Primary Care and Behavioral Health: An Inevitable Marriage?
Primary Care and Behavioral Health: An Inevitable Marriage? | Integrated healthcare, behavioral health, primary care, accountable care organizations, meaningful use, health reform, Centerstone, Vanderbilt University Medical Center, James Powers, Ben Middleton

Ben Middleton
Experts Say Health Reform May Offer Integration Opportunities

“There’s not one person who would disagree with you that there’s a relationship between the mind and the physical body. Yet the reality is that we don’t practice that way; we practice in isolation.”

Those are the words of Ben Middleton, chief operating officer of Centerstone Tennessee, which operates 63 behavioral health facilities in 20 Middle Tennessee counties. Middleton’s comment is recognition that healthcare today still compartmentalizes services, and for the most part, primary care and behavioral health remain separate enterprises.

Yet a healthcare buzzword these days is “integration,” and the marriage of physical and mental health services may be a notion that’s gaining traction not only among practitioners but payers, as well. In fact, Middleton said Centerstone is “ahead of the curve” when it comes to putting primary care and mental health providers side-by-side in care settings.

Centerstone is in partnership with a pediatric practice in Columbia, as well as Centennial Pediatrics’ locations at Centennial Park, Southern Hills and Clarksville. This partnership means a Centerstone provider is based at each pediatric office and is readily available to treat patients’ mental health needs when and where they arise.

It was a bold experiment three years ago, and the concept has proven itself since. “We’re still growing within the clinics, and those services are being viewed by the medical providers as valuable and important to the care of the patients they are seeing. We are touching the lives of people we would likely not have touched had we not been in that position,” said Middleton, adding the situation has afforded Centerstone the opportunity to introduce patients to additional Centerstone services at its own facilities across the region.

Centerstone Indiana is already in the business of integrated care at federally qualified health centers treating patients of all ages, but so far, Centerstone Tennessee has stuck to the model of integrating behavioral health and pediatrics. Yet Middleton said other primary-care categories are ripe for integration here.

James Powers, MD, certainly agrees. Powers is a Vanderbilt University geriatrician who’s a strong advocate for integration, believing the model offers a number of benefits for all patients, but especially for older ones.

Powers said he’s seen primary care physicians come to the realization through the years that “perhaps as many as 20 to 30 percent of their patients will have some emotional component to their medical illness.” Primary care doctors routinely treat mental and behavioral issues, he noted, usually with medication and mostly with positive results. Yet sometimes the patient needs more — and that’s especially true for depressive disorders more common in the elderly. That’s when integrated service can be a real blessing, offering convenient counseling for patients who perhaps aren’t a mobile as they once were.

Powers said he’s seeing the number of psychologists and psychiatrists specializing in geriatric care rising and working in concert with primary care physicians such as himself. Some of these behavioral specialists even consult in long-term care settings.

“For years in the past, it was hard to get a psychiatrist who would visit a patient in the nursing home, even though that’s where some of our more severely needy, severely depressed, severely agitated patients are,” he said.

Powers also pointed to behavioral health nurses in primary care settings as effective bridges to care.

While acknowledging that there remain “holes in the safety net system,” Powers held out hope that health reform might help with reimbursement of integrated services. “I think the jury is out yet on the uniform benefits of the insurance exchange, whether mental health benefits will have parity with medical, physical benefits. That has been a disparity for years.”

Middleton, too, sees some health reform proposals as door-openers to integration. “Where the growth is really in play is accountable care organizations. There’s a wonderful opportunity,” he said. “There’s an incentive now to come together as providers and really look to building one healthcare initiative with multiple providers in various disciplines to provide care to specifically Medicare and Medicaid populations.”

Middleton added that the “meaningful use dollar” will also help drive integration, allowing providers across the board to electronically “follow a patient as never before.” That available funding – what he called “a good shot in the arm” – is yet another encouragement for behavioral health and primary care to “work in lockstep,” he said.

The latest twist in this primary care/behavioral health movement is the question of whether it’s more effective to offer behavioral health in a primary care setting – or vice versa. In other words, who should follow whom?

“Across the nation, we’re really starting to see behavioral healthcare and physical healthcare partnering in a way where it’s likely and possible that primary care services will be offered in what was formerly a behavioral healthcare setting, as opposed to what we have been doing – putting behavioral healthcare in a primary care setting,” Middleton said. “Now it’s kind of survival of the fittest and who moves first. There’s just such an opportunity now, and I think benefit to the consumer and the patient is going to be the outcome here.”

So, when does Centerstone Tennessee hire its first family practitioner? “Great question!” Middleton responded with a smile. “A lot of homework, and I mean that literally, has to be done. But I can assure you that we have started that process.”