NHMH NO HEALTH WITHOUT MENTAL HEALTH A 501(c)(3) non profit   San Francisco - Washington DC Director’s blog


Previously NHMH has chronicled the experiences of various private or non-governmental healthcare systems (Mayo, Montefiore, Pittsburgh Regional Health) implementing  behavioral healthcare in their primary care sites.  Now for the second time, following the State of Washington example in the MHIP program, we examine the experience of state-wide integrated care.  In this case, the State of New York, which early on recognized the effectiveness of evidence-based integrated care, and has found ways to successfully undertake state-wide integrated care implementation.

New York State (NYS) intends to make behavioral health integration (BHI) in primary care an embedded part of their state medical policy and practice goals.  Their effort can be divided into two sequential chapters:  initially, a 2 and ½ year federal Graduate Medical Education (GME) grant that funded the Hospital Medical Home Program which program ended in December 2014.  Followed by a Medicaid supplemental payment mechanism, to support the integration implementation program and aimed at full implementation of Collaborative Care throughout the State.  This second chapter will diversify the participating primary care clinics beyond primary care resident training sites (part of the GME grant) to include federally qualified healthcare centers (FQHCs), as well as independent physician associations (IPAs) as participating prmary care sites.   For this second phase, the NYS Office of Mental Health is procuring an independent third party to provide an economic analysis to assess cost outcomes.

The first segment, called the NYS Collaborative Care Initiative (NYS-CCI), ran from July 2012 through December 2014.   It represented perhaps the largest state sponsored behavioral health integration in primary care to date --  implementing the evidence-based Collaborative Care (CC) model of care across 19 academic hospital medical centers and 32 primary care clinics which served over one million patients.

The NYS-CCI succeeded in implementing the required elements of full integration of depression care in primary care, and achieved positive health outcomes. It demonstrated significant clinical improvements in patient depression care and revealed important lessons learned in the process.  That knowledge and experience provides a platform to generate further state government and private uptake of BHI in primary care, state-wide and nationally.

The purpose of the NYS-CCI project was to detect and manage depression care in primary care, utilizing the University of Washington-developed Collaborative Care model.  This care delivery innovation involves universal patient depression screening via the validated, standard PHQ-9 screening tool, diagnosis of depression, enrollment of patients into an integrated, evidence-based care plan,  monitoring and tracking the patient’s progress via web-based technology, and focused quality improvement efforts all directed towards depression symptom improvement or condition remission.

The State of New York has historically been a leader in advancing mental health care.  It realized early on that despite enormous scientific data proving the effectiveness of the Collaborative Care model of care, nonetheless wide-scale implementation across the country has been limited.  The NYS-CCI project has achieved the dual results of not only underscoring once again the underlying clinical efficacy of CC, but also revealing  the barriers to, and needed solutions for, widespread scaling of this effective urgently needed primary care delivery model to address patient needs.

The first segment involved a federal Graduate Medical Education grant such that BHI occurred at primary care residency training sites.  This is logical given the need to train the next generation of PCPs in innovations in primary care practice.  A second distinctive characteristic of the NYS-CCI was that it involved partnership and close cooperation between two state entities, the NYS Department of Health and the NYS Office of Mental Health, working together to determine whether CC was feasible, effective, sustainable and scalable in their state.

While adapting new care processes was found to be critical, training and ongoing supervision and recruiting and retaining the healthcare team staff, was also found to be essential.  The UW AIMS Center provided technical assistance along with New York’s Institute of Family Health. Quarterly reporting from the participating clinics was required on the project deliverables, listed below:

These required reporting metrics allowed NYS OMH to assess fidelity to the core components of CC, without which patient health outcomes could not be achieved. The data on deliverables was collected by the NYS Department of Health.

In all these measures, the project showed significant improvement across the duration of the GME grant. Interestingly, while initially many primary care clinic sites said they had some depression screen in place, in fact less than half (46%) were shown to actually screen patients for depression.  By the grant’s end, 85-100% of patients were being screened for depression at the project sites.  The PHQ-9 screening tool had become standard practice in the clinic sites much like taking a blood pressure reading.

Further, as the number of patients with positive depression screens increased, the number of those diagnosed with depression increased over the grant period, indicating fewer patients were falling through the cracks.  PCPs were becoming more comfortable diagnosing depression and treating their patients for this condition.  The rate of diagnosis of depression among patients with positive screens increased from 44% to 66% from start to end, as an average across clinics.  The patients diagnosed who were enrolled in CC, went from 32% to 43%.  6,000 patients were enrolled in CC by the final quarter of the project, a three-fold increase from the previous year.  

As clinics became familiar with CC, they also improved their patient engagement and retention in care.  PCPs, importantly, reported that CC is very helpful in being  “a pragmatic approach” and they appreciated the psychosocial support given their patients, and wished to continue this care approach. Anecdotally, patients reported very high levels of satisfaction with CC.

By the project end, 45-46% of patients in treatment for 4 months improved their PHQ-9 scores to <10 (equivalent to almost no depressive symptoms or mild symptoms).

What can the New York State Collaborative Care Initiative experience tell us?  

  1. The challenge facing practitioners, both medical and BH, to learn new roles and skills, is fundamental and formidable.  This reality needs to be appreciated and addressed by interested care systems from the start.  Still, it can be done with proper planning.
  2. The current macro environment of primary care practice is in tremendous flux;  nonetheless as primary care practices are adequately supported (by ongoing TA), they are able to detect and treat depression in primary care patients - patients that PCPs had known for years to be ill  but had never before been screened, diagnosed or effectively treated.
  3. A core component to realize successful CC implementation, is the model’s financial sustainability.  Providers need to be able to count on the certainty of sustained permanent payment for the evidence-based CC care services they deliver.  Two promising payment mechanisms are:  shared savings with behavioral health quality measures, and a case rate (or capitated per enrolled patient per month) provider payment where significant pay-for-performance is included.
  4. Regulatory and licensing burdens make scaling of CC very difficult.  Approaches must be found to reduce overly onerous administrative burdens, such as licensing requirements for both departments of health and mental health.
  5. Providers’ capacity to respond to multiple third party quality improvement data requests is challenging, and ways to address this challenge need to be developed.
  6. A core requirement of CC implementation is the need for continued support for training and supervision of the healthcare team, including recruitment and retention, especially the care manager and psychiatric consultant.

With the success of the NYS-CCI, New York State health leaders plan to continue this journey of BHI in primary care, buoyed and sustained by  “the enthusiasm that comes from experiencing success in implementing an effective treatment that patients like.”*

*NYS CollabCare Init 2012-2014  Psych Quart Sederer etal 6.2015.pdf