“Given that over one-half of primary care patients have a mental or behavioral diagnosis or symptoms that are significantly disabling, given that every medical problem has a psychosocial dimension, given that most personal care plans require substantial health behavior change—a Patient Centered Medical Home is incomplete without behavioral healthcare fully incorporated into its fabric.” (Baird M, Blount A, Brungardt S, Kessler R. et al. Joint principles: integrating behavioral health care into the patient-centered medical home. Ann Fam Med. 2014; 12(2): 184-185)
In October 2016 The UVM Department of Family Medicine hosted the “Transforming Primary Care and Behavioral Health” conference. The theme for the conference was to provide strategies for prioritizing and measuring behavioral integration into medicine, and the presenters discussed specific integration strategies for helping primary care practices improve their patient care.
VITL participated in the conference as a sponsor/exhibitor, and I was able to attend some of the sessions. There were many informative presentations pertaining to research, case studies and practical recommendations for primary care practices. What impressed me the most, as someone coming from the technology side of health care, was that treating the ever-increasing population of opioid dependent patients in primary care settings has been extremely challenging.
This is an important factor in the shortage of treatment options for people who are experiencing behavioral health issues such as drug dependence, and must seek treatment in emergency rooms or other facilities where their condition may not be viewed as a chronic medical illness, but instead as “a social problem that requires interdiction and enforcement.” (Drug Dependence, a Chronic Medical Illness. JAMA. 2000; 284: 1689-1695). Another viewpoint that has stigmatized treatment is the replacement of one addicting substance for another, such as buprenorphine for heroin, which is perceived as continuing the dependency.
As stated during his presentation, Daniel Mullin, director of the Center for Integrated Primary Care at the University of Massachusetts School of Medicine said, “the immediate need of a chemically dependent individual is the chemical.” Once the receptors in the brain of an opioid dependent individual are occupied by a receptor agonist (instead of the antagonist), then the person’s other issues become workable, which can reduce the harm of their high risk behaviors. The interventions of “Medication Assisted Treatment” (MAT) require medication to replace the addicting substance, along with behavioral interventions to treat the patient. Mr. Mullin recognized that primary care providers struggle with prescribing controlled substances, and that practices often do not have the resources to perform behavioral interventions.
During the day, other presenters discussed options for educating teams that are integrating behavioral health, new opportunities through the Affordable Care Act, and expectations for Patient-Centered Medical Homes (PCMH) to integrate behavioral care through the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APM). During a session with Sarah Hudson Scholle of the National Committee for Quality Assurance (NCQA), she discussed their PCMH expectations which include:
- Patient-Centered access
- Team-based care
- Population health management
- Care management & support
- Care coordination & transitions
- Performance measurement & improvement
Meeting these expectations will require working with behavioral health providers, training care teams, and creating workflows that integrate behavioral health within the practice. It will also require increased use of technology and analysis of clinical data to achieve the goals.
Some of my (obvious) take-aways from the conference:
- Opioid dependence among all demographic groups in our state, regionally and nationally is growing.
- Secondary and tertiary treatment options such as hospital emergency rooms and incarceration cannot respond effectively to the growing need for long-term treatment options.
- Expectations for the integrated treatment of behavioral health issues is shifting more and more toward primary care.
- As our health care system shifts to value-based payments with incentives for performance improvements, there will be an increased reliance on health information exchange from networks such as the Vermont Health Information Exchange managed by VITL, and clinical data analysis, which in Vermont will be supplemented with VITL’s data warehouse and analytics solutions.