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Research Brief

Key Findings

  1. Mental health clinics cannot reform the integrated health care system alone. Legislative changes are needed at the state level to facilitate and support clinic efforts to provide consumers with integrated care.
  2. General medical and specialty mental health providers must all share responsibility for consumers' "whole person" health. That is, mental health providers must assess and work to improve consumers' physical health, and primary care providers must similarly assess and intervene to ensure that consumers' mental health needs are met. Strategies to promote shared accountability for consumers will also likely require interventions from the state.
  3. It is crucial to develop a sustainable revenue stream for integrated services.

New York state is implementing several new initiatives designed to improve the physical health of adults with serious mental illness by integrating primary care and mental health services. Adults with serious mental illness are a population that, despite high use of medical care, tends to be in poor physical health and have poor access to primary and preventive health care services. The New York State Health Foundation funded a RAND Corporation study of three New York state initiatives focusing on integrated care for adults with serious mental illness.

Integrating primary care services into mental health settings is challenging. Historically, mental health and primary care services have been delivered through distinct systems, each with its own state regulatory agency (In the case of New York, the Office of Mental Health and Department of Health), resource streams, and financial structures. Overcoming the obstacles to integrated care requires simultaneous change at many levels, including the culture within mental health and primary care clinics, linkages among related health care institutions and payers, and regulatory oversight by the state.

The three initiatives studied by RAND addressed these barriers in different ways and to different degrees. A review of information obtained through visits to mental health and partner medical clinics throughout the state, along with surveys of mental health clinic administrators and associated health care professionals, revealed strengths and weaknesses in all three initiatives.

Primary and Behavioral Health Care Integration (PBHCI) grants, administered by the Substance Abuse and Mental Health Services Administration, provide up to $500,000 per year for four years to enhance screening and coordinate access to primary care services. The grants fund not only direct services (e.g., peer specialists, wellness classes) at mental health clinics but also one-time costs of establishing a new program (e.g., clinic renovations, staff training for integrated care). The new capacities may have helped to grow a culture of shared responsibility among mental health and primary care providers, which, in turn, supports consumer access to and use of a range of primary and preventive health care services. However, funding for the grant-supported services will come to an end.

A New York State Office of Mental Health initiative created a financial incentive for licensed mental health clinics to provide basic primary medical services (i.e., screening and monitoring). Approved clinics can bill Medicaid for reimbursement while expanding the billable scope of their practice. However, participating clinics tended to implement only those services for which they could bill, which involved identifying patients' needs but not connecting them to treatment.

The third initiative, New York state's Medicaid Health Homes, is intended to improve integration across physical health, behavioral health, and long-term services and support for populations with chronic conditions by providing financial support for "difficult-to-reimburse" services. In particular, the program supports case managers who are meant to coordinate all aspects of an individual's care within an established network of participating providers, including such diverse services such as supportive housing, legal assistance, and food assistance. This initiative has the potential to improve access to health care through better collaboration and information sharing. However, at the time of this research, the initiative was too new to assess its success, with many primary medical providers not yet aware of the program. Also, core Health Home providers expressed concerns about the program's financial sustainability.

Recommendations for Policymakers

The full report offers a number of recommendations for providers, technical assistance, and future research. This brief includes a selection of suggestions for what policymakers can do to facilitate mental health clinics' programs of integrated care.

Licensing

Expedite licensing: Explore state-level policy strategies that further simplify and expedite mental health clinic licenses to provide primary care medical services.

Special licenses for freestanding clinics: Consider different licensing options for mental health clinics that are freestanding rather than hospital-affiliated. Because freestanding clinics typically have less experience and fewer resources for implementing primary care services, policymakers may wish to offer these clinics alternative licensing options that (1) require fewer clinic structural changes compared with a typical primary care clinic, but (2) require more investment in creating formal referral networks for primary care services that are not provided on site.

Focus first on clinics with the most potential: Consider whether all mental health clinics are appropriate settings for on-site primary care services. Given the scarcity of providers willing and able to provide primary care to adults with serious mental illness, policymakers may choose to focus resources on settings most likely to benefit consumers, such as multi-service settings (e.g., Personalized Recovery Oriented Services, or PROS clinics) that have proven strategies for engaging consumers in long-term, multi-specialty care.

Joint Accountability

Identify and implement strategies that promote joint accountability: Strategies to establish joint accountability among providers caring for, and plans covering, consumers' health care needs may be applied in training, practice, health plan contracts, performance incentives, and other mechanisms, including clinic and health system culture. Strategies may also include the promotion of a full "package" of services for adults with severe mental illness through an integrated primary care/behavioral "health home."

Data and Information Sharing

Track and report results: Develop a regular "report card" to track the implementation of reforms designed to facilitate integrated care and report the results to stakeholders.

Improve information sharing: Consider creating incentives for electronic health record businesses to create products that interface with available clinical information systems (e.g., partner primary care records, case management systems, regional health information organizations, Psychiatric Services and Clinical Knowledge Enhancement System), facilitate effective communication among provider teams, and support "measurement-based care."

Sustainability

Assess costs and sustainability during evaluations of integration initiatives: Policymakers should consider collecting cost and sustainability information during pilot tests of integrated care programs to facilitate decisionmaking. Some clinics have chosen not to participate in programs they thought were not financially sustainable.

Provisions for rural clinics: Consider special provisions for clinics in rural settings to address provider shortages, lack of alternative transportation, and longer distances for consumers to reach clinics, hospitals, and specialists.

Support for peer specialists and primary care case managers: There are few mechanisms to support peer specialists and primary care case managers. Clarifying their roles might help to stimulate consistent and reliable billing opportunities and ensure that these positions are staffed by individuals with the skills and qualifications needed to maximally benefit consumers.

This report is part of the RAND Corporation research brief series. RAND research briefs present policy-oriented summaries of individual published, peer-reviewed documents or of a body of published work.

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