In an effort to treat the whole patient, Accountable Care Organizations (ACOs) across the country are finding innovative ways to integrate mental and behavioral healthcare into their programs. While each ACO might approach integration in its own way, experts say the integration of behavioral healthcare in commercial-payer and Medicaid ACOs is only predicted to grow in the years ahead.
"In order to get to the Triple Aim—better care, better health and lower per capita costs—ACOs are going to need to develop an integrated behavioral health strategy. And the data on this is really clear," says Mara Laderman, senior research associate at the Institute for Healthcare Improvement (IHI). "Integrating behavioral health can lead to improved patient experience, improved provider satisfaction, improved medical and behavioral outcomes, and now the time is really right for ACOs to start thinking about this."
Stuart Guterman, vice president for Medicare and Cost Control at The Commonwealth Fund, says that integrating behavioral health and substance abuse services into patient care not only provides more coordinated care for patients, but it also benefits the ACO itself.
"If you don't address the underlying issues that drive their conditions, then you're facing a situation where people will just be repeat users of the healthcare system, which runs up a lot of costs that hopefully could be avoided with appropriate care for the underlying conditions," Guterman says.
While there is a growing recognition among ACOs that mental health and substance use issues need to be addressed to more effectively treat patients, David Muhlestein, director of research at Leavitt Partners, says the method and level of integration an ACO chooses varies greatly based on the individual organization.
For instance, for some, the integration may be as simple as patient referrals to behavioral healthcare providers within the ACO, while others might co-locate behavioral healthcare services within the same building as primary care or include mental health professionals as part of the primary care delivery team. Such links could mean more immediate service delivery with same-visit “hot transfers” from one provider to another.
The goal of the ACO, of course, is to deliver outcomes that translate into bonus payments from its payer partners. Experts say whether behavioral healthcare providers receive some of the shared savings for improving patient care also depends on the individual ACO and how the integration effort is structured.
New York ACO
At the Crystal Run Healthcare ACO in New York, three psychiatrists are embedded within a medical office building that also houses primary care physicians, neurologists, endocrinologists and infectious disease specialists. The psychiatrists share a waiting room with other medical specialists and use a connected electronic health record with the other providers.
"We felt like if we were in this kind of model, it would be really important for all specialties to be able to share that information to collaborate," says Lisa Batson, MD, one of the psychiatrists on staff. "We have all of our records open which has been really helpful for the primary care docs, for the subspecialties, to know what our plan is and what's going on with the patient and to see medically what the patients are coming in for or what they've been struggling with."
Crystal Run ACO also recently formed a mental health assessment team, which allows primary care physicians and other specialty physicians to meet with a case manager and psychiatrists on a regular basis to present cases they may want advice about or might want to co-manage alongside the behavioral healthcare staff. The team approach helps improve patient access to behavioral services because the psychiatrists are able to offer input for primary physicians to treat the patient, even if the patient isn't able to see a psychiatrist immediately.
"It's essentially an educational process too," Lisa Batson says. "It's nice for the primary care docs to get a little bit more knowledge on how we might use medications and how we might see diagnoses. So, that's been really helpful and well received."
According to Nicholas Batson, MD, a psychiatrist practicing along with his wife Lisa at Crystal Run Healthcare, integrating behavioral healthcare doesn't just benefit the primary care staff, it also helps behavioral healthcare professionals see beyond the mental health symptoms a patient might display.
"A patient may come in with depression and anxiety, but at the same time, there may be other medical conditions that are affecting the depression and anxiety—maybe hypothyroidism, maybe they have chronic pain—and so we can add that to our assessment and give them a more specific, a more patient centered, treatment plan," he says.
Optimize care teams
To help primary care teams across the country find the best ways to address whole person health, the Institute for Healthcare Improvement has launched its initiative to optimize primary care teams to meet medical and behavioral needs. The 12-month collaborative with the MacColl Center for Healthcare Innovation is scheduled to begin this year and will use education to help participating organizations redefine the roles of primary care to create highly functional, multi-disciplinary teams that address patients physical and mental health needs.
"It's an opportunity for organizations who are getting serious about working on behavioral health integration and primary care to actually get started and learn from each other as well as from the faculty that are teaching the content," Laderman says.
Participating organizations in the collaborative will be able to use whatever integration method works best for them.
Barriers to engagement
Guterman says ACOs that fail to explore behavioral healthcare integration could ultimately lose out on potential savings because they may not be treating the true issues affecting the patient. Typically, proving outcomes for patients with behavioral health disorders can be more difficult because the processes and measurements are not as clearly defined as surgical procedures or medical conditions.
"It's a daunting task to try to take that on," Guterman says.
Laderman says financial barriers such as trying to wrangle reimbursement for providing behavioral health services are some of the most difficult for ACOs considering behavioral healthcare integration.
But the hurdles can be theoretical, too. There are often professional-cultural barriers as different types of providers try to figure out how to work together as a team. Accountable care today usually relies on a primary provider as the quarterback, but that’s not always the case.
"It's really important for the leaders of the organizations to set the culture and set the expectation that everybody is working together to address the patient's whole person health and so that all the staff really understands that this is their mission together and that efforts are made to mitigate some of those cultural clashes that can arise between different types of providers now operating in the same space," Laderman says.
Regardless of the challenges, experts agree that interest in behavioral healthcare integration is growing among ACOs and will likely be even more prevalent in the years ahead.
"I think we'll reach a point where integration becomes the standard of care," Laderman says. "We might remember a time where we talked about behavioral health integration as a separate piece of care, but as integration continues to move forward at more and more organizations, it's just what patients expect. And it's just what providers expect."
Jill Sederstrom is a freelance writer based in Kansas City
Read more about Crystal Run Health’s ACO here
Read more about ACO quality results here