Integrating behavioral health services within military health system: a model for opportunities and challenges.

Background–The 2010 Department of Defense Quadrennial Defense Review report was the impetus for a review of strategies, programs and resources including healthcare. A section of this report focused on lowering military health systems cost, while striking a balance with the “Quadruple Aim” (1) maximizing readiness, (2) improving the health of the population, (3) enhancing the patient experience of care, and (4) responsibly managing per capita cost of care. The Patient-Centered Medical Home (PCMH) was a primary target to reach the goals of the Quadruple Aim. What is the basis for integration of behavioral health services into Department of Defense Military Health System (MHS)?–The PCMH is an initiative to reorganize primary care to improve health outcomes. The implementation and evaluation of transformed primary care systems into PCMHs across the USA is also taking place in the Department of Defense MHS. Unlike most PCMHs, the MHS effort considered the integration of behavioral health services essential to PCMH implementation. Although the Navy, Air Force, and Army all have integrated some aspects of behavioral health into their models, there was a need for an overall MHS systemwide vision and implementation. A 2007 Taskforce on Mental Health recommended the integration of mental health professionals into primary care settings to improve the access and outcomes of behavioral healthcare within MHS. In response to this recommendation, A Mental Health Integrated Working Group (MHIWG) established recommendations for integrating behavioral health providers and care facilitators into primary care that included staffing, evidence-based assessment and treatment, and workforce development. How was the policy for integrating behavioral health services developed?–Once funding was secured, the recommendations from the MHIWG were transformed into a Department of Defense policy. This policy ensures minimum standards, competencies, and evaluation of impact within and across the services. Although currently in draft form, it is estimated that after a 12-month coordination process, it will be formally published. How will the workforce be developed to facilitate this implementation?–Behavioral health professionals are often trained for assessment and intervention in specialty clinics where appointment length and reporting are longer and more detailed than in other health care settings, particularly PCMH. The difference in culture, clinical setting, and the unique delivery system warrants minimum training criteria and core competencies for behavioral health providers consistent with Air Force, Navy, and Army publications. Training will include didactic and experiential training prior to seeing patients. How will the integration of behavioral health services be evaluated?–Evaluation of this initiative is imperative for long-term sustainability and effectiveness. Because behavioral health providers and care facilitators were not part of overall PCMH evaluation outcomes, separate evaluation variables are being planned. These include patient, provider, and clinic, and system level, process, measures that align with the Quadruple Aim. Research questions, methods, data collection, and statistical analysis are being proactively determined and they will correspond with measures collected. Bottom line: The development, implementation, and evaluation a policy to integrate behavioral health services into Military Health Service is complex but has the potential to improve care while lowering military health systems cost and striking a balance with the goals included in the Quadruple Aim. This initiative can be used as a model of behavioral health services integration in other PCMHs. Policy implications: It is necessary to involve many different groups in policy development and implementation strategies. These stakeholders should be engaged at all levels and leaders and champions identified and utilized. Specific rationale for the policy needs to be clear and evidence-based. Evaluation needs to be considered in the planning stages of a policy to integrate behavioral health services to gain robust measures that demonstrate policy effectiveness. Research implications: It is necessary to identify expected impact from integration and develop a set of quality metrics and effective evaluation design that will allow scientifically robust conclusions to be drawn. Developing these measures and using them consistently across care systems can help build the evidence of the importance of behavioral health services integration.