![](media/image1.jpeg){width="4.047916666666667in"
height="1.4236111111111112in"}

March 27, 2001

# Integration of Primary & Behavioral Care Services

irk Stroessel, a consultant who has previously worked with the Bureau of
Primary Health Care (BPHC), addressed CAP Grantees in a conference call
on March 27 about the pressing need for an interface between behavioral
health and primary care services. Increasingly, primary care providers
are the treatment source of choice for people experiencing mental health
and chemical dependency problems. For ease of reference, these problems
are categorized in this call summary as behavioral disorders.

The incidence of behavioral disorders is alarmingly high:

-   Recent studies indicate that 7 out of 10 people in community health
    center waiting rooms present for treatment due to mental disorders,
    including depression, anxiety disorders, substance abuse, or some
    combination of these.

-   A recent survey of 800 medical care providers was implemented to
    determine what percentage of patients in a typical clinic workweek
    presented with behavioral disorders. Using the most stringent coding
    standards, responses indicated that a full 50% of patients
    experienced these disorders. Using a more relaxed set of coding
    criteria increased positive responses significantly to at least 70%
    of primary care patients.

-   Among 2000 patients in a Chicago clinic complaining of headaches,
    dizziness or gastro-intestinal distress, only 1 in 10 was diagnosed
    with a non-behavioral illness at the end of the treatment period.

In addition to concerns about the alarming number of people who
experience behavioral disorder symptoms, there is growing concern at the
community level about uninsured patients who may not have a chronic
illness but may be depressed, anxious, or beginning to abuse alcohol or
other substances. Studies indicate that 50% of people with behavioral
disorders never seek help, and that those who do seek help are likely to
be shifted to the primary care system despite their need for specialized
services. Because people with behavioral disorders typically use double
the amount of service resources as other sick people, this shift to the
primary care system is costly and inefficient as well as often
ineffective.

In this era of managed care, primary care providers are expected to
examine and diagnose patients in time blocks of 10-15 minutes.
Ironically, this time constraint is keenly felt among patients who are
increasingly intent upon spending more time telling their providers
about the various domestic, employment, and other environmental
stressors in their lives. This information is particularly important to
physicians as they consider behavioral and other physical disorders that
may co-exist. The result of this conflict between available time and
needed information is often a mismatch between patients' perceived
health issues and the care they receive. Given the high incidence rates
cited above for behavioral disorders, this is clearly a problem of major
proportion for both providers and their patients.

The mission of the primary health care system focuses on
population-based care with the goal of raising the health of the entire
community. In contrast to this, the goal of the specialty model of care
is to deliver a broad array of services to a relatively small percentage
of the community. It is well documented that the higher volume and
higher frequency of contacts that characterize the primary care system
are essential for handling the influx of patients with behavioral
disorders. One indication that this need is beginning to be addressed is
the commitment demonstrated by the BPHC Technical Assistance Program,
which has increased its Service Expansion Awards this year from 17 to 80
in support of health care centers interested in integrating services.
These \$100,000 permanent base allocation increases are specifically
geared toward hiring behavioral health staff to assist primary
caregivers in dealing with clients who present with behavioral
disorders.

There are many challenges to integrating behavioral health and primary
care services, one of which is the desire on the part of consumers for
one-stop shopping. For various reasons that range from convenience to
stigma related to behavioral disorders, patients are often unwilling to
move from the primary care system to a behavioral care system that can
best provide the treatment they need. In fact, when primary care
providers attempt to refer patients to behavioral care systems, fully
40-70% of patients fall through the cracks and are lost to treatment.
Key factors that must be addressed to successfully integrate primary
care and behavioral health services include:

-   Location -- Co-locating services to help keep behavioral care
    patients from falling through the cracks

-   Consolidation -- Reducing red tape and paperwork requirements
    related to payment and patient history

-   Philosophical consistence -- A clearly perceived sense that primary
    care and behavioral care providers are on the same page in the best
    interests of the patient

Since additional funding is unlikely to be forthcoming, creative
solutions are needed to effectively address this issue. The mission of
medical care must shift to finding ways to influence the behavioral
health of the community with currently available resources. Primary care
providers should strongly consider such strategies as:

-   Teaching primary health care providers to effectively intervene on
    behalf of patients with behavioral disorders by recognizing the
    existence of the disorder and providing clear next steps for those
    who need behavioral care

-   Placing behavioral health providers in the medical practice area
    along with primary care physicians. The continuum of
    location-specific integration possibilities range from hiring part
    time behavioral health providers in specific primary care locations
    through using a "circuit-rider" approach where behavioral health
    providers serve a number of clinics in a specific geographic area.

Clearly, the need to develop innovative ways to integrate behavioral
health and primary care services is a critical health issue that
requires immediate attention. Creative strategies that utilize current
health services infrastructures and resource bases must be designed and
implemented to provide quality health service delivery that addresses
behavioral as well as primary health care needs. Those grantees
interested in participating in training workshops and follow-up onsite
help may contact Audrey Smolkin (<asmolkin@hrsa.gov>) for referrals and
further information.

INTEGRATION OF PRIMARY & BEHAVIORAL CARE SERVICES CALL PARTICIPANTS:

+------------------+---------------------------------------------------+
| ###### Name      | ###### Organization                               |
+------------------+---------------------------------------------------+
| Amber Slichta    | Health For All, Buffalo NY                        |
+------------------+---------------------------------------------------+
| Amy Bartells     | Arizona Board of Regents, University of AZ        |
+------------------+---------------------------------------------------+
| Amy Housen       | Choice Regional Health Network, Olympia WA        |
+------------------+---------------------------------------------------+
| Ana O'Connor     | Alameda Medical Center, CA                        |
+------------------+---------------------------------------------------+
| Anne Kircher     | Sangre de Cristo Community Health Partnership, NM |
+------------------+---------------------------------------------------+
| Anne Witmer      | Louisiana Public Health Institute                 |
+------------------+---------------------------------------------------+
| Audrey Smolkin   | HRSA Philadelphia, PA                             |
+------------------+---------------------------------------------------+
| Betsy Wheeler    | Delaware Health Care Commission                   |
+------------------+---------------------------------------------------+
| Bob Stolarick    | Shelby County Health Care Corp., TN               |
+------------------+---------------------------------------------------+
| Brenda Theus     | Shelby County Health Care Corp., TN               |
+------------------+---------------------------------------------------+
| Christie         | HRSA Central                                      |
| Bordeaux         |                                                   |
+------------------+---------------------------------------------------+
| Dave Fant        | Shenandoah Valley Medical System, WV              |
+------------------+---------------------------------------------------+
| David Deere      | University Affiliated Program of AR               |
+------------------+---------------------------------------------------+
| Debbie Bardin    | Hudson Headwaters Health Network                  |
+------------------+---------------------------------------------------+
| Dennis Williams  | NC Department of Health and Human Services, Pitts |
|                  | County                                            |
+------------------+---------------------------------------------------+
| Eric Gopleru     | SAMHSA                                            |
+------------------+---------------------------------------------------+
| Ginger Ryan      | Chiricahua Community Health Center/ Copper Clean  |
|                  | Community Hospital                                |
+------------------+---------------------------------------------------+
| James Delgado    | Sangre de Cristo Community Health Partnership, NM |
+------------------+---------------------------------------------------+
| Jo Paulla        | Baca First Choice Community Healthcare, Inc.      |
+------------------+---------------------------------------------------+
| Joanne Omi       | NY City Health & Hospital                         |
+------------------+---------------------------------------------------+
| John Cragin      | Boston Medical                                    |
+------------------+---------------------------------------------------+
| John Harold      |                                                   |
+------------------+---------------------------------------------------+
| John Heard       | Kirksville College of Osteopathic Medicine, MO    |
+------------------+---------------------------------------------------+
| John H. Werner   | Broward Regional Health Planning Council, Inc.,   |
|                  | FL                                                |
+------------------+---------------------------------------------------+
| Judith Chaconas  | Delaware Health Care Commission                   |
+------------------+---------------------------------------------------+
| Judy Szalapski   | Hennepin County Medical Center, MN CAP            |
+------------------+---------------------------------------------------+
| Karl Ray         |                                                   |
+------------------+---------------------------------------------------+
| Katherine        | Middlesex Health System, Inc., CT                 |
| Schneider        |                                                   |
+------------------+---------------------------------------------------+
| Kay Freeman      | Leon County, FL                                   |
+------------------+---------------------------------------------------+
| Kirk Strosahl    |                                                   |
+------------------+---------------------------------------------------+
| Linda Potts      | Community Health Initiative                       |
+------------------+---------------------------------------------------+
| Lisa Craig       | Health Improvement Partnership                    |
+------------------+---------------------------------------------------+
| Liz Whitley      | Denver Health & Hospital Authority, CO            |
+------------------+---------------------------------------------------+
| Lori Hunt        | Coordinated Care Network, PA                      |
+------------------+---------------------------------------------------+
| Luanne Nyberg    | Hennepin County Medical Center, MN                |
+------------------+---------------------------------------------------+
| Lynn Evans       | Reister Inova Health Care Services                |
+------------------+---------------------------------------------------+
| MAC              | Management Assistance Corporation                 |
+------------------+---------------------------------------------------+
| Mady Chalk       | SAMHSA                                            |
+------------------+---------------------------------------------------+
| Margaret Flinter | Middlesex Hospitals                               |
+------------------+---------------------------------------------------+
| Mark Snyder      | Cherokee Health Systems, TN                       |
+------------------+---------------------------------------------------+
| Mike DeLucca     | FL CAP                                            |
+------------------+---------------------------------------------------+
| Nick Zucconi     | HRSA                                              |
+------------------+---------------------------------------------------+
| Nicole Wheeler   | Yavapai                                           |
+------------------+---------------------------------------------------+
| Pam Galbraith    | UNM Health Sciences Center                        |
+------------------+---------------------------------------------------+
| Paula Williams   | New Horizon Family Health Services, SC            |
+------------------+---------------------------------------------------+
| Rhoda Nichola    | Department of Health, UT                          |
+------------------+---------------------------------------------------+
| Robert Joseph    | Cambridge MA (Linda Cundiff)                      |
+------------------+---------------------------------------------------+
| Ruth Woolum      | SKYCAP Hazzard                                    |
+------------------+---------------------------------------------------+
| Sandra McCollum  | UNM Health Sciences Center                        |
+------------------+---------------------------------------------------+
| Seema Verma      | Marion County CAP                                 |
+------------------+---------------------------------------------------+
| Sharon Morris    | Health Care Coalition of Southern Oregon          |
+------------------+---------------------------------------------------+
| Sr. Mary Walz    | DC St. Elizabeth Health Center                    |
+------------------+---------------------------------------------------+
| Stacy Kelly      | Daughters of Charity Health Services, Austin TX   |
+------------------+---------------------------------------------------+
| Steve Dorage     | HRSA                                              |
+------------------+---------------------------------------------------+
| Steven Walker    | Columbia Mental Health Center                     |
+------------------+---------------------------------------------------+
| Suanne Stewart   | Coordinated Care Network, PA                      |
+------------------+---------------------------------------------------+
| Tammy Eberly     | Tiahoga CAP                                       |
+------------------+---------------------------------------------------+
| Tom Brown        | Palmetto Health Alliance, SC                      |
+------------------+---------------------------------------------------+
| Tom Lewis        | MD CAP                                            |
+------------------+---------------------------------------------------+
| Tom Irons        | NC CAP                                            |
+------------------+---------------------------------------------------+
| Tori Leuteman    |                                                   |
+------------------+---------------------------------------------------+
| Tracey Bush      | New Orleans, Louisiana CAP                        |
+------------------+---------------------------------------------------+
| Synthesis        | Synthesis Professional Services                   |
| Writers          |                                                   |
+------------------+---------------------------------------------------+

Summary Developed By: Synthesis Professional Services, Inc.