A quarter of American adults suffer from diagnosable mental health disorders every year and it is estimated that PCPs manage between 40% and 80% of these patients [8,9].Rates of detection and adequate treatment in primary care settings are currently suboptimal, leading to poor disease management and driving excess utilization. Using claims data within the Partners’ primary care population, we have found medical expenditures are 45% higher for patients with a mental health diagnosis. Over 70% of mental health patients have additional illnesses, and the presence of a mental health disorder complicates overall clinical management [10].This results in a substantial increase in medical cost, independent of psychiatric medical spending [11].In addition, psychiatry shortage and access have become a major issue in mental health services [12].Over 70% of PCPs nationwide reported difficulty in finding high-quality outpatient mental health care for their patients [13].
The dominant clinical model for mental health integration is the collaborative care model (CCM), and evidence for its effectiveness is growing. Randomized controlled trials and meta-analyses have shown that CCMs are successful at improving detection and treatment of mental health disorders [14–16].Cost-savings analyses for many of these programs demonstrate considerable savings and favorable return on investment (ROI). Several CCMs that use nonmedical specialists and consulting psychiatrists to augment the management of mental health disorders for low- to moderate-risk primary care patients have been implemented . However, a majority of the CCMs are disease-specific—eg, integrating depression treatment resources into primary care. The challenge for ACOs is to determine how to build a comprehensive CCM that helps primary care manage the major primary care–based mental health conditions—depression, anxiety and substance abuse—in a coordinated, cost-efficient model. The ACO must consider how to implement both its high-risk program and its CCM programs in a way that is not disruptive but supportive to primary care practices.
Partners is implementing a multipronged strategy to address mental health issues within primary care. First, a universal screening program for mental health disorders using brief, well-validated screening tools (eg, Patient Health Questionnaire 2 and 9) will improve the identification of patients with mental health disorders. Second, consulting psychiatrist and mid-level health care providers, functioning as mental health specialists, will be virtually or physically integrated into our primary care teams. They will assist with issues such as initial clinical assessment; coordinate initiation of a mental health treatment plan; monitor the patient’s response to treatment; provide recommendations for treatment change based on evidence-based protocols and guidance from a consulting psychiatrist; provide therapy and mental health services to patients when indicated; and work closely with the patient to engage, activate, and educate him/her in order to promote disease management and treatment adherence. A unique feature of this integration program is the creation of a network-wide mental health access line for rapid mental health assessment and advice. Third, Partners is deploying sustained, network-wide educational programs that will train primary care personnel in brief interventions for improved disease management such as motivational interviewing, behavioral activation, problem-solving therapy, and other first-line interventions suitable for a primary care setting. Fourth, all primary care practices are developing and deploying standard workflows for the identification and treatment of mental health illnesses, starting with depression. Fifth, telehealth technologies will be used to improve access to specialty care and provide care in the most cost-effective setting. An initial focus is on online cognitive behavioral therapy, with virtual visit technologies to follow. Finally, registries will track mental health outcomes and provide prompts to ensure that follow-up screening tests are administered at periodic intervals and that treatment plans can be modified if progress is insufficient.