"One-stop shop": Physical and mental health care under one roof

Providing medical care and behavioral health services in a single community-based setting is emphasized by health care reform, but how successful have California practitioners been in merging the two systems?   That's the topic of a new policy brief by the UCLA Center for Health Policy Research that evaluates how five large community health centers — which treat anywhere from 12,000 to 70,000 patients per year — have integrated medical and behavioral health services.   Integration of mental and physical health services into a "one-stop shop" — rather than forcing patients to contend with two care systems in different locations — can produce better outcomes, according to the study. Medical and behavioral problems are often entwined — especially in complex patients who have a chronic disease and severe behavioral problems and are, consequently, twice as likely to end up in emergency rooms as those with only physical problems.   The merging of physical and mental health care enables medical doctors and behavioral health professionals to have face-to-face discussions and better coordinate patient care instead of acting in separate "silos," the study's authors said. Approximately 70 percent of behavioral health conditions are first diagnosed and treated with medication in a primary care setting, according to existing research, said the authors.   "A general practitioner might spot a mental health issue, but patients often fall through the cracks because they have to wait weeks and travel to separate facilities before they get care. Many don't even go," said Nadereh Pourat, director of the Center's Health Economics and Evaluation Research (HEER) Program and lead author of the study. "But if a mental health professional works in the same office and even sees the patient at the same time as their GP, treatment is more likely to be immediate and effective."   According to the Office of Statewide Health Planning and Development, less than half (41 percent) of the state's community health centers employ behavioral health providers, and the level of integration is unknown.   Best of the best
The five health centers evaluated in the study were some of the most successful in integrating mental and physical health. All employed behavioral health professionals (some also had full-time psychiatrists), fully shared electronic records, and had regular (sometimes daily) team meetings to discuss shared patients and coordinate their treatment plans.   Yet even the most successful centers had more to do to fully integrate care, according to the study's authors.   As a tool to help providers and medical groups integrate their practices, the study's authors created a 1-6 scale to identify best practices.   Obstacles to integration
The major challenges to integrating care at community health centers had to do with financial resources. For example:  

• Infrastructure. Co-locating and promoting daily communication requires bigger or restructured facilities to house medical and behavioral health providers within easy reach.
• On-staff behavioral health professionals. Recruiting a sufficient number of behavioral health professionals with the right training was a significant part of the problem. One center had nearly 30,000 patients per psychiatrist and more than 4,500 patients per psychologist or other behavioral health specialist.
• Same-day or joint visits. The inability to bill for same-day physical and behavioral health visits was a major challenge. Same-day appointments significantly increase the likelihood that the patient — especially one with more severe problems — will follow through on meeting with the behavioral health specialist.

  Some community health centers used strategies such as tele-psychiatry or provided brief joint visits regardless of reimbursement the authors note. Some also used community health workers, interns or other workers trained to support integration activities to promote integration.   Pourat says that while reaching the highest level of integrated care may be difficult, the five centers in the study show that some level of integration is still possible. First steps towards integration include, employing behavioral health specialists, making patient data easily available to both providers, and promoting communication between these providers.   "Integrated care can result in better health outcomes and may lower costs for complex patients, a goal of the Affordable Care Act," said Pourat. "But, without commitment and sufficient financial resources, it will be tough — there can be improvement, but it will be difficult to attain anywhere near full integration."   Read the policy brief: One-Stop Shopping: Efforts to Integrate Physical and Behavioral Health Care in Five California Community Health Centers   Blue Shield of California Foundation provided funding for this project.   The UCLA Center for Health Policy Research is one of the nation's leading health policy research centers and the premier source of health policy information for California. The Center improves the public's health through high-quality, objective, and evidence-based research and data that informs effective policymaking. The Center is the home of the California Health Interview Survey (CHIS) and is part of the UCLA Fielding School of Public Health. For more information, visit www.healthpolicy.ucla.edu.

About the UCLA Center for Health Policy Research
The UCLA Center for Health Policy Research (CHPR) is one of the nation’s leading health policy research centers and the premier source of health policy information for California. UCLA CHPR improves the public’s health through high quality, objective, and evidence-based research and data that informs effective policymaking. UCLA CHPR is the home of the California Health Interview Survey (CHIS) and is part of the UCLA Fielding School of Public Health. For more information, visit healthpolicy.ucla.edu.