Connecting Two Worlds: Integrating Physical and Behavioral Health Care

While mental health and medical providers recognize that their patients frequently have both physical and behavioral health needs, the two delivery systems and payment streams are often completely separate. In a series of blog posts building off work NASHP has been doing with the support of the Kaiser Community Health Benefit, we’ve contemplated a more tightly-knit delivery system in which health care providers of all types work together more closely to deliver coordinated, high-value care. As we reach the end of our series, we will consider a critical facet of delivery system integration: better coordination between physical and behavioral health care.
A truly integrated delivery system requires combining different kinds of services and supports, including behavioral and physical health care. With the Affordable Care Act (ACA) requiring parity between behavioral and physical health benefits in the new insurance exchanges, and the ACA’s Medicaid expansions bringing coverage to a population with a range of behavioral and physical health needs, integration of the two has never been more important.
States are taking different approaches to supporting integration. Minnesota has launched ACO models within Medicaid that combine accountability for physical and behavioral health care. Participating providers assume financial accountability for services, including outpatient mental health and chemical dependency services in addition to medical services. The demonstration’s quality measures include depression remission and participating groups can propose additional measures, including behavioral health measures.
Washington will be using the health home model under the ACA, which builds on the patient-centered medical home model and better coordinates primary and behavioral health care. The state will also participate in a federal demonstration project for beneficiaries dually eligible for Medicare and Medicaid. Under this demonstration, capitated health plans will be responsible for a full range of services—including mental health, chemical dependency, long-term services and supports, and medical—under a single capitated rate.
Innovative providers are helping states to make integration a reality. Kitsap Mental Health Services, a behavioral health organization in Washington featured on a recent NASHP webinar, uses capitated payments (and, more recently, a grant from the CMS Innovation Center) to support its work, in which multidisciplinary care teams collaborate to meet the varied needs of their patients. The care teams are aided by patient registries and care management reports that support care coordination and inform real-time decision-making. At this stage, staff supported by the Innovation Center grant manually combine the separate funding streams and work around the data infrastructure differences. While the organization has been successful in achieving integration, eliminating payment, regulatory and data silos would help make the process more systematic and streamlined.
In a recent webinar hosted by NASHP, Jane Beyer identified key lessons for states as they pursue the integration of physical and behavioral health care, including:

• Providers need help managing and combining separate funding streams. Physical and behavioral health care are often paid for separately, offering challenges to delivery systems that attempt to integrate services. Separate funding streams can create or reinforce care silos if flexibility in payment methodologies isn’t allowed. Hennepin Health, a safety-net accountable care organization (ACO) in Minnesota, integrates medical care with behavioral health (and other social and county-funded services) under a capitated payment.

• Data sharing across providers is key to integration. Physical and behavioral health providers often have distinct data infrastructures in place (such as different electronic health record systems), reinforcing existing care silos. Moreover, while the Health Insurance Portability and Accountability Act (HIPAA) allows providers to share health information, the law requires additional protections on mental health and substance use data. Integration requires navigating these technical and regulatory issues. Washington uses a decision support tool known as PRISM (Predictive Risk Intelligence System) to identify risk scores for patients based on predictive modeling, which consolidates information and data from across systems to support care management interventions for high-risk beneficiaries.

• Models that meet the varied needs of beneficiaries who cross systems are needed.Individuals with physical and behavioral health needs are better supported through a whole-person, recovery-oriented approach to their care. They benefit from bi-directional systems, in which they can access behavioral health services in primary care settings and vice versa. Kitsap has provided psychiatric consultation and brief interventions at a Federally Qualified Health Center for nearly twenty years. Similarly, a primary care provider has been co-located on the Kitsap campus since 2012.

What is your state doing to integrate physical and behavioral health care? Let us know in a comment below or in our behavioral health discussion.
As part of NASHP’s integration delivery system project, we’ve added documents, reports, and insights on every topic covered in this blog series. The results of all this work, along with additional related resources—including NASHP’s State Accountable Care Activity map and Multi-Payer Resource Center—can be found on State Refor(u)m in an Integrated Delivery Systems Toolkit.