ACT shows the way to integrated care

One size does not fit all, but all can have a size that fits
March 2, 2016

The results are in from a pioneering five-year, $3.9 million experiment to see how eight primary care practices and three mental health centers across Colorado might integrate behavioral health and primary care. The biggest finding, the Advancing Care Together (ACT) program’s leaders at the University of Colorado School of Medicine say, is that integrated care can be done well in different types of clinics with diverse patient populations – but that local practices gain from the flexibility to tailor the approach to their particular circumstances rather than adopting one-size-fits-all templates.

That’s good news for UCHealth, which views care integration as central to its primary care practice transformation efforts.

The findings, published as a special supplement to the Journal of the American Board of Family Medicine (JABFM), also pointed out two major issues that must be solved to enable integrated care on a large scale: improving electronic health records to enable better data capture and sharing across primary care and behavioral health, and reforming payment approaches to make sure clinics providing behavioral health services can afford to do it.

Different strokes

“Advancing Care Together’s primary goal was to change practice,” Green said. “And our method for doing that was to work with people with their own ideas and their own communities – not tell them what to do, but invite them to tell us what they thought they could do under local conditions.”

The clinics received up to $50,000 a year for three years, mostly for evaluation services and learning activities; many spent far more than that, Green said. “This was closer to maybe $15 million worth of work – just a huge amount of work by these amazing people.”

One of ACT’s defining features was the diversity of the 11 participating clinics, which represented a range of publicly and privately owned, rural and urban. Denver Health and Kaiser Permanente, Green and colleagues assumed, would tackle care integration differently than Midvalley Family Practice in Basalt or Plan de Salud del Valle in Brighton. They were right.

The practices were well-motivated. There is no shortage of data showing that integrating primary care and behavioral health – which encompasses mental health and substance use disorder conditions, health behavior change, life stressors and crises, and stress-related physical symptoms – pays off both financially and in terms of patient well-being. On the financial side, Steve Melek, an actuary and principal at Milliman who worked with the ACT team, estimates that care integration could save the U.S. health care system $26 to $48 billion – roughly 5 percent to 10 percent of the $525 billion spent each year on patients with behavioral conditions. He adds that those with behavioral conditions typically cost the health care system double to triple that of the average patient.

The ACT report further highlights the prevalence of the problem: 20 percent of primary visits are mental health related; 67 percent of adults with behavioral health disorders don’t get proper treatment; depression goes undiagnosed in more than half of primary care patients; two-thirds of primary care providers are unable to connect patients with outpatient behavioral health providers due to a shortage of providers and barriers created by insurance; depression and anxiety comprise two of the top five conditions driving overall health care cost (obesity, arthritis and back/neck pain round out that woeful list).

Larry Green, MD, a CU School of Medicine Department of Family Medicine physician, and Maribel Cifuentes, RN, BSN, led the study. The Colorado Health Foundation paid for it.

Key points

What did the ACT program find? While what worked varied from practice to practice, a few things stood out:

Maribel Cifuentes, RN, BSN, and Larry Green, MD, of the CU School of Medicine’s Department of Family Medicine. Green and Cifuentes led the five-year, $3.9 million ACT behavioral health integration project.
  • Facilitation helps – that is, bringing in a coach from outside the clinic to shepherd the changes needed to integrate care pays dividends. Clinics are running full-out already, Green says, and benefit from someone who can help to streamline the process.
  • Screening all patients for depression helps – with the caveat that practices lacking the resources to handle the depression find rightly avoid it, Green says. There are, he adds, “well-established ethical principles saying you shouldn’t systematically look for things, tell people that they have them, and say, ‘good luck.’”
  • Changing around workspaces in such a way that behavioral health professionals and primary care providers easily intermingle can pay off in better communications.
  • Integration saves money, but it costs money, too – money  that practices do not have and cannot afford in current payment models. It cost the 11 ACT practices an average of $64,000 to get rolling and an average of about $40 a month per patient after that, though the numbers varied widely depending on practice capacity and the scope of the intervention. The bottom line: While the costs are far from stratospheric by health care industry standards, practices will need financial help to get integrated care going and sustain it.
  • Electronic health records generally do a poor job of collecting and sharing combined behavioral and physical health data. But work spearheaded by Cifuentes showed that rather than waiting for EHR vendors to catch up to the integrated-care vanguard, several ACT practices found serviceable workarounds.

The JABFM reports go into detail in these and other areas, including preparing the workforce for care integration; designing clinical workspace; and building strategies that cover staffing, scheduling and engagement. The authors teamed with the leaders of a second, related Integration Workforce Study led by Benjamin Miller, PsyD, director of  the Eugene S. Farley, Jr. Health Policy Center at the CU School of Medicine, to come up with five “organizing constructs” that shape integrated practices as well as the “three Cs” – consulting, coordinating and collaborating – of interdisciplinary professionals, which evolve to enable team-based care.

Taken together, it’s pathbreaking work, says Frank deGruy, MD, chairman of CU’s Department of Family Medicine and a longtime evangelist for integrated care.

“This is the most significant empirical advance in integrated care since the beginning of time,” deGruy said. “This is a very big deal.”

The road ahead

That said, he and others agree that there’s much work to do. To continue to move forward, information barriers presented by today’s EHRs need to come down. Insurers need to join with providers in sharing the costs of integrated care, which doesn’t adequately happen now (UCHealth’s A.F. Williams Family Medicine Clinic, which has been working on care integration for years, has only been able to do so because deGruy’s department helps foot the bill). According to Melek, the savings gained from integration more than justify it: Allocating just 10 percent of savings to psychiatrists could boost their average annual earnings 50 percent, he says.

The health care ecosystem around primary care needs to evolve quickly, too, Miller adds, because “people are doing things so innovative that there are no payments and policies to support them.” The changes needed to make integrated care the norm extend well beyond the clinic, into the technical, the financial, the administrative, and the policy realms. In Colorado, for example, there are multiple agencies responsible for behavioral health, Miller says. This perpetuates fragmentation, which is not in the best interest of those on the ground trying to integrate care, he maintains.

The good news is, Colorado is at the forefront of making these sorts of changes. The state is ramping up work on a four-year, $65 million State Innovation Model (SIM) grant from the federal Centers for Medicare and Medicaid Innovation. The aim is to integrate care in 400 Colorado primary care practices and community health centers representing 80 percent of the state’s residents by 2019. Six UCHealth practices are among the SIM vanguard.

Green says ACT’s findings are informing the SIM grant effort, which he called “Colorado’s major next step in the journey to care integration.”

As much as anything else, he adds, ACT shows that “it’s not possible to say in the U.S. anymore that folks aren’t interested in integrating care and don’t want to.” In addition, while none of the ACT practices achieved their full aspirations, he says, they all made progress – and none of them want to go back to the old status quo.

“All of them moved the dial,” Green said. “And whatever their movement was, in whatever direction, they’re not going back. These innovators deserve our deepest thanks.

“People need and want integrated care,” he continued. “Practices want to provide it. It makes good business sense. We know it can be done and much about how to do it. Millions of people are waiting for us to get it done.”

About the author

Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado, where he was a Ted Scripps Fellowship recipient in Environmental Journalism. He is author of “A Beard Cut Short,” a biography of a remarkable professor; “The Laser That’s Changing the World,” a history of lidar; and “From Jars to the Stars,” a history of Ball Aerospace.