Weaving Together Mental and Physical Health Care Outside the Safety Net

Mental health issues commonly present in primary care. Twenty percent of primary care visits relate to mental health, and 79% of antidepressants are prescribed by primary care providers (PCPs). However, many PCPs do not have the time and expertise to diagnose and treat mental illness. In addition, only 3% of psychiatrists and psychiatric nurse practitioners coordinate care with PCPs.

Benefits of Integrated Care

A growing body of evidence shows that integrating mental health into primary care services can increase mental health care access and coordination, improve patient outcomes, and reduce health care costs, particularly for those with co-occurring chronic conditions. Traditional safety-net providers have made strides toward offering mental health services in tandem with physical health services. In part this integration has been supported by payment systems. Yet most people covered by Medi-Cal, California’s Medicaid program, receive care outside the safety net, where integration has not yet taken hold.

This paper focuses on opportunities to support practice change in primary care to deliver integrated care outside the safety net. It is the result of research and interviews conducted between February and May of 2019 with 15 people at different types of entities, focused on both challenges and strategies for integration outside the safety net.

Interviewees included payers (commercial, Medicare, and Medi-Cal plans), managed behavioral health organizations, and physical and behavioral health providers (independent practice associations, medical groups, and integrated delivery systems). (See report appendix for complete list of interviewees.) The paper was also informed by three provider interviews conducted in late 2018 about adoption of the PHQ-9 depression screening questionnaire, as part of developing a standardized measure set in partnership with the Integrated Healthcare Association.

Collaborative Care Model

The Collaborative Care Model, an evidence-based care model, came up in many of the interviews, and is thus one focus of this paper. Notably, this paper does not discuss the integration of primary care into specialty mental health care clinics, nor the integration of financing of specialty mental health care into managed care.