The Affordable Care Act promotes the integration of physical and behavioral health care, but clinicians still don't know the answer to a key question: Is it enough to simply co-locate psychologists and other mental health professionals in or near primary-care offices or is integrating them fully into primary-care teams the best way to improve patient care?
"We haven't done the research to answer that question," says Suzanne Bennett Johnson, PhD, a professor of behavioral sciences and social medicine at Florida State University College of Medicine.
That's why Bennett Johnson and others were so excited by the announcement in August that a University of Vermont-based research team had received an $18.5 million grant from the Patient-Centered Outcomes Research Institute (PCORI) to do that research. Established by the Affordable Care Act, PCORI aims to provide evidence to help patients, clinicians, insurers, policymakers and others make more informed health-care decisions.
The project will be led by principal investigator Benjamin Littenberg, MD, a professor of medicine at the University of Vermont College of Medicine, and co-principal investigator Rodger Kessler, PhD, an associate professor of family medicine there. The multidisciplinary research team will study 30-plus family medicine clinics, internal medicine practices and community health centers nationwide as they transition from having co-located behavioral health clinicians — the control arm of the study — to the active arm of full-fledged integration.
The researchers plan to randomly select at least 60 adult patients with behavioral health concerns from each of the 30 practices and follow all 1,800 of them for five years to see how their health and functioning change as integration increases. They will also examine how the patients feel about the care they have received.
The research team will be made up of psychologists, physicians, scientists, nurses and patients themselves. Most of the project leads at the participating practices will be psychologists. The project's research and advisory group includes APA President-elect Susan H. McDaniel, PhD, of the University of Rochester, Parinda Khatri, PhD, of Cherokee Health Systems and Andrea Auxier, PhD, of Beacon Health Options — a group that PCORI has dubbed a "dream team," Kessler says.
Kessler says such research on integrated care is overdue.
"I've been in primary care as a psychologist for about 25 years and have become very aware of all the efforts around the country to move toward co-located, collaborative and integrated care," says Kessler, who is also associate chair for research and evaluation in Arizona State University's behavioral health program. "The major dilemma with those efforts is that they have been done mostly without any empirical support."
Over the last two decades, Kessler's practice has evolved from what was essentially a private psychology practice located within a primary-care office into a fully integrated part of the medical practice. Along the way, he and his research team have developed some resources that will be used during the PCORI project.
One is the Practice Integration Profile, a tool that allows practices to measure how far along the continuum of primary care/behavioral health integration they are, with a final score providing a benchmark for progress. In the past, says Kessler, "there has been no way to codify what integration looks like practice to practice."
The project will also draw upon another resource the University of Vermont team is developing: a National Institutes of Health-funded primary-care integration toolkit. The toolkit walks practices through the steps they can take to increase integration in three key areas: management and decision-making, team composition and planning and implementation. The toolkit can help practices move from contracting with outside organizations to provide behavioral health care to hiring their own clinicians, for example. Other steps include ensuring that both behavioral health and primary-care clinicians can use the same electronic health records and making registration, check-in and appointment scheduling processes the same no matter what kind of clinician a patient is seeing. The researchers will also develop new tools.
Led by psychologist Daniel Mullin, PsyD, with help from psychologist Alexander Blount, EdD, of the Center for Integrated Primary Care at the University of Massachusetts Medical School, UMass and Arizona State's behavioral health program will create online training modules. Along with existing UMass modules, these new resources will teach participating physicians, behavioral health clinicians, nurses, front-desk staff and anyone else whose job involves contact with patients how to integrate behavioral health care into primary care. The training program will be "asynchronous" to allow users to work at their own pace and according to their own schedules. With support from researcher Constance Van Eeghen, DrPH, of the University of Vermont, a facilitator in each practice will help smooth the transition to integrated behavioral health care.
The fact that PCORI has funded a project focusing on behavioral health and involving so many psychologists is a major accomplishment, says W. Douglas Tynan, PhD, director of integrated health care at APA. "In its first couple of years, PCORI was really focused on getting physicians and medical care to be more patient-centered," says Tynan. "This adds the element of mental health services to the picture."
The project has the potential not just to change clinical practice but also to affect policy, adds Tynan.
"The payment system — particularly Medicare — is moving very rapidly toward payment for high-quality service and good outcomes," he explains. "If this project shows that co-location or integration yields better outcomes, those are data that health-care providers can cite when negotiating with insurance companies and explaining why they should pay for psychological services."