Integrating Behavioral Health and Primary Care: Small Practices Tackle the Challenge

One in five New Yorkers suffer from such common mental health disorders as depression, anxiety, and substance abuse, all of which have a direct impact on physical health—and health care costs. But studies have found that 80 percent of patients with depression or anxiety within a primary care practice are undiagnosed or untreated.

Small primary care practices have a particularly difficult time helping these patients, as they often lack the trained staff and other resources to systematically screen for and treat behavioral health issues. Inadequate or no reimbursement can also be a problem for these resource-constrained practices. To overcome this disconnect, eleven small primary care providers—six in New York City and five upstate—are testing out a framework for phasing in behavioral health screening, assessment, and treatment to their practices, a project funded in part by United Hospital Fund. Members of the practices gathered for a roundtable at UHF on December 5 to discuss progress made, lessons learned, and obstacles still to be overcome.

Dr. Henry Chung
The innovative framework offers a step-by-step approach that allows practices to gradually initiate and expand on activities and resources in eight areas that together allow for fully integrated behavioral health care. It was developed, with UHF support, by a team headed by Henry Chung, MD, senior medical director at Montefiore Medical Center and professor of psychiatry at Albert Einstein College of Medicine, and Harold Pincus, MD, vice chair of the Department of Psychiatry and co-director of the Irving Institute for Clinical and Translational Research at Columbia University. The framework is described in the 2016 report Advancing Integration of Behavioral Health into Primary Care: A Continuum-Based Framework.

“When health care is fragmented, people fall through the cracks,” Dr. Chung told roundtable participants. There is ample clinical evidence, however, that integrating behavioral health into primary care can fill those cracks and bring patients the help they need, he said, adding that there are now some policy levers in place in New York State that can ease such integration.

This follow-up effort to move the framework from theory to practice is jointly funded by UHF and the New York State Health Foundation (NYSHealth).The practices involved in the project are testing a variety of approaches, in part based on their resources and locations. Together, they will screen up to 25,000 people during the course of the project for behavioral health conditions; they estimate that 1,000 to 2,000 individuals will benefit from integrated services provided in the practices. During the roundtable, three of the participating practices reported on their progress to date (presentations available for download below).

Delmont Medical Care, Far Rockaway, NY
Delmont Medical Care serves a challenging patient population in one of the poorest, and most medically underserved, neighborhoods in Queens, noted CEO and founder Dr. Jacqueline Delmont. Some 60 percent of the 3,500 patients a year that the practice serves are enrolled in Medicaid. Her goal is to improve care for patients with co-morbidities and behavioral health issues and keep them out of the emergency room and hospital, but one of the biggest challenges is the inconsistency and variation in reimbursement for behavioral health screening, she said. Although they screen every patient, they do not always get reimbursed for those services.

Last year Dr. Delmont started co-locating primary care offices in behavioral health centers in the community, and vice versa, in order to improve patient access. The change has led to increased screening and better coordination of services, she's found. Because 68 percent of her patients are Hispanic and 20 percent are African American or Caribbean, she stressed, “cultural sensitivity plays a huge role in whether patients follow through with care.” Many of her patients are not comfortable talking about mental health issues, but the power of co-location—including existing familiarity with their primary care providers—has made them more comfortable with behavioral health services.

Keuka Family Practice Associates of Accountable Health Partners, Bath, NY
Dr. Dennis O'Connor's rural family practice in the Finger Lakes region of New York serves about 7,000 patients annually, and he is determined that those with behavioral health issues receive coordinated, excellent care—a tough challenge in an area with few mental health resources. The practice has three primary care physicians, but Dr. O'Connor said that perhaps the most valuable member of the team is Sue Sutherland, RN, who joined in 2015 as a case manager. She connects patients to community services, coordinates their care, and teaches them to self-manage their health conditions.

Dr. O'Connor described a particularly challenging patient in the practice, a 41-year-old homeless woman with multiple co-morbidities, including bipolar disease, major depression, anxiety, type 2 diabetes, and obesity. Although she had seen a number of different health professionals, there was no care coordination and her mood swings alienated many local service providers, leaving her with virtually no supports in the community. The Keuka practice was able to get her into supportive housing and an adult day-care center, coordinated all her physical and behavioral care needs, and worked with her to self-manage her medications and office appointments. “We made a real, positive change in her life,” Dr. O'Connor said. “This shows that it takes a team to manage a patient.”

Koinonia Primary Care, Albany, NY
Dr. Robert Paeglow, CEO and founder of the Koinonia practice, is on a mission to help the underserved West Hill neighborhood of Albany because he grew up there, poor and with a mentally ill mother. His practice serves some 2,300 patients per year; to meet their behavioral health needs he added a psychiatric nurse practitioner to his small staff, along with a part-time behavioral health specialist and a volunteer social worker. Because over half his patients are Medicaid beneficiaries or uninsured, he acknowledges struggling with a lack of resources. The behavioral health project “provides us with encouragement, organization, resources, and legitimacy,” he told the meeting. “It is like an oasis in the desert.”

Centro Medico de las Americas, Queens
Dr. Scarfuri + Associates, Staten Island
Metro Community Health Center, the Bronx
South Shore Physicians, Staten Island
Tremont Health Center of Community Healthcare Network, the Bronx
Champlain Family Health of Hudson Headwaters Health Network, Champlain
Hudson River Healthcare at Hudson, Hudson
Lourdes Primary Care, Owego

Dec. 19, 2017
Focus Area
Clinical-Community PartnershipsQuality and EfficiencyCoverage and Access
Innovation Strategies