The Body and Beyond

That’s one way to skin the proverbial cat of behavioral/primary care integration: by adding primary care services to behavioral care resources. Alternatively, you can introduce behavioral care into the primary care environment. That’s a route taken by Tennessee’s Cherokee Health Systems, which has polished its approach with three decades of integration experience.

Informing its perspective is that Cherokee actually began life in 1960 as a mental health resource, the Mental Health Center of Morristown. It ventured into primary care in the ’80s and took its current name in 1993 to reflect a comprehensive mission of integrated primary and behavioral care.

“If you look at the area of behavioral health, most people who seek help end up going to primary care rather than to a specialty behavioral health provider,” says CEO Dennis Freeman, PhD. “So in thinking about access to behavioral healthcare, the best place to provide that would be in primary care. On the other side, if we’re looking at better outcomes in primary care, a lot of it really has to do with the health behaviors of the patient. We can have the right diagnosis and the right medicine prescribed, but unless patients embrace their responsibility for taking care of themselves and following the guidance of their providers, we’re not going to have the outcomes we want. So really a lot of primary care is behavioral in nature too.” 

Embedded BHCs

Cherokee fields a workforce of more than 600 that includes physicians, nurses, psychologists, social workers, public health professionals, pharmacists and dentists. Last year these providers cared for 64,300 patients across 14 counties of eastern Tennessee. It’s both an FQHC and a CMHC. Its model has been highlighted by the SAMHSA-HRSA Center for Integrated Health Solutions as a successful example of healthcare integration.

Cherokee employs behavioral health consultants (BHCs) embedded into primary care teams, along with common support staff. The BHCs make real-time behavioral consultation available to primary care providers and let patients get help immediately, without a lengthy process or referral that may never be utilized.

Cherokee’s consultants are generally licensed psychology providers with behavioral health orientations. They’re brought in whenever a primary care provider determines there are psychosocial factors involved in the patient’s presenting complaints or that negatively affect their response to treatment, and can deliver brief, targeted assessments and interventions to address the psychosocial aspects of primary care.

“People have stress, they have anxiety issues, they may have some kind of emotional challenge in their life—maybe there’s abuse of substances,” says Freeman. “Maybe slightly more than half in our system are those kinds of things that might in the past have led to a referral.”

The BHCs assist with things like:

• Consultation and comanagement in the treatment of mental disorders and psychosocial issues;

• Psychological problems such as anxiety and depression;

• Substance use disorders and risk reduction;

• Psychological components of physical illness, both acute and chronic;

• Management of the psychosocial aspects of chronic and acute diseases;

• Application of behavioral principles to address lifestyle and health risk issues;

• Promoting prevention and self-help by helping patients build resiliency and develop personal responsibility;

• Factors impacting health status: stress, nonadherence, health behavior, social support. 

“A lot of it’s about health behaviors,” says Freeman. “Say a person has diabetes, their numbers aren’t good, and the primary care provider sees that and has questions about health behaviors and the person’s acknowledgement that they really have this disorder and have to do something different. So they hand that person off to the behaviorist, who goes through things like willingness to change, readiness to change, helping the patient embrace that. They’ll look at whether they’re taking their medications, whether they’re exercising, what their diet is like, whether they’re smoking. It’s dealing with those kinds of things as well.”

More times than not, people don’t come in with just one issue—many have several things going on. “Some of them might have social issues, they might have psychological issues, there may be physical illnesses,” Freeman adds. “Especially as people get older, developing a chronic medical condition is more likely, and there are often psychological aspects to that. So it’s usually not just one problem, it’s multiple issues.”

Still, most patients who enter the specialty behavioral healthcare system are only seen once, and Cherokee’s setup allows more than 80% of patients with mental health problems to be managed in primary care without referral to specialty psychiatric services. Often they can benefit from behavioral alternatives to psychological and pharmaceutical interventions, and when medications are warranted, simultaneous behavioral strategies can enhance their effectiveness. When follow-up is needed, it can be aligned with future primary care visits, increasing the likelihood of follow-through.

Collaborative Approach

Working in a primary care environment poses some different requirements to mental health providers, though. They need certain characteristics and skills.

For instance, primary care practices are volume-based and rely on moving patients through at a faster pace than a psychologist may be used to. Cherokee’s BHCs see 8–15 patients a day and consult with primary care providers on a similar number.

“Clinicians need to be high energy, and they need to like to work in teams,” says Freeman. “It’s a very collaborative approach, with a lot of back and forth. They need excellent diagnostic skills, because there’s not a lot of time with patients. Behaviorists have to blend right into that flow and not slow the train down.”

Other needed qualities include an interest in health and fitness, clinical intervention skills and an investment in educating patients and developing health literacy.

Integrated-Care Training

Designing an integrated practice also has more mundane requirements involving scheduling, supervision, training, access, compensation and measuring outcomes. That’s all covered in the integrated-care training Cherokee offers.

Yes, its evangelism for the model extends to training other organizations in the blending of care services. The Cherokee team has assisted more than 300 organizations nationwide, as well as presenting at meetings and conferences around the country and to state officials and even hosting a pair of national integrated care conferences.

“We’re kind of missionaries about this approach,” says Freeman. “From a population-based perspective, we think we can treat so many more people. And we really want to help other providers—especially safety-net providers; that’s kind of our niche—learn how to do this. It really grew out of having a lot of visitors, a lot of people wanting to come see what we do. We had so many requests, it was hard to accommodate them and not interrupt our clinical flow.”

Cherokee began offering two-day academies about six years ago. Organizations’ leadership teams visit to learn about the clinical model, operations and financing. Because it was challenging finding behavioral clinicians who could thrive in the primary care environment, Cherokee also started offering academies just for behaviorists, teaching the skills they’ll need as well. It has its own American Psychological Association-approved internship program for doctoral candidates in psychology, which trains them for a year in the integrated care model, and affiliations with local universities to provide student trainees in a range of fields.

The care-integration academy revolves around three primary goals:

• Changing the delivery of community health services to expand access and improve the quality of behavioral and medical services;

• Bringing together and creating a community of people and organizations working to develop and implement innovative practice systems in primary care; and

• Providing training to organization leaders and clinicians to more effectively practice in an integrated care environment.

Customized offerings cover staffing, technology and communications, an integrated patient record, financial modeling for sustainability, operational planning and clinical training that includes shadowing.

It’s not just healthcare organizations that can use some guidance in this growing field; payers and even educators also need brought up to speed on why it’s feasible to promote an integrated model.

“In many states the payers might not have caught up with this model,” says Freeman. “But generally we’ve been pretty successful in working with our payers to work out payment methodologies where everyone benefits.”

Outcomes

That includes the patient. Some of the metrics associated with Cherokee’s use of BHCs include:

• A 28% decrease in medical utilization for Medicaid patients;

• A 20% decrease in medical utilization for commercially insured patients;

• A 27% decrease in psychiatry visits;

• A 34% decrease in psychotherapy sessions;

• A 48% decrease in crisis visits.

Generally, a growing base of literature demonstrates benefit to the blended primary/behavioral care model, and patients say they like the convenience. Without the separation of mental health services, stigma is reduced for those who seek and receive them. The model also captures patients who might not otherwise get access to behavioral treatment. And understandably, primary care providers appreciate having a method at hand to deal with aspects of their patients’ problems that are often beyond their control. 

Conclusion

Sufferers of serious mental illness die a startling 25 years earlier, on average, than those without. At least 60% of this premature mortality is due to medical conditions that can potentially be prevented or mitigated by addressing risk factors. That’s good reason, even before the cost savings, to develop models that avail patients of both physical/primary and mental/behavioral healthcare services.

Pursuing the model requires finding the right kind of provider, though, and working out a financial model that’s not just sufficient but sustainable. “A lot of these programs started with grants, and most grants don’t last forever,” Freeman notes. “There has to be some sustainability plan.

“The goal is not to produce encounters for the behaviorists, so fee-for-service methodology often isn’t the best approach. If, by having consultation available, the primary care provider can give better care, that’s great, but there may not then be any reimbursement for the consultation provided to the PCP by the behaviorist. Generally a financing model needs to provide some stream of revenue for the nonclinical components of an integrated model.”

Sidebar: A Morning in the Life of a Cherokee BHC

8:00    “Rounds” check-in

8:30     L.R.       Chronic pain/depression

9:00     K.F.       Trauma/assessment

9:15     K.F.       Compliance/coping skills

9:45     H.S.       Transplant/psychoeducation

10:00   G.W.      Multiple ER visits, chest pain

10:15    R.W.     Domestic abuse/depression

10:30    N.R.      Depression/substance abuse

10:45    C.G.      Dx clarification/Tx plan

11:00    S.F.      Bipolar/diabetes/asthma/obesity

11:15    P.B.      Weight management/obesity

11:45    E.K.      Anxiety management

—Source: Cherokee Health Systems, Taking a Road Less Traveled, presentation to the American College of Mental Health Administration, 2007

* Note: Patient initials changed for privacy 

Take-Home Points

• Most people who need behavioral health assistance seek it initially through primary care resources.

• Behavioral health consultants embedded in primary care teams can offer patients real-time consultation without referral or delay.

• Cherokee’s use of BHCs has been linked to reductions in medical utilization, psychiatry visits and crisis visits.