Primary care providers (PCPs) are increasingly playing a vital role in addressing patients’ behavioral health care needs given the shortage of behavioral health providers and other challenges in the health care system.1
- More than half of adults with behavioral health conditions in the U.S. go without treatment—27 million people.2
- Approximately half of all care received for behavioral health conditions is provided by PCPs.3
- About 80% of patients with behavioral health conditions seek treatment in emergency rooms and primary care clinics, and 60-70% of them are discharged without receiving care.4
- Fewer than 35% of adults with opioid use disorder (OUD) accessed care in 2019.5 More than 80% of those with OUD have not received evidence-based medications for opioid use disorder (MOUD) treatment in the last year or more.6
- National estimates indicate there is usually a gap of, on average, four to seven years between the onset of OUD and beginning treatment among those who obtain treatment.7
- For people with substance use disorder (SUD) in rural areas, seeking treatment is even more difficult due to fewer behavioral health providers and programs, travel and transportation barriers, stigma, and lack of anonymity.8
Addressing challenges in rural communities
Evidence has shown that integrating behavioral health care into primary care practices effectively increases access to mental health and SUD treatment and improves outcomes.9 Behavioral health integration (BHI) also can help primary care practices deliver behavioral health care more effectively, improve practice efficiency, increase PCPs’ confidence and competence in addressing behavioral health issues, and enhance their ability to manage patients’ overall health.10 Given challenges that rural PCPs face, however, they will need additional resources and support to successfully integrate behavioral health into their practices and care for patients with SUD.
To help rural PCPs implement BHI, UR Medicine Recovery Center of Excellence is highlighting the role of the Behavioral Health Care Manager (BHCM) in primary care practices. This role has been well documented as a core component of the evidence-based Collaborative Care Model (CoCM), developed by the University of Washington Advancing Integrated Mental Health Solutions (AIMS) Center. We have drawn upon best practices and learnings from the comprehensive CoCM and adapted the BHCM role to make BHI practicable for rural primary care practices.
We developed the adaptation because many of the requirements for the more traditional CoCM implementation are difficult to implement in rural practices. This includes formal education/specialized training in behavioral health and a training program recommended by the AIMS Center model. A more streamlined approach may help rural communities, where primary care practices often face staffing challenges and where there is a lack of specialty mental health and substance use providers. In this approach, a practice implements a more general BHI model in which the BHCM functions in a manner between a registered nurse (RN) care manager and a CoCM BHCM as described by AIMS. This BHCM can be qualified clinical staff, such as an RN already in the practice, who can be provided appropriately tailored training in evidence-based interventions for mental health and substance use disorders. While the qualifications are more flexible, it is important that this clinician have experience and/or special interest in behavioral health and that they pursue further education and training over time to refine their role and improve their skills.
Role of BHCM in adapted model
Under this model, when patients present in a rural primary care practice, the BHCM identifies those with probable SUD or other behavioral health concerns through screening. With appropriate training, the BHCM can facilitate patient engagement, provide basic education and self-management skills, gauge patients’ readiness to initiate medications and/or engage in specialty substance use or mental health treatment, and provide evidence-based behavioral interventions such as behavioral activation (BA) or problem-solving therapy (PST).
The BHCM will assist in systematic screening and monitoring of patients, coordinate care with the PCP and other providers, maintain regular patient interaction, track response to treatment, and adjust the care plan as appropriate. To ensure the BHCM has robust clinical support and guidance, the practice must establish an arrangement with a psychiatric provider (psychiatrist or psychiatric nurse practitioner) to provide caseload-focused consultation to the BHCM on a regular basis and for provider-to-provider consultation as needed. The psychiatrist’s role will also be to make medication recommendations for the PCP to consider.
Many of the interventions managed by the BHCM can be done via telehealth (phone or video). This approach would allow the BHCM to serve multiple practice sites in a rural area—rotating among several practices, while supporting access to the other sites remotely.
For patients with SUD, we emphasize the following:
- The BHCM provides culturally competent care management including assessment, education, fostering motivational change, and transitions of care.
- The BHCM coordinates treatment with an MOUD provider. There is potential for this to occur via telehealth for a period of time if the PCP is not currently providing maintenance MOUD treatment.
- The BHCM establishes relationships with hospital emergency departments, SUD treatment organizations, and others throughout the community involved in SUD treatment and recovery to lay the foundation for warm handoffs.
Connecting with behavioral health specialists, such as psychologists and therapists, even via telehealth, is often difficult in rural communities due to the shortage of providers. Having a member of the primary care team, the BHCM, available to provide supportive interventions and monitor symptoms enables the PCP in the practice to manage the behavioral health needs of a majority of their patients when symptoms are in the mild to moderate range. For those patients whose symptoms are severe or chronic enough to require a specialty referral, this model allows the team of PCP and BHCM to manage the patient’s care more effectively and safely until a referral can be made.
While rural practices will incur start-up costs as they implement this model of care, financial sustainability or at least some reduction in cost is possible over time as Medicare, Medicaid in most states, and many commercial payers reimburse for BHI services.11 Additional reimbursement opportunities may be available. See our financial tool for more on sustainability.
Please visit the Q&A with program lead George Nasra, M.D., M.B.A., professor of clinical psychiatry, University of Rochester Medical Center, to learn more about integrating behavioral health and the role of the BHCM. By prioritizing this role and taking a long-term approach in working toward collaborative care, BHI implementation can be more manageable and less of a heavy lift for rural primary care practices.
Subject Matter Expert
George Nasra, M.D., M.B.A.
George Nasra is Professor of Clinical Psychiatry at the University of Rochester Medical Center, where he serves as chief of the Division of Collaborative Care and Wellness.
References
[1] University of Michigan Behavioral Health Workforce Research Center. (2019). Behavioral health service provision by primary care physicians. University of Michigan School of Public Health.
[2] Reinert, M, Fritze, D. & Nguyen, T. (2021). The state of mental health in America 2022. Mental Health America, p. 8.
[3] University of Michigan Behavioral Health Workforce Research Center. (2019).
[4] Klein, S., & Hostetter, M. (2014). In focus: Integrating behavioral health and primary care. Commonwealth Fund. Cited in National Academies of Sciences, Engineering, and Medicine. (2020). Caring for people with mental health and substance use disorders in primary care settings. National Academies Press, p. 1.
[5] National Academies of Sciences, Engineering, and Medicine. (2019). Medications for opioid use disorder save lives. National Academies Press, p. 110.
[6] Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, p. 55.
[7] National Academies of Sciences, Engineering, and Medicine. (2019).
[8] Blanco, C., Ali, M. M., Beswick, A., Drexler, K., Hoffman, C., Jones, C. M., Wiley, T. R. A., & Coukell, A. (2020). The American opioid epidemic in special populations: Five examples. NAM Perspectives. Discussion Paper, National Academy of Medicine, pp. 5-6; National Academies of Sciences, Engineering, and Medicine. (2019).
[9] Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., Dickens, C., & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 10, CD006525; Watkins, K. E., Ober, A. J., Lamp, K., Lind, M., Setodji, C., Osilla, K. C., Hunter, S. B., McCullough, C. M., Becker, K., Iyiewuare, P. O., Diamant, A., Heinzerling, K., & Pincus, H. A. (2017). Collaborative care for opioid and alcohol use disorders in primary care: The SUMMIT randomized clinical trial. JAMA Internal Medicine, 177(10), 1480-1488.
[10] BHI Collaborative. (2018, February). Behavioral health integration compendium, pp. 12-13.
[11] California Health Care Foundation (CHCF). (2020, September). Cracking the codes: State Medicaid approaches to reimbursing psychiatric collaborative care.
August 2022
