No Place Like Medical Homes, Experts Say

Liam Davenport

April 16, 2015

When it comes to integrating behavioral and physical healthcare, there's no place like patient-centered medical homes (PCMHs) to reduce costs and improve patient experience and population health, US experts say.

A series of novel recommendations developed at a recent PCMH research conference focuses on building demonstration projects to test existing approaches to integration, develop interdisciplinary training, implement population-based behavioral health and integration strategies, and eliminate funding "carve outs."

"We believe these recommendations will expand the state of knowledge about the PCMH and will improve the delivery of high-quality, population-focused, integrated care," the authors, led by Jeremy Ader, a postgraduate student at the Yale School of Medicine, New Haven, Connecticut, note.

"Population behavioural health issues, in addition to being very prevalent, often first present in the primary care setting, so this is a very unique opportunity within primary care to recognise and treat problems early on," they add.

Speaking to Medscape Medical News, Ader added that "these behavioral health issues are very common amongst people living with multiple chronic conditions...and this identifies an opportunity to address not only behavioral health issues but also integrate the treatment of behavioral health and physical health issues side by side."

The article was published online April 13 in Pediatrics.

Consensus Conference

To develop a set of recommendations that would help PCMHs diagnose, treat, and manage physical and behavioral health concerns, a number of key organizations and institutions came together at a dedicated conference in May 2013.

Of the five expert working groups that were assembled, the behavioral health workgroup consisted of researchers, policy makers, family and patient advocates, and primary care and behaviors health clinicians.

The aim was to develop a set of research and policy priorities that would form the basis of five recommendations to improve the integration of behavioral health and primary care. Specifically, the recommendations were as follows:

  • Build demonstration projects to test existing approaches; evaluate using common conceptual framework.

  • Develop interdisciplinary training programs to support critical members of the care team.

  • Implement strategies to improve population health; strengthen relationships between primary care practices and community resources.

  • Eliminate carve-outs; align innovative payment models with demonstration projects.

  • Develop population-based measures to evaluate behavioral health integration.

Discussing each recommendation in turn, Ader explained that the demonstration projects will be built so as to scale up previously successful models and evaluate them in different settings.

"A key part of a successful approach, and of the innovations that have happened around the country, is the provision of care and coordination of services through the care team of healthcare professionals," he added.

"So our second recommendation is to develop interdisciplinary training programs throughout clinicians' professional training to support the development of this team."

Ader said that the third recommendation includes factors such as behavioral healthcare screens, adding: "We want to develop policies to better implement these across practices, as well as strengthen relationships between primary care practices and key community resources, like the juvenile justice system, schools, and employee wellness programs."

The fourth recommendation focuses on reimbursement, with the elimination of the provision of behavioral and physical health reimbursement through separate payment systems, about which Ader commented: "These 'carve outs' continue to lead to uncoordinated and fragmented care."

"Our last recommendation concerns evaluation of these programs going forward," he concluded.

"We are calling for the development and implementation of more population-based measures that focus on goal measures of wellness and that really capture the impact of integrated behavioral health on society as a whole."

Stopping Stigma

In an accompanying commentary, Jane M Foy, MD, FAAP, from Wake Forest University School of Medicine, Winston-Salem, North Carolina, argues that the PCMH is "at the hub of transformative changes to address the triple aim of reducing health care costs, improving the patient experience, and bettering population health."

Emphasizing that the PCMH research conference set out "an ambitious and worthy research and advocacy agenda," Dr Foy noted that "it is gratifying to see that the primary care research community has united behind it."

In an interview with Medscape Medical News, Dr Foy noted that there are a number of reasons why the recommendations are important.

"The prevalence of these problems in pediatrics is high, they often go undetected, they often present to primary care first, and because of a disjointed system in the US, it's very difficult even once the problem is recognised to fund services for patients," she said.

"Another very large reason is simply stigma; it is generally more acceptable to patients, certainly more convenient to patients and less embarrassing to them, to receive their services in a facility that broadly addresses all healthcare concerns rather than one focused on behavioral health," Dr Foy added.

When putting the recommendations into practice, Dr Foy believes that the full spectrum of severity should be addressed in the models.

"In my experience, when primary care physicians come together with behavioral health specialists to develop ideas for delivering care in new ways, the primary care world is thinking about the mild–moderate severity, whereas as the behavioral health specialist is focused in his or her mind on those with severe and persistent mental illness," she said.

"There may be different approaches necessary for those populations, so I think it's important that the full spectrum be addressed and that we be clear about how the model serves each group."

Finally, Dr Foy emphasized that youths and parents should be involved in advancing the recommendations.

"If there's one message I've heard clearly again and again from consumers of mental health services in the United States, it's 'nothing about us without us,' " she said.

"I think we can't just make these plans in vacuum. We have to know that they are meaningful and understandable by those whom they will serve."

She concluded that this should include patients with mild to moderate conditions, who are traditionally underrepresented by advocacy groups, alongside those with more severe and persistent mental health problems.

The article was developed in partnership with the Agency for Healthcare Research and Quality, the Veterans Health Administration, the US Department of Veterans Affairs, and the Commonwealth Fund. The authors and Dr Foy report no relevant financial relationships.

Pediatrics. Published online April 13, 2015. Abstract, Commentary


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