Primary care providers can do better at identifying patients with behavioral problems

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The Sandy Hook mass shooting has stirred debate on how we can control guns and reform our mental health system to help prevent such tragedies. We at the Jewish Healthcare Foundation would like to offer this suggestion: Improve behavioral health screening and intervention services in primary care settings, such as doctor's offices and emergency rooms.

Primary care professionals are well-positioned to identify behavioral health issues and provide evidence-based treatment before conditions grow in severity. But only half of patients with depression are identified, and less than half of patients with a behavioral health diagnosis receive any kind of treatment. Only 13 percent receive more than minimal treatment. Referring patients to specialists also presents challenges due to limited access and follow-up.

Proven models exist that help primary-care providers better identify and treat behavioral health conditions among adults. More than 40 randomized, controlled trials have demonstrated that collaborative care is more effective than usual care.

Collaborative care is a systematic approach in which primary care providers are supported by a care manager and a consulting psychiatrist to treat depression and other common mental disorders, rather than sending patients to specialists. This method more than doubles the effectiveness of depression treatment and reduces health care costs.

Here's what a care manager does:

• Helps patients understand mental health diagnoses and treatment options;

• Administers symptom questionnaires at the time of diagnosis and follows up periodically to identify the severity of a condition and the effectiveness of treatment;

• Works with patients to implement care plans, including medication and/or referrals for types of counseling that have been shown to be effective;

• Facilitates communication between patients' primary care providers and consulting psychiatrists who offer treatment recommendations based on guidelines and patients' progress; and

• Delivers "behavioral activation" therapy and other initial interventions to engage patients in activities that alleviate depression, such as exercise.

Such care management services can be delivered cost-effectively by nurses, medical assistants, social workers or health educators who receive the appropriate training and work under the supervision of a primary care provider.

To make evidence-based collaborative services routine in health care settings across the United States, barriers must be removed and incentives instituted.

Providers cite financing as the biggest roadblock. Medical care is largely driven by billing codes, which do not exist for primary care depression management and regular psychiatric consultation -- even though they improve outcomes and reduce costs.

Another barrier is lack of staff time and resources to implement collaborative care services.

Yet another problem is that most providers are engaged in other reforms, such as implementing electronic medical record systems, improving clinical care for other chronic conditions, gathering data for various initiatives, obtaining recognition as "medical home" or "accountable care" organizations and keeping up with ever-changing professional and legal requirements.

Therefore, I would suggest:

• 1) Create new billing and reimbursement models to support collaborative care services. One example is Minnesota's depression-care management system. Certified medical groups receive a monthly payment for each patient who receives evidence-based depression care under the supervision of a care manager, the patient's primary care provider and a consulting psychiatrist.

• 2) Implement quality measures to help make evidence-based collaborative services a priority for providers. One standard measurement is percentage of patients in remission from depression six months after diagnosis. Programs that have used this measure include Partners in Integrated Care, which operates in Pennsylvania and other states and is funded by the federal Agency for Healthcare Research and Quality, and the Minnesota DIAMOND initiative (Depression Improvement Across Minnesota, Offering a New Direction). Other programs use other measures.

• 3) Enhance efforts to educate health care purchasers about collaborative care services. National and state organizations of business leaders, human resources professionals, health insurers and individuals who purchase health care benefits should be among those targeted. These efforts should include suggestions on how to advocate for collaborative care services with payers and providers.

Investments in evidence-based collaborative care services for depression would help build the infrastructure needed to introduce new screening, intervention and treatment services for other types of patients, such as adolescents, and other behavioral conditions. And this, in turn, might help head off potential tragedies like Sandy Hook.


Karen Wolk Feinstein is president and CEO of the Jewish Healthcare Foundation (


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