The need, benefit, and desirability of behavioral health integration in primary care is generally accepted and has acquired widespread positive regard. However, in many health care settings the economics, business aspects, and financial sustainability of practice in integrated care settings remains an unsolved puzzle. Organizational administrators may be reluctant to expand behavioral health services without evidence that such programs offer clear financial benefits and financial sustainability. The tendency among mental health professionals is to consider positive clinical outcomes (e.g., reduced depression) as being globally valued indicators of program success. Although such outcomes may be highly valued by primary care providers and patients, administrative decision makers may require demonstration of more tangible financial outcomes. These differing views require program developers and evaluators to consider multiple outcome domains including clinical/psychological symptom reduction, potential cost benefit, and cost offset. The authors describe a process by which a pilot demonstration project is being implemented to demonstrate programmatic outcomes with a focus on the following: 1) clinician efficiency, 2) improved health outcomes, and 3) direct revenue generation associated with the inclusion of integrated primary care in a public health care system. The authors subsequently offer specific future directions and commentary regarding financial evaluation in each of these domains.
Swedish Family Medicine Residency, Littleton, Colorado and the Colorado Health Foundation, Denver, Colorado Practitioners working in primary care (PC) encounter a different model of patient care than those who practice in a traditional outpatient psychotherapy setting. PC physicians commonly serve multiple members of the family and are typically serving numerous patients in the same community. Given the lack of financial sustainability for the behavioral health provider (BHP) position, it is uncommon that a practice will have more than one BHP and therefore, there is increased likelihood that the BHP will be asked to provide services for a family member or roommate of a patient seen in the recent past. The ethical code regarding multiple relationships can sometimes pose challenges that require careful forethought and clinical anticipation. The ethical code, if followed too rigidly in the population-based care model of PC, could potentially be harmful to patients who otherwise have no access to mental health resources or would not seek traditional care. This paper proposes a framework to aid anticipatory decision making regarding multiple relationships in the PC setting, with the goal of reducing potential patient harm and maximizing potential for care opportunities.
The primary care system is a fertile ground for professionals to be trained to promote positive health behaviors. However, most primary care systems that integrate physical and behavioral health struggle with financial start-up and sustainability. The growth and development of mechanisms for supporting grass roots integration highlight the creativity and sheer will of communities, states, and healthcare systems to innovate their way to health. And now, for the first time, national-level funding initiatives have begun to support integration. This article highlights funding mechanisms at the state, foundation, payor, and federal levels that have been used to champion innovation. It provides a historical and future-oriented primer of the various mechanisms for initiating and advancing integration in primary care settings.
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