The document discusses barriers to integrating behavioral health and primary care. Some key barriers include different conceptual models between primary care and specialty mental health care, lack of provider time and training, and organizational and financial barriers between practices. Steps to improve care include adopting a problem-focused approach in primary care, clarifying roles and responsibilities between primary care physicians and behavioral health specialists, and facilitating better communication and coordination between providers.

1. Behavioral Health and Primary Care David Eisenman MD and John Luo MD Departments of Medicine and Psychiatry

2. Behavioral Health and Primary Care Understand barriers to integration of behavioral health and primary care Implications in caring for patients Steps to improve care

3. Barriers between Primary Care and Behavioral Health Historical Conceptual Patient Provider Practice Health Plan Population/Community/Policy

4. Conceptual Issues: Primary Care vs. Mental Health Specialties Different perspectives Majority of literature comes from specialty (and often tertiary) care settings Diagnostic systems such as DSM-IV often seen as too complex and specialty-focused Need to adapt strategies and approaches to the primary care setting (e.g., problem vs. DSM focus) Linkages between and among various systems (SUD, social services, consumer directed) , etc.)

5. Provider Barriers Time Interest Tools Training

6. Practices Issues Organization does not enhance patient-provider interactions & promote successful outcomes Who is responsible for care? Limited communication and teamwork between primary care and mental health specialties How should care be provided? Consultative? Collaborative? Integrated? When should care be provided? Lack of longitudinal focus

7. WHO Responsibility for Care PCP BHS Assessment/diagnosis Evaluate preferences Initiation of referral Initiation of medication Psychoeducaton/Counseling Longitudinal follow-up/monitoring Medication follow-up (including labs) 2nd level or adjunctive medications Link with community resources

8. Referral Consultative Care Collaborative Care Integrated Team Independent Autonomous (PCP) Autonomous (MHS) How

9. When Continuing Care Short-term Management Diagnosis/ Assessment Risk Factor Identification/ Prevention

10. Plan Barriers Separation by carve-out Practitioner affiliation/communication/incentives Confidentiality/HIPAA

11. Health Plans Money Flow and and Communication No risk Health Plan A. Indemnity Model Mental Health Plan B. Carve-out Model No Shared Risk Primary Care Provider Mental Health Specialist Legend Primary Care Provider Mental Health Specialist High communication Low communication Money Flow

12. Primary Care Tasks Assessment/diagnosis Intervention/management Communication with patient Communication with mental health specialist Develop strategies that are: Patient specific Problem focused Time phase sensitive Sector/role relevant Developmentally appropriate

13. “ Systems of care that force the separation of “mental” from “physical” problems consign the clinicians in each area of this dichotomy to a misconceived and incomplete clinical reality that produces duplication of effort, data, and ensures that the patient cannot be completely understood” Institute of Medicine, 1996