With a four-year, $65 million federal grant to unite behavioral health and primary care in Colorado poised to go operational, a handful of UCHealth’s primary care practices are gearing up to lead the pack. The practice leaders will tell you, though, that while the financial, technical, professional and political support is most welcome, they’ve been working on this for a long time – since 1987, in the case of Austin Bailey, MD.
Bailey is a family medicine physician and medical director of UCHealth’s Colorado Health Medical Group (CHMG), which runs 26 family medicine clinics in northern Colorado.
“We hired our first integrated therapist in my practice in 1987,” Bailey said. “That was back when it was almost total heresy.”
The bifurcation of behavioral and bodily health happened with the early days of managed care in the 1980s, he explained – payers didn’t want to spring for mental health consultations, fearing runaway costs. Now they know that behavioral health problems are complicit in many maladies that end up on their ledgers anyway.
The 2014 “Joint Principles for Integrating Behavioral Health Care into the Patient Centered Medical Home,” a manifesto spearheaded by University of Colorado Department of Family Medicine Chair Frank deGruy, MD, said that more than half of primary care patients have “a mental or behavioral diagnosis or symptoms that are significantly disabling.” Twenty percent of those behavioral diagnoses qualify as serious.
It’s well-known that patients with chronic diseases such as heart failure or diabetes often suffer from depression or other behavioral health problems that can make treatment 30 percent to 70 percent more expensive, said Larry Green, MD, a CU Family Medicine physician who in 2011 won a $3.9 million Colorado Health Foundation grant to unite primary care and behavioral health in 11 clinics across Colorado. One study found that integrating behavioral health and primary care could save the U.S. health care system $26 billion to $48 billion a year; others have shown that such integration brings better patient outcomes, too.
“We know that patients who don’t adhere with treatment plans tend to have a high correlation with a mental health diagnosis,” Bailey said.
Six UCHealth clinics are involved in the first phase of the work: University of Colorado Hospital’s A.F. Williams Family Medicine Clinic, Women’s Integrated Services in Health, and the Seniors Clinic; and CHMG’s Snow Mesa, Timberline and Sterling clinics. Travis Sherman, UCHealth’s senior director of population health, said the others (UCHealth has three dozen clinics across the Front Range) will have the opportunity to join as the program progresses.
While the SIM grant involves many interrelated initiatives, Sherman said the focus is on three major areas.
Corey Lyon, DO, medical director of UCHealth’s A.F. Williams Family Medicine Clinic.
First, he said, “Organizations like UCHealth are being paid a share of the money to figure out how you integrate these services in innovative ways.”
Second is working with CORHIO and others to develop a health information technology framework that allows disparate providers to share integrated health data in real time and enables new models of care.
The third goal is have providers work with commercial insurers in the state (there are about 440 of them) to get them to align behind a viable payment model for behavioral health care.
“There’s low supply in Colorado and it’s poorly integrated, in part because it’s not paid for in a way that motivates,” Sherman said.
Ahead of the game
Sherman said those approaches are to be determined. They might involve creating combinations of telehealth, co-locating behavioral health experts in primary care offices, involving mental health counselors with referrals, and other options. The six practices involved will try different things, he said, in addition to seeing how new IT and payment approaches work. The practices that follow will apply those lessons while trying to tailor approaches to their practices’ specific traits, he said.
In northern Colorado, the clinics will be building on a solid foundation. The Sterling clinic, for example, launched a telepsychiatry pilot on Feb. 1. It’s led by James “Jay” Shore, MD, a psychiatrist with CU’s Depression Center. The pilot involves a psychiatric nurse practitioner linking from the Anschutz Medical Campus to Sterling via an audio/video link that allows her to work directly with patients, doctors and nurse practitioners, as well as offline via Epic, Bailey said. If all goes well, he added, the group would like to roll it out across CHMG’s practices.
More broadly, Bailey envisions CHMG doing a tiered approach with respect to behavioral health. A “mid-level primary care person” would look at behavioral-health screenings and touch base with providers about patients with possible issues.
Those providers would do a brief intervention, then hand patients off to a psychiatric care professional, either in-house or in the community. For example, Bailey said, CHMG has built a strong relationship with Heart-Centered Counseling in Fort Collins, which, in addition to seeing CHMG patients within 24 hours regardless of insurance status, has embedded a licensed professional counselor at the Snow Mesa clinic.
Onsite @ A.F. Williams
Similarly, A.F. Williams has made big strides in integrating behavior health and primary care. Corey Lyon, DO, A.F. Williams’ medical director, pointed to the clinic’s registry of depression patients. Clinic staff use it to check in between appointments to make sure patients are taking and tolerating their medications and don’t miss appointments. The clinic also has three doctoral psychology students who serve as health coaches in such areas as tobacco cessation, weight loss, and diabetes management. That’s in addition to three CU faculty psychologists who rotate in for full-time coverage, both for direct patient care and for “warm hand-offs” for acute needs.
“If there’s a crisis, we can grab a psychologist and we can all talk in the exam room,” Lyon said.
Colleen Conry, MD, vice chair of Quality and Clinical Affairs for the CU Department of Family Medicine.
A.F. Williams has also integrated 60-minute co-consults that involve patients, providers and psychologists in the clinic workflow, he said. That helps to instill trust with patients who know their primary care providers but don’t know the psychologist and boosts the provider’s confidence that he or she is making the right calls.
That’s not to say the SIM grant’s boost isn’t welcome, Lyon said. The depression registry and other behavioral-health-related processes tend to be manual and, as a result, cumbersome. It’s also hard to gather data useful in optimizing and justifying behavioral-health programs, he said.
Some of the grant will pay for UCHealth “practice coach” time, which will help clinics settle upon consistent, repeatable processes, Lyon added. And having payers step up for behavioral health will be vital, he added. The Department of Family Medicine had continued to subsidize that care at A.F. Williams, a luxury few practices enjoy.
The SIM grant will lend structure to the practice transformation required to broadly integrate behavioral health and primary care, said Colleen Conry, MD, vice chair of Quality and Clinical Affairs for the CU Department of Family Medicine. Building that structure will involve some heavy lifting, she added.
“Practices must evaluate their clinical protocols and flows, new job descriptions must be created, and most importantly, new teams must be created and function well,” Conry said in an email. “Medical providers must learn how to work with behavioral health providers and develop a trust in their skill set. Together they must learn how to hand off patients and how to have great communication.”
For Bailey, the SIM grant’s financial boost is less important than the political statement it makes.
“This brings tremendous focus,” he said. “The governor’s office and UCHealth are saying, ‘We’re behind this.’”