The promise and challenge of integrating primary care into community-based mental health centers

By | February 21, 2021

There is ample evidence that patients with severe mental illness are at high risk for significant medical comorbidities. A complex combination of factors contributes to this excess risk and consequential poor outcomes. Socioeconomic factors, side effects from psychiatric medications, poor access to health care as well as smoking, alcohol, and substance use, prevalent in this population, are some of the factors that contribute to patients with mental disorders dying of medical illness an average of 8.2 years younger than the rest of the population.

Based on this evidence, it makes sense that an integrated care model that enhances access to high-quality primary care and increases patient engagement would result in better outcomes. Unfortunately, there is limited research available that proves the improved impact of the integrated care model. This is attributable in part to the heterogeneity of deployed integrated care models, which makes comparisons and measurement of outcomes very difficult.

Providing primary care to patients with serious mental illness is a challenging task that requires highly skilled, experienced practitioners who are comfortable with the full array of biopsychosocial problems with which these patients present. For example, understanding the side effect profiles of psychiatric medications and their impact on problems such as diabetes and other complex endocrinopathies requires highly evolved clinical skills.

Optimally, these patients’ care is provided in close collaboration among the mental health team — the prescribing psychiatrist and the patient’s primary care provider. Indeed, integrated care models are becoming more prevalent with patients being cared for by primary care and behavioral health teams collocated in the same practice.

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The COVID-19 pandemic and the resultant increase in telehealth services for behavioral health has proven that more important than the physical co-location of these teams, is the ability of the behavioral health and medical teams to share a single electronic health record (EHR) where information is comprehensive and accessible by all who care for the patient. Because of the specific and disparate workflows that behavioral health care teams and medical teams follow, it is imperative that this shared electronic platform be able to fully support the workflow, documentation, and regulatory requirements of both teams. Organizations that have collocated teams but remained in siloed electronic environments have continued to struggle in spite of their best efforts.

There are predictions that by 2033 there will be a shortfall of up to 52,000 primary care physicians in the United States.  Because of the unique challenges of providing primary care to patients with serious mental illness, this shortage might disproportionately impact integrated care organizations’ ability to recruit and retain highly skilled primary care providers. Finding an optimal balance among physicians, nurse practitioners, and physician assistants is one of the keys to success in staffing these practices.

It is encouraging to see the integrated care model gaining momentum across the country. Continued study and research will be required to further refine the model to ensure high quality, cost-efficient, and compassionate care is offered to this highly vulnerable segment of the population. Fortunately, the deployment of truly integrated health IT platforms in these practices will also generate the clinical, quality, and cost data that can provide the insights needed to further refine and scale this essential care model.

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Betty Rabinowitz is chief medical officer, NextGen Healthcare. She can be reached on Twitter @DrBettyR.

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