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Service Delivery Innovation Profile

Integrating Behavioral Health and Nutrition Services Into Primary Care Clinics Significantly Reduces Mental Health–Related Hospitalizations for Staff-Model Health Maintenance Organization


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Snapshot

Summary

In an effort to provide more comprehensive care to pediatric and adult members, Grand Valley Health Plan, a 10,000-member staff model health maintenance organization, integrated mental and behavioral health care and nutrition services into six of its primary care clinics. Because mental health care is provided under the same roof—and often on the same day—as a patient's medical appointment, the physician and mental health professional can seamlessly collaborate to deliver "whole" person care, rather than the traditional approach through which patients receive separate care from separate providers. Between 2002 and 2006, this integrated approach decreased mental health–related hospitalizations by more than 50 percent, from 5.86 to 2.69 hospitalizations per 1,000 members, while leading to well-above average scores on key mental health metrics.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation data on the number of mental health–related hospitalizations and post-implementation comparisons to national benchmarks on key HEDIS® measures for behavioral health.
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Developing Organizations

Grand Valley Health Plan, Grand Rapids, MI
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Problem Addressed

Patients with mental and behavioral health conditions are often seen in the primary care setting. But most primary care physicians (PCPs) are ill equipped to treat mental illness on their own, and patients referred to outside specialists often fail to keep their appointments due to the stigma associated with mental illness. Integrating behavioral health into the primary care setting can yield clinical and cost benefits,1 but PCP practices often have difficulty getting reimbursement for mental health services provided in their offices.
  • Psychological issues often behind patient symptoms: According to one report, 70 percent of all primary care visits are driven by psychological factors.2 The 10 most common problems that adult patients report (chest pain, fatigue, dizziness, headache, swelling, back pain, shortness of breath, insomnia, abdominal pain, and numbness) account for 40 percent of all visits, but doctors can identify a biological cause for the complaint in 26 percent or fewer of these patients.3 People who have a psychological disorder often bring physical problems without disease (a phenomenon known as "somatizing") to their PCPs.1
  • PCPs often treat mental illness but are ill equipped to do so: One-half of all mental health care is provided by PCPs, and 92 percent of elderly patients receive mental health care from their PCP.1 Yet, PCPs often fail to diagnose or successfully treat mental health conditions. For example, one study of 500 primary care patients found that 29 percent of patients had mental health conditions, but providers identified only 33 percent of the existing mental health conditions over a 5-year period.4 Grand Valley Health Plan wanted to improve its scores on HEDIS® (Healthcare Effectiveness Data and Information Set) measures of mental health care quality to the highest levels relative to national benchmarks.
  • Stigma prevents access to specialists: Only one of four patients referred to a mental health specialist actually makes the first appointment due to the stigma associated with mental illness.1 Grand Valley Health Plan patients also failed to make appointments when referred to mental health providers due primarily to the stigma attached to visiting a mental health care center located outside of a patient's primary care offices.
  • Collaborative care can reduce hospitalizations and the need for medical services: Primary care practices that offer a collaborative team of providers and social workers to work with elderly patients have reduced hospitalizations by 44 percent and the need for medical services and office visits,5 and increased medication adherence.6 The patients receiving collaborative care also reported fewer physical symptoms, more social activities, and a more stable perception of their overall health.5
  • Reimbursement often not available: PCPs often have difficulty obtaining reimbursement for mental health services provided in the primary care setting.

What They Did

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Pertinent Quality Measures

Specifications for the current HEDIS® measures of antidepressant medication management can be found in the National Quality Measures Clearinghouse at: http://www.qualitymeasures.ahrq.gov/search
/search.aspx?term=hedis+measure+antidepressant+medication+management
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Description of the Innovative Activity

To address the full spectrum of problems that adult and pediatric patients bring to their PCPs, Grand Valley Health Plan, a staff model health maintenance organization (HMO), staffed each of its six primary care clinics with a social worker and a part-time nutritionist/dietitian. These individuals, known as counseling and wellness staff, make it easier for patients to receive comprehensive medical and behavioral health services. Key elements of the program are described below:
  • Onsite behavioral health counselors and nutritionists: One behavioral health counselor and a part-time nutritionist are embedded in each primary care clinic as part of the primary care team. They work alongside each clinic's physician, physician assistant, nurse, and other staff. To raise awareness of mental health and behavioral issues, the counselor's desk is located in close proximity to the physician's offices, thus facilitating the ability to involve the counselors in patient care when appropriate.
  • Initial PCP assessment and in-house referral if needed: The PCP assesses each patient and recommends that any patient with mental health issues speak with a wellness counselor. When there is an immediate need for counseling, the PCP obtains patient permission to involve the counselor and then provides a "warm handoff" to the counseling staff during the medical appointment. The counselor's schedule is typically only half filled with preexisting appointments so that he or she can be readily available for these immediate referrals. Patients may also be referred to established groups or classes to encourage self-management and/or to psychiatrists, psychologists, or psychotherapists for more intensive, long-term treatment. In 2006, approximately 26.7 percent of the HMO's patients were referred to the wellness counselors. Of this group, 21.8 percent were referred for behavioral health counseling, whereas the remainder were referred for nutrition counseling.
  • Ongoing behavioral health and nutrition services within the practice: Once a patient is referred, the behavioral health counselor and nutritionist act as consultants and full members of the health care team, providing basic triage, assessment, consultation, and health counseling. They typically meet with patients three or four times, with each session lasting 15 to 30 minutes. For example, a patient with diabetes experiencing depression may first meet with the nutritionist to address dietary issues and then with the counselor on one or more occasions to address the depression.
  • Patient care plans that incorporate medical, mental health, and lifestyle goals: Wellness staff members not only focus on traditional health and dietary issues but also address lifestyle and behavior factors that may affect a member's health and/or the management of a disease. The counselors and PCPs collaborate to create a patient care plan that incorporates medical, mental health, and lifestyle goals. For example, a patient with diabetes may work with a nutritionist to make better food choices and also work with the counselor and provider to recognize and treat depression, develop coping skills to deal with stress, and ensure proper adherence to antidepressant medication.
  • Ongoing case management: The counselors also take on the role of ongoing case manager, educating patients about self-management skills, following up with patients to ensure attendance at visits and medication compliance, and monitoring high-risk patients. For example, the counselor will call a patient 1 week after he or she begins antidepressants to check on the patient's reaction to the treatment. If a patient does not return for a followup appointment, the counselor will send a letter and/or call the patient at home.
  • Provider training: To raise awareness among providers, the counselors regularly train the PCPs and nurses about behavioral health and dietary issues. This can occur informally during daily consultations about patients, or practices can incorporate formal, staff-wide training sessions to raise awareness of psychosocial issues.
  • Clinical oversight: The health plan contracts with a psychiatric specialist who provides clinical supervision of the counseling and wellness staff, making sure that assessments and referrals are in adherence with best practices.
  • Reimbursement: As a staff model HMO, Grand Valley Health Plan provides mental health services to enrollees as a part of their basic benefits package. As a result, the provision of such services is incorporated into its compensation arrangements with PCPs.

Context of the Innovation

Grand Valley Health Plan, a staff model HMO with 10,000 members in Kent County, MI, has six primary care clinics along with pharmacy, x-ray, mammography, ultrasound diagnostic services, and laboratory services. Historically, the health plan offered mental health counseling services in one centralized location to which providers referred patients. However, many patients failed to make appointments due primarily to the stigma attached with visiting a mental health care center. The health plan's president, a psychiatrist, promoted the idea of integrating mental and behavioral health services into the primary care clinics to reduce the barriers associated with receiving care, including stigma and the inconvenience of having to travel to a central site.

Did It Work?

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Results

The integration of behavioral health into the primary care setting has helped Grand Valley Health Plan PCPs better recognize and make referrals to counseling and wellness staff for mental health disorders, leading to a more than 50-percent reduction in mental health–related hospitalizations and well-above average performance on key mental health metrics.
  • Better recognition of mental health conditions: Grand Valley Health Plan's counseling and wellness staff provided services to 26.7 percent of HMO members in 2006, up from 20.5 percent in 2004. This increase suggests that PCPs are getting better at recognizing mental health conditions in the patients they see.
  • Significantly fewer mental health–related hospitalizations, leading to lower costs: Since 2002, hospitalizations for mental health issues have declined by 54 percent among Grand Valley Health Plan's members, from 5.86 to 2.69 hospitalizations per 1,000 members.
  • High rankings for behavioral health: Grand Valley Health Plan placed first among Michigan health plans on all six effectiveness of care measures included in the HEDIS® measures for behavioral health in 2007. One of the HEDIS® measures has since been retired. Grand Valley Health Plan also tripled access to and use of mental health services over a 3-year period and scored high relative to national benchmarks on key metrics related to use of ambulatory services for mental health7:
    • Enhanced access to care: In 2006, 12.9 percent of Grand Valley Health Plan's primary care patients received mental health services, compared with a national average of 8.6 percent.
    • Appropriate prescribing and high levels of medication adherence: The number of Grand Valley Health Plan patients diagnosed with depression who took prescribed antidepressant medication was 60.8 percent in 2006, compared with the national average of 53 percent.
    • Appropriate ongoing and followup treatment: In 2006, 33.5 percent of Grand Valley Health Plan patients continued to see a provider for depression treatment (as recommended in best practice), compared with a national average of 31 percent. That same year, 93.5 percent of Grand Valley Health Plan patients hospitalized for a mental health issue received followup care within 30 days of discharge, compared with a national average of 87.6 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation data on the number of mental health–related hospitalizations and post-implementation comparisons to national benchmarks on key HEDIS® measures for behavioral health.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Establishment of an integration champion: A counseling and wellness coordinator served as the program "champion." This individual, who had the backing of the health plan, owned, promoted, and oversaw implementation of the initiative. He also closely monitors its impact by assessing key behavioral health metrics over time.
  • Placement of counselors in close proximity to providers: Initially, Grand Valley Health Plan PCPs were hesitant to work collaboratively with counseling and wellness staff. As a result, a decision was made to locate the counselors in close proximity to the PCPs, which helped to break down barriers between physicians and counselors.
  • Hiring of consultant: An implementation specialist brought in from outside the health plan was highly effective in overcoming the professional barriers during the implementation process.
  • Establishment of referral, monitoring, and followup protocols: The decision was made to allow only PCPs to refer patients for mental health services. Counselors follow established guidelines, including National Guideline Clearinghouse recommendations, for monitoring patients' treatment compliance and followup appointments.

Resources Used and Skills Needed

  • Staffing: Six full-time social workers and six part-time nutritionists serve as wellness coordinators across the six PCP clinics. Although these coordinators may develop specialties over time (e.g., in working with teen populations), they are trained to work with all populations. One of the six social workers spends half of his time overseeing the program, including tracking referrals and other utilization trends. Most counselors have a master's degree in social work and strong communication skills that allow them to act as consultants and full members of the health care team. The integration consultant had the skills necessary to build a strong team spirit among the physicians and social workers.
  • Costs: Cost data are not available.
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Funding Sources

Grand Valley Health Plan, Grand Rapids, MI
The program was funded internally.end fs

Tools and Other Resources

Strosahl K, Robinson P. Integrating primary care and behavioral health services: a compass and a horizon. PowerPoint presentation, Virginia's State Rural Health Plan; 2009. Available at: http://www.va-srhp.org/docs/2009-summit/behavioral-health-integration.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).

Specifications for the current HEDIS® measures of antidepressant medication management can be found in the National Quality Measures Clearinghouse at: http://www.qualitymeasures.ahrq.gov/search
/search.aspx?term=hedis+measure+antidepressant+medication+management
.

Adoption Considerations

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Getting Started with This Innovation

  • Assess the demand for services: This program works best if there is significant unmet demand for mental health services among primary care patients.
  • Evaluate the organization's capacity to integrate behavioral health into primary care: Key issues to consider include the extent to which the current care process supports this type of change, whether there are available funding sources, whether there are significant barriers such as provider resistance (and if they can be overcome), and whether the integration will make the delivery of services more cost-effective.
  • Take steps to secure buy-in among providers: PCPs and nurses must accept the idea of having in-house mental health specialists. To help secure buy-in and acceptance, Grand Valley Health Plan brought in an outside consultant with expertise in building teamwork across the disciplines. The decision to place the counselors in close proximity to physician offices also facilitated acceptance.
  • Provide patient-centered care: For example, providing patients with same-day mental health appointments provides a tremendous convenience, which, in turn, facilitates access to care.

Sustaining This Innovation

  • Ensure mission compatibility: Be sure that the counseling services are consistent with the mission and objectives of the primary care clinics.
  • Ensure that wellness counselors understand appropriate role: To be successful over the long-term, the PCP must remain in charge of care.
  • Encourage counselors to raise awareness among PCPs: The wellness counselor can assist the PCPs and other staff in becoming more aware of mental health issues, so that they better understand when to make referrals.
  • Apply program broadly: The service needs to be available to a large percentage of the eligible population to make it financially viable.

More Information

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Contact the Innovator

Barbara Luskin
Quality Manager, Grand Valley Health Plan
829 Forest Hill Ave. SE
Grand Rapids, MI 49546
(616) 949-2410
E-mail: luskinb@gvhp.com

Innovator Disclosures

Ms. Luskin has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

This profile is adapted from an Improvement Report by the Institute for Healthcare Improvement, available online at http://www.ihi.org/knowledge/Pages/ImprovementStories
/IntegratedCounselingWellnessServicesinPrimaryCare.aspx
.

Strosahl K, Robinson P. Integrating primary care and behavioral health services: a compass and a horizon. PowerPoint presentation, Virginia's State Rural Health Plan; 2009. Available at: http://www.va-srhp.org/docs/2009-summit/behavioral-health-integration.pdf.

HEDIS® benchmark data can be found in The State of Health Care Quality 2007. Washington, DC: NCQA. Available at: http://www.ncqa.org/Portals/0/Publications/Resource%20Library/SOHC/SOHC_07.pdf.

Footnotes

1 Strosahl K, Robinson P. Integrating primary care and behavioral health services: a compass and a horizon. PowerPoint presentation, Virginia's State Rural Health Plan; 2009. Available at: http://www.va-srhp.org/docs/2009-summit/behavioral-health-integration.pdf.
2 Bruns D. Why did Kaiser change? Health Psychology and Rehabilitation. 1998. Available at: http://www.healthpsych.com/practice/ipc/primarycare3.html.
3 Kroenke K, Mangelsdorf A. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med. 1989;86:262-6. [PubMed]
4 Jackson J, Passamonti M, Kroenke K. Outcome and impact of mental disorders in primary care at 5 years. Psychosom Med. 2007;69:270-6. [PubMed] Available at: http://www.psychosomaticmedicine.org/cgi/content/abstract/69/3/270.
5 Rose V. Collaborative care can improve health status of elderly patients. Am Fam Physician. March 15, 1999. Available at: http://www.aafp.org/afp/990315ap/conference.html.
6 Miller K. Tips from other journals: is collaborative care better in treatment of panic disorders? Am Fam Physician. April 1, 2002. Available at: http://www.aafp.org/afp/2002/0401/p1453.html.
7 HEDIS® benchmark data can be found in The State of Health Care Quality 2007, Washington, DC: NCQA. Available at: http://www.ncqa.org/Portals/0/Publications/Resource%20Library/SOHC/SOHC_07.pdf.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 23, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 29, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 24, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.