Improving human health is a goal shared by mental healthcare and physical healthcare practitioners. Yet, far too often, these two realms of human health are treated in siloes. We believe that by integrating them, a positive shift in healthcare will occur. Collectively, integration will allow us to work toward achieving the quadruple aim of healthcare reform, which encompasses stronger healthcare outcomes, reduced healthcare costs, and an increase in both patient experience and satisfaction levels.1
Achieving the Quadruple Aim through Integrated Behavioral Health
Simply put, Integrated Behavioral Health (IBH) combines medical and mental healthcare, aiming to equitably deliver whole person care by connecting patients to interdisciplinary, collaborative provider teams and incorporating population health principles. In this brief primer, we provide clear, easy-to-understand definitions of the different approaches to IBH, as well as the benefits of each. We close by reinforcing how it drives the quadruple aim of healthcare reform.
Stopping the Silo: Why Healthcare Practitioners Should Integrate Mental Healthcare with Physical Healthcare
Mental and physical health are connected. Physical health outcomes, like improved blood pressure and well controlled blood sugar, are strongly influenced by our mental health. When we are feeling well from a mental health perspective, we can improve our ability to care for our physical health. At the same time, physical conditions can be isolating, while poor nutrition can influence how people feel from a mental health perspective. And yet, many health systems are siloed; the team that provides care for a patient’s mental health does not often or easily communicate with the team addressing a patient’s physical health.
An estimated one in nine primary care visits are for a mental health concern2. However, when Primary Care Physicians (PCPs) identify a mental health need, such as depression or anxiety, they often first attempt to refer to psychiatrists or therapists in the community. Unfortunately, only 50% of these referred patients ever attend an initial appointment with a specialist.3 As a result, PCPs often end up treating patients with mental health issues on their own. In fact, one study found that PCPs prescribe 79% of antidepressant medications and provide care for 60% of patients undergoing treatment for depression across the country.4 This practice, wherein PCPs manage treatment independently and intermittently make referrals to specialists, is commonly referred to as “usual care.”
“It is unsurprising that usual care outcomes for common mental health conditions are generally poor, with data from Minnesota estimating that less than 20% of patients experience relief from depression symptoms.”
Why “Usual Care” Perpetuates Poor Outcomes
Several factors restrict the effectiveness of usual care. These include:
PCPs and their staff often have limited mental health training
Their practice workflows are rarely adapted to optimally manage chronic mental health problems over time
Even when PCPs successfully connect their patients with mental health specialists, communication between the PCP and specialist is rarely systematic and often infrequent or non-existent.
Therefore, it comes as no surprise that usual care outcomes for common mental health conditions are generally poo. In fact, one statewide database from Minnesota estimated that less than 20% of patients experience relief from depression symptoms.5
IBH: The Answer to Realigning Modern Health
Integrated Behavioral Health (IBH) takes a different approach. With IBH, a multidisciplinary team works together to help a person with physical and mental health concerns. By redefining and realigning the modern healthcare team, we can work toward achieving the quadruple aim of healthcare reform: improved health outcomes, lower healthcare costs, improved patient experience, and improved provider satisfaction.6
“Integrated Behavior Health helps to achieve the quadruple aim of healthcare reform: improved health outcomes, lower healthcare costs, improved patient experience, and improved provider satisfaction.”
How IBH is Delivered
There are several specific, evidence-based models to integrate mental health care with physical health care. The importance of adopting an evidence-based approach to achieve integration cannot be overstated. The two most widely adopted models are the Primary Care Behavioral Health (PCBH) Model and the Collaborative Care Model (CoCM). Additional approaches include Measurement-Based Care (MBC) and telehealth interprofessional consultation.
Primary Care Behavioral Health (PCBH)
What it is: PCBH is a primary care population-based approach that adds a BHC (Behavioral Health Clinician) to the primary care medical team. The BHC is a licensed behavioral health clinician, such as a psychologist, who assists the primary care team in early detection and interventions for mental health concerns, suboptimal health behaviors and chronic health conditions. According to a recent academic journal article, although definitions of PCBH have historically differed across sources, the model ideally incorporates generalist (broad clinical scope), accessible, team-based, high-productivity, and educational approaches, while making the BHC a routine primary care team member.7
Why PCBH is beneficial:
Studies evaluating PCBH have noted high levels of patient satisfaction, improvements in specific behaviors (e.g., tobacco use), and significant evidence for successful implementation (e.g., fewer referrals to specialty mental health).8 A 2021 systematic review with 33 trials also noted improvements in anxiety and depression symptoms.9
The Collaborative Care Model (CoCM)
What it is: CoCM, which is predicated on the adult chronic care model, empowers a specially trained Behavioral Health Care Manager (BHCM) to practice in concert with PCPs and systematically evaluate patients’ mental health care needs using common patient-reported outcome instruments (e.g., the 9-Item Patient Health Questionnaire for depression), all while receiving regular input and supervision from a designated psychiatric consultant.10
In CoCM, a caseload approach and other population health methods are leveraged to treat common mental health concerns, such as depression or anxiety. A defined subgroup of patients within the primary care practice is identified and tracked through a registry. CoCM incorporates MBC and a treatment registry to help the team identify and measure key mental health symptoms over time. The Psychiatric Consultant provides treatment recommendations including medication, when indicated, for the PCP to consider and carry out. The BHCM delivers brief therapeutic interventions (e.g., motivational interviewing, behavioral activation) to help patients with their BH symptoms.
Why CoCM is beneficial: Extensive evidence supports the use of CoCM, with its efficacy being demonstrated by more than 90 randomized controlled trials (RCTs) and several meta-analyses across diverse diagnoses (e.g., depression, anxiety, bipolar disorder), patient populations (e.g., older adults, patients with chronic medical problems), and treatment settings (e.g., Federally Qualified Healthcare Centers, the Veterans Health Administration).11 Additionally, CoCM has been shown to reduce racial and ethnic disparities in treatment outcomes12 and is effective when implemented in rural13 and disinvested urban14 treatment settings. Finally, CoCM has designated billing codes that are reimbursed by Medicare, most commercial payers, and a growing number of state Medicaid plans, leading the model to be financially sustainable.15