Mental Health Services in Patient-Centered Medical Homes
Abstract and Introduction
Purpose: The purpose of this study was to understand mental health, substance use, and health behavior activities within primary care practices recognized by the National Committee for Quality Assurance as patient-centered medical homes (PCMHs).
Methods: We identified 447 practices with all levels of National Committee for Quality Assurance PCMH recognition as of March 1, 2010. We selected the largest practice from multisite groups, and 238 practices were contacted. We received 123 responses, for a 52% response rate. A 40-item web-based survey was collected.
Results: Of PCMH practices, 42% have a behavioral health clinician on site; social workers were the most frequent category of provider delivering behavioral services. There are also were care managers—distinct from behavioral health clinician—at 62% of practices. Surveyed practices were less likely to have procedures for referrals, communication, and patient scheduling for responding to mental health and substance use services than for other medical subspecialties (50% compared with 73% for cardiology and 69% for endocrinology). More than half of practices (62%) reported using electronic, standardized depression screening and monitoring; practices were less likely to screen for substance use than mental health. Among the practices, 54% used evidence-based health behavior protocols for mental health and substance use conditions. Practices reported that lack of reimbursement, time, and sufficient knowledge were obstacles. Practices serving a higher proportion of low-income patients performed more mental health organizational and clinical activities.
Conclusions: In PCMHs, practice organization and response to behavioral issues seem to be less well developed than other types of medical care. These results support further efforts to develop whole-person care in the PCMH, with greater emphasis on access to and coordination of mental health, substance abuse, and health behavior services. Focusing primary care practices on this aspect of whole-person care will benefit from program sponsors' support and rewarding better integration with behavioral health.
Even though primary care is the setting for a large portion of care for behavioral health problems (defined here as care for mental health, substance use disorders, and health behaviors), these problems are often inadequately addressed in primary care. Little has been written about current behavioral health clinician capacity in primary care. It has been suggested that less than 10% of psychologists practicing work in primary care settings. Kathol estimates that less than 10% of the behavioral health workforce practices in primary care. Data concerning the percentage of primary care practices with integrated behavioral health are unavailable, except about services in federally qualified health centers (FQHCs). Lardiere et al report 70% of FQHCs provide behavioral services, 20% provide substance abuse services, and 20% provide both.
The growing adoption of the patient-centered medical home (PCMH) model of care offers the potential for improving how primary care practices address the behavioral health needs of their patients. The PCMH model calls for practices to reorganize to improve whole-patient care. Yet there are still concerns that barriers and changes at multiple levels that need to occur for the potential to be recognized.
A recent complimentary set of joint principles for the PCMH specify that behavioral health should be fully integrated into the PCMH. The principles align closely with the categories agreed on in the initial PCMH joint principles published in 2007. This position has been endorsed by the following organizations: the American Academy of Family Physicians (AAFP), the AAFP Foundation, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the North American Primary Care Research Group, the Association of Departments of Family Medicine, and the Association of Family Medicine Residency Directors. There is a great deal of planning and implementation of mental health substance abuse and health behavior services into PCMHs, seemingly in response to a number of factors, including increased recognition of need and provider frustration with the established lack of access to behavioral health services for primary care patients.
There is little information to help gauge the effect of these efforts on how PCMH practices address the behavioral health needs of their patients. The purpose of this study was to explore how early adopters of the PCMH model address behavioral health care.
The Collaborative Care Research Network, a subnetwork of the AAFP National Research Network, worked with the National Committee for Quality Assurance (NCQA) to survey NCQA-recognized PCMH practices to assess current clinical and organizational response to patients' behavioral health issues, identify barriers to implementation of the services, and compare these to care for general medical needs.