2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Reducing Access Barriers through Collaborative Care

Poor access to behavioral health services remains a significant barrier to care for clients within our current healthcare landscape in the United States. According to Mental Health America, one out of every five American adults with a mental health condition, or about nine million adults, struggles with an unmet behavioral health treatment need. Showing little decline since 2011, inadequate access to services has most often been attributed to silos between primary care and behavioral health systems, a persistent workforce shortage, and inequitable insurance coverage for mental health services. However, amid this current healthcare landscape, Collaborative Care, an evidence-based treatment model for integrated care, has emerged in the last few decades as a clinically effective strategy to fill these treatment gaps on a national scale. Collaborative Care tackles the issue of poor access to care along three fronts: integrating behavioral health and primary care systems, optimizing the expertise of mental health professionals, and inspiring the addition of new medical payment codes.

Founded on the premise of integrated care or the integration of behavioral health services into the primary care setting, Collaborative Care bridges the artificial divide between physical and behavioral health within our current system in order to enhance client access to holistic treatment. Collaborative Care circumvents the challenge of low referral rates to mental health by adding two behavioral health specialists to the primary care environment to create a four-person care team, including the roles of the client, the primary care provider, the psychiatric consultant, and the behavioral health care manager (usually a licensed mental health clinician), and this interdisciplinary, team-based approach has consistently outperformed treatment as usual across a breadth of patient outcomes, including but not limited to increased patient engagement in and satisfaction with care, reduced time to remission, and improved quality of life. Simply put, Collaborative Care brings mental health treatment to the traditional primary care sphere, aptly realizing the common behavioral health catchphrase of meeting our clients where they are at.

Collaborative Care further overcomes the systemic access barrier of behavioral health workforce shortages by embedding strategies to optimize the expertise and reach of mental health professionals. Two critical components of the Collaborative Care model are 1) the flexible provision of mental health services through a combined telephonic and in-person approach to treatment delivery and 2) the augmentation of psychiatric expertise within medical settings through psychiatric consultation. The option of utilizing the telephone as not merely an outreach mechanism but one of treatment delivery allows for the extension of behavioral health care to both individuals that encounter obstacles around in-person treatment, due to factors as varied as mobility issues, financial stress, work schedules, and childcare responsibilities, among others, as well as to under-resourced communities. At Concert Health, this telephonic approach to treatment delivery is particularly leveraged to provide behavioral health services to rural communities across the country, where mental health services did not previously exist, as well as to enhance the reach of Spanish-speaking clinicians to a wider range of geographically disparate populations.

The strategy of establishing the psychiatric consultant role also serves to enhance client access to behavioral health care. Shifting away from the traditional role of the psychiatric provider as a direct practitioner, whose time is generally dedicated to a single evaluation or three twenty-minute medication management appointments per hour, Collaborative Care instead invests in indirect psychiatric consultation. Within Collaborative Care, the main role of the psychiatric provider is to meet with the behavioral health care manager to review the cases of those clients, who are demonstrating insufficient clinical improvement, or in other words, those clients, who are not getting better in treatment. This role transition allows a single psychiatric provider to oversee a caseload of 60-90 clients with the same time investment of one hour per week. Further empowering primary care providers to prescribe psychotropic medications to their client panels with the support of weekly psychiatric oversight, this workflow consequently frees up the scarce resource of psychiatric providers to see clients with more complex behavioral health presentations. Through the implementation of these two innovative strategies, telephonic treatment delivery and psychiatric consultation, Collaborative Care thus creatively expands access to care within the confines of a systemic workforce shortage.

Lastly, Collaborative Care has contributed to improved access to care by successfully inspiring payment reforms amidst an ongoing fight for more equitable insurance coverage for mental health services in the United States. In response to the consistent research literature highlighting Collaborative Care’s superior effectiveness to treatment as usual for behavioral health and the outcomes of state-wide demonstration projects, including those spearheaded by the New York State Office of Mental Health, in 2016, the Centers for Medicare and Medicaid Services (CMS) launched nationally recognized CPT codes (99492-99494), billable under the primary care provider, for Collaborative Care’s value-based approach to behavioral health. Since CMS’s support of the model, commercial payers across the country have also begun to reimburse organizations for these services, and Concert Health has partnered with diverse medical groups, from large hospital networks to private family medicine, women’s health, and pediatric practitioners, to successfully implement this model of care. The systemic endorsement of Collaborative Care by insurance payors not only facilitates the financial sustainability of these services long-term but also carries with it the significant downstream patient benefits of reduced cost and increased access.

According to Mental Health America, of the over 44 million American adults with a mental health condition, 56.4% of people receive no treatment, and among youth with rising mental health needs, the rates are even higher. Driven by antiquated conceptualizations of health that separate the body from the mind, our current healthcare system is characterized by large treatment gaps that undermine people’s efforts to access behavioral health care. Collaborative Care represents one integrated care model that seeks to bridge that divide. Gaining traction among patients, interdisciplinary providers, and payers, the Collaborative Care model allows us to step into a new era of healthcare, where everyone has access to the treatment that they need.

About the authors. Eunice Kim, LCSW, is Director of Training at Concert Health; Virna Little, PSyD, is Chief Operating Officer; and Micaela Mercado, PhD, is Director of Research. All correspondences can be directed to Dr. Virna Little at virna@concerthealth.io.

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