symptoms of the patient, but not always the root cause, as they aren’t trained to diagnose and treat psychiatric conditions. Yet, if they are the only doctor that patients see – the onus falls upon them. Even if the patient only presents with physiological symptoms, their mental health is a strong outcome indicator that is frequently ignored.
Studies have shown the presence of comorbidity between mental health disorders and chronic conditions negatively impacts outcomes, including diabetes patients. On average, 40% of diabetes patients present with signs of depression and are more susceptible to developing depression (Terry, 2016). On the other side of the coin, patients with depression are more likely to develop unhealthy lifestyles leading to greater risk of Type II diabetes and other chronic conditions. Managing a diabetes patient’s glucose levels during the presentation of depression is also difficult, as they are sensitive to external triggers and glucose can fluctuate dramatically. Patient non-compliance is vastly heightened in patients that present with comorbidity of a mental health disorder and diabetes, and one small change can make a significant difference in their health. It’s a cycle that is challenging to reverse once it starts.
Addiction is a rampant issue in the United States, as evidenced by the opioid epidemic declared as a Public Health Emergency in 2017. Unfortunately, emergency departments tend to be the only resource for these populations but this is generally at the time of an overdose. For patients struggling with addiction, an ounce of prevention is worth a pound of cure but receiving preventative care is a tremendous challenge. The average wait to schedule a non-emergency psychiatric appointment can range from 15 – 54 days with private health insurance, and up to 90 days for individuals covered by government programs. If primary care physicians and urgent care centers regularly screen for addiction and other mental health disorders, behavioral care can be delivered faster, prior to a critical episode that would result in an expensive visit to an emergency department. With true integrated behavioral care, appointment wait times for behavioral services can decrease to a few days or hours from the time of diagnosis.
Behavioral health integration is the closest option to a magic pill that improves outcomes and decreases the overall cost of care across patient populations. Primary care and behavioral care providers can be more effective because they can assess the entirety of the patient. They can develop an individualized, comprehensive care plan, that ultimately reduces medical costs and improves patient health.
Step 2: Know Your Patient Population
Behavioral health integration directly addresses access to behavioral care for general patient populations and patients with comorbidity that includes a mental health diagnosis. Understanding why and how BHI will work for each individual practice is important to success. We’ll address external barriers to implementation but consider barriers within your patient population. Why do your patients need BHI? How will BHI benefit your patients?
States with larger rural populations experience significant behavioral access challenges. For example, Mississippi has one primary care physician for every 954 people, and that includes two counties without a single primary care physician, further complicating the access problem. Within these states, patients can be in a lower socioeconomic tax bracket, with many being under-insured or without insurance. In these cases, primary care physicians may be the only source of care. Primary care’s increased exposure to this population makes them the most viable option for behavioral access, otherwise, these patients may never get the mental healthcare they need.
Cultural norms and social stigmas can dictate views on mental healthcare, or all medical care, reducing the number of patients seeing physicians. When this is the case, once a patient gets in the door physicians want to ensure they are comprehensively treated. Primary care is uniquely positioned as there isn’t as strong of a stigma associated as there is with behavioral healthcare. If there is a mental health issue, patients may be more inclined to voice concerns as they’re just seeing a regular doctor, and not a ‘shrink’, and the issue can then be further addressed.
For Nuestra Clinica Del Valle, a part of the Sí Texas initiative, the patient population faced a combination of indicators reducing their access to mental healthcare. Many patients exhibited signs of mental health issues, but in this burgeoning Southern Texas region, many individuals don’t have the time to make a series of appointments to see a mental health provider. Other patients have insufficient insurance coverage, or no coverage at all, creating a financial barrier. To complete the hattrick, there’s an underlying cultural norm against mental healthcare to tackle, according to Nuestra Clinica’s Data Manager, Marco Mata, “It’s ingrained in our culture, our Hispanic culture, our machismo culture…. Like, either you adapt or figure it out all on your own….It’s mostly [due] to that lack of education.”
Behavioral health integration is the new standard of care for Nuestra Clinica, challenging the cultural norm. Every patient meets with a mental health clinician, who treats all patients equally, which aims to normalize mental healthcare and reduce the stigma. Making mental health a consistent feature of primary care means fewer patients will fall through the cracks and receive the care they need.
Step 3: Target Goals & Set Benchmarks
Any new initiative requires a valid business justification or a clear improvement in patient outcomes. Before setting up your integrated care strategy, it is a best practice to identify your desired goals and then evaluate the BHI model that best suits those objectives. Some commonly held goals include:
- Increased Compliance
- Decreased Utilization of Physician Group Services for specific populations
- Improved Outcomes
- Increased Capacity for Patient Load
- Improved Quality Scores
- Increased Patient Satisfaction
- Improving Behavioral Referral Appointment No-Show Rates
In 2016 the Journal of the American Medical Association published a study comparing Traditional Practice Management (TPM) to models with Integrated Behavioral Care or Team-Based Care (TBC). Data from this study provides multiple metrics that can serve as benchmarks for your BHI plan. This comparative analysis covers 113,000+ unique patients over a 4-year period and benefits included a 22% reduction in emergency department visits and 7% reduction in primary care physician encounters, along with the following highlights:
Step 4: Implementing Behavioral Health Integration
Implementation of BHI will require an understanding of potential constraints, with the leaders being:
- Implementation costs
- Insurance reimbursement
- Lack of mental health providers
Costs for physician groups are a significant concern for physician-run practices. Hiring a mental health provider, administrative costs, and extended appointment times all have the potential to add up and be a roadblock to implementation. Upfront costs can vary amongst practices, but in the end, the return on investment is worthwhile for everyone involved. In most cases, the costs of investment can be offset by:
- Adding new revenue through Medicare BHI reimbursement
- Increased capacity due to fewer visits from patients with chronic conditions
- Improved quality metrics that drive increased reimbursement rates under shard cost models. Other insurers are sure to follow, including Medicaid
Insurance coverage for mental health services can also vary across plans and providers. As legislation and billing policies are in never-ending flux, reimbursement is a natural priority. It is worth noting, however, that the landscape is constantly changing in favor of support towards BHI and telehealth.
Center for Medicare & Medicaid Services (CMS) began supporting BHI in January of 2017 with 4 new reimbursement codes that include revenue opportunities for:
- Administering Behavioral Assessments
- Delivering psychiatric collaborative care through a behavioral care manager
- Behavioral healthcare planning
- Facilitation and coordination of behavioral health
- Maintaining a continuous relationship with a designated behavioral specialist
Depending on the allotted time and service provided, CMS reimbursement ranges from $48 for 20 minutes of services, to $140 for up to 70 minutes of services, making BHI implementation actually profitable in Medicare-insured populations – and feasible for physician groups to adopt.
Mental Health Providers
There is a national shortage of mental health providers, which can be a stubborn barrier to BHI implementation. Nationwide, there is 1 mental health provider for every 529 people, including psychiatrists, psychologists, clinical social workers, counselors, therapists, and nurse practitioners specializing in mental health. Over 111 million people in the United States live in an area low on mental health providers, and ⅔ of primary care clinicians have trouble issuing mental health referrals. Clearly, many practices are fighting this barrier.
Leveraging Existing Resources | Advocate Care
Behavioral health integration is best achieved not by simply training already busy staff. Capacity is a major constraint that needs to be resolved by integrating behavioral providers into a primary care practice as part of a collaborative care team. The integrated providers can either be full-time employees or associated with the practice on a contractual basis for a collaborative care approach.
Conversely, primary care groups can implement a non-collaborative care approach in which they actively screen for psychological disorders and administer assessments. Those identified with a mental health diagnosis are then referred to behavioral providers that are best suited to treat an identified disorder. In this model, primary care groups build looser referral-based affiliations by developing and maintaining relationships with multiple behavioral providers.
Advocate Care in Downers Grove, IL adopted a BHI – but with over 250 sites, including 12 hospitals staffed with mental health providers – provider access was not their issue. While a larger network with staffing capabilities, they still had to be resourceful. Their staff of behavioral health professionals sees patients alongside the primary care clinician, but nurses at specific sites are also trained to conduct behavioral health screenings. A Mobile Integrated Behavioral Health Hub works alongside the ED and inpatient departments to manage care and streamline services to primary care physicians. Combining their existing resources with new ideas made their behavioral health integration a network-wide success.
Step 5: Go Virtual
Patient demand for behavioral care is undoubtedly high, but access to behavioral providers is not only low but is the number one reason why primary care groups are hesitant to implement BHI. If your practice doesn’t have the means to train or hire to meet this demand in-house, consider the virtual route. Virtual workflows increase productivity and efficiency when incorporating BHI collaborative and non-collaborative care models. This approach provides avenues to the delivery of additional services without the increased overhead. It is a true example of efficiency that leads to added topline revenue.
Atrium Health Virtual Model
Atrium Health had an influx of mental health patients coming into the ED and added extra services to maintain efficiency and profitability. Instead of including costly measures, they adopted a BHI in 2011 to serve their 20+ ED, and it was a big success. Within this adoption, CHS launched a telepsychiatry system for 24/7 use to provide video assessments on-site. Using this technology, they have completed a monthly average of 900 – 1,000 psychiatric evaluations, with 800 – 900 behavioral inpatient recommendations.
In 2014, CHS expanded virtual behavioral health integration into their primary care practices. Under the direction of psychiatrists, licensed social workers and other behavioral health professionals visit patients alongside the primary care physician to assess the patient’s overall well-being. The program features telephone outreach, a virtual call center, and telebehavioral support to manage patients in the primary care setting. Chief Clinical Officer of Behavioral Health, Dr. Manuel Castro said, “Of clients who came to the BHI program reporting suicidal ideation, 83 percent no longer had these thoughts on graduation. For me, this is worth everything.” The results for these patients speak to the holistic improvements virtual BHI have in primary care settings.
Step 6: Leverage A Virtual Behavioral Health Network
While CHS had their own behavioral staff to execute their Virtual Behavioral Health Integration, outsourcing behavioral staff is a great way to fill the gap and meet the need. VisuWell, an asset-light platform, has their own network of mental health providers that can practice within primary care networks nationwide. This network takes the effort out of outsourcing behavioral health providers, but still provides the opportunity for patients to get comprehensive care.
Behavioral health providers on the VisuWell platform’s network are all licensed practitioners, providing extensive biographical data, so you can familiarize yourself with their experience, specialty, and interests. You can conduct online interviews from a catalog of quality providers in mere minutes. Our platform is HIPAA-compliant and provides the HR capabilities of a project management software tool – meaning it’s not only secure but also productive for your business. The intuitive nature of the platform and the multi-device capabilities helps the platform conform to your business model, not the other way around.
We’re at the pulse of technology, constantly improving our platform to meet the needs of our clients, and to keep up with legislative policy changes. We understand that Virtual Behavioral Health Integrations require funding, and that reimbursement is extremely important. Complicating matters, different states have different rules on reimbursement – but we’ve taken care of that. Check out our Reimbursement By State Map to see how reimbursements work in your state. VisuWell is here to help. We’ve seen the pain points from the provider end, so we’re a good resource.