Technology for advancing behavioral health integration: implications for behavioral health practice and policy.

Behavioral health integration (BHI) encompasses the integration of general health, mental health, and substance use care. BHI has promise for healthcare improvement, yet several challenges limit its uptake and successful implementation. Translational Behavioral Medicine published the Continuum-Based Framework by Goldman et al., 2020 to create comprehensive guidance for BHI within primary care settings. Technology can help advance BHI and provide evidence to support it. This commentary describes challenges and illustrative use cases in which technology solutions help organizations achieve BHI through the Continuum-Based Framework domains. Two rounds of semi-structured interviews with field leaders, practice sites, and technology stakeholders identified key barriers in BHI amenable to technology solutions, applications of technologies, and how they facilitate BHI. Findings showed that technology can facilitate the implementation and scaling of BHI by reducing care fragmentation and improving patient engagement, accountability and financial sustainability, provider experience and support, and equitable access to culturally competent care. Continued efforts by stakeholders to address legacy policy and implementation issues (e.g. incentives, investment, privacy, and workforce) are needed to optimize the impact of technology on BHI.

Behavioral health integration (BHI) combines physical, mental, and substance use care to enhance overall well-being. While BHI offers benefits, it faces challenges. Researchers developed the Continuum-Based Framework to aid primary healthcare centers in implementing BHI. Technology is key to supporting BHI effectiveness. Researchers examined how technology can assist with BHI by interviewing experts and analyzing real-world examples. They found that technology helps healthcare centers address BHI challenges by ensuring comprehensive and equitable care delivery, promoting patient engagement, and supporting healthcare providers. Technology can improve BHI practices over time, but policy, investment, and privacy changes are necessary for optimal integration.

Providing Behavioral Health Care in PACE - A Review of Federal and State Manual Regulations.

OBJECTIVES: Present analysis of the federal and state regulations that guide The Program of All-Inclusive Care for the Elderly (PACE) operations and core clinical features for direction on behavioral health (BH). DESIGN: Review and synthesize the federal (Centers for Medicare and Medicaid Services [CMS]) and all publicly available state manuals according to the BH-Serious Illness Care (SIC) model domains. SETTING AND PARTICIPANTS: The 155 PACE organizations operating in 32 states and the District of Columbia. METHODS: A multipronged search was conducted to identify official state and federal manuals guiding the implementation and functions of PACE organizations. The CMS PACE website was used to identify the federal PACE manual. State-level manuals for 32 states with PACE programs were identified through several sources, including official PACE websites, contacts through official websites, the National PACE Association (NPA), and public and academic search engines. The manuals were searched according to the BH-SIC model domains that pertain to integrating BH care with complex care individuals. RESULTS: According to the CMS Manual, the interdisciplinary team is responsible for holistic care of PACE enrollees, but a BH specialist is not a required member. The CMS Manual includes information on BH clinical functions, BH workforce, and structures for outcome measurement, quality, and accountability. Eight of 32 PACE-participating states offer publicly available state PACE manuals; of which 3 offer information on BH clinical functions. CONCLUSIONS AND IMPLICATIONS: Regarding BH, federal and state manual regulations establish limited guidance for comprehensive care service delivery at PACE organizations. The absence of clear directives weakens BH care delivery due to a limiting the ability to develop quality measures and accountability structures. This hinders incentivization and accountability to truly all-inclusive care. Clearer guidelines and regulatory parameters regarding BH care at federal and state levels may enable more PACE organizations to meet rising BH demands of aging communities.

Behavioral health integration in the Program of All-Inclusive Care for the Elderly (PACE): A scoping review.

BACKGROUND: The Program of All-inclusive Care for the Elderly (PACE) is a community-based care model that delivers collaborative care via an interdisciplinary team to meet the medical and social needs of older adults eligible for nursing home placement. Fifty-nine percent of PACE participants are reported to have at least one psychiatric disorder. PACE organizations (POs) function through an interdisciplinary model of care, but a behavioral health (BH) provider is not a mandated role on the interdisciplinary team. Published literature regarding how POs integrate and provide BH services is limited; however, the National PACE Association (NPA) and select POs have made significant contributions to behavioral health integration (BHI) efforts in PACE. METHODS: PubMED, EMBASE, and PsycINFO were searched for articles published between January 2000 and June 2022; hand-searching was also conducted. Research articles and items involving BH components or programming in POs were included. Evidence of BH programming and initiatives at the organization and national level was summarized. RESULTS: This review reported on nine primary items addressing BH in POs from 2004 to 2022. It found evidence of successful BH initiatives in PACE and identified a gap of published information given an evident need for BH services in the PACE participant population. Findings also indicate the NPA works to advance BH integration in POs with a dedicated workgroup that has produced the NPA BH Toolkit, BH training webinar series, and a site coaching program. CONCLUSIONS: In the absence of PACE-specific BH delivery guidelines and guidance from the federal or state level for PACE programs, BH service inclusion has been developed unevenly across POs. Assessing the landscape of BH inclusion across POs is a step toward evidence-based and standardized inclusion of BH within the all-inclusive care model.

Integrating Behavioral Health and Serious Illness Care in a Post-COVID-19 Environment.

Individuals with serious medical illnesses experience high rates of comorbid behavioral health conditions. Behavioral health comorbidity affects outcomes in serious illness care. Despite this consequence, behavioral health remains siloed from serious illness care. Prior to the COVID-19 pandemic, the authors presented a conceptual model of behavioral health integration into serious illness care. In this column, the authors reflect on this model in the context of the challenges and opportunities posed by COVID-19.

Bridging the Behavioral Health Gap in Serious Illness Care: Challenges and Strategies for Workforce Development.

Comorbidity with behavioral health conditions is highly prevalent among those experiencing serious medical illnesses and is associated with poor outcomes. Siloed provision of behavioral and physical healthcare has contributed to a workforce ill-equipped to address the often complex needs of these clinical populations. Trained specialist behavioral health providers are scarce and there are gaps in core behavioral health competencies among serious illness care providers. Core competency frameworks to close behavioral health training gaps in primary care exist, but these have not extended to some of the distinct skills and roles required in serious illness care settings. This paper seeks to address this issue by describing a common framework of training competencies across the full spectrum of clinical responsibility and behavioral health expertise for those working at the interface of behavioral health and serious illness care. The authors used a mixed-method approach to develop a model of behavioral health and serious illness care and to delineate seven core skill domains necessary for practitioners working at this interface. Existing opportunities for scaling-up the workforce as well as priority policy recommendation to address barriers to implementation are discussed.

A Model to Improve Behavioral Health Integration into Serious Illness Care.

Behavioral health problems are highly prevalent among people with serious medical illness. Individuals living with these comorbidities have complex clinical and social needs yet face siloed care, high health care costs, and poor outcomes. Interacting factors contribute to these inequalities including historical separation of behavioral and physical health provision. Several care models for integrating behavioral health and general medical care have been developed and tested, but the evidence base focuses primarily on primary care populations and settings. This article advances that work by proposing a Behavioral Health-Serious Illness Care model. Developed through a mixed methods approach combining literature review, surveys, interviews, and input from an expert advisory panel, it provides a conceptual framework of building blocks for behavioral health integration tailored to serious illness care populations and the range of settings in which they receive care. The model is intended to serve as foundation to support the development and implementation of integrated behavioral health and serious illness care. The key components of the model are described, barriers to implementation discussed, and recommendations for policy approaches to address these barriers presented.

Evolving Models of Integrated Behavioral Health and Primary Care.

PURPOSE OF REVIEW: Mental and physical disorders commonly co-occur leading to higher morbidity and mortality in people with mental and substance use disorders (collectively called behavioral health disorders). Models to integrate primary and behavioral health care for this population have not yet been implemented widely across health systems, leading to efforts to adapt models for specific subpopulations and mechanisms to facilitate more widespread adoption. RECENT FINDINGS: Using examples from the UK and USA, we describe recent advances to integrate behavioral and primary care for new target populations including people with serious mental illness, people at the extremes of life, and for people with substance use disorders. We summarize mechanisms to incentivize integration efforts and to stimulate new integration between health and social services in primary care. We then present an outline of recent enablers for integration, concentrating on changes to funding mechanisms, developments in quality outcome measurements to promote collaborative working, and pragmatic guidance aimed at primary care providers wishing to enhance provision of behavioral care. Integrating care between primary care and behavioral health services is a complex process. Established models of integrated care are now being tailored to target specific patient populations and policy initiatives developed to encourage adoption in particular settings. Wholly novel approaches to integrate care are significantly less common. Future efforts to integrate care should allow for flexibility and innovation around implementation, payment models that support delivery of high value care, and the development of outcome measures that incentivize collaborative working practices.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care.

BACKGROUND: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both). AIMS OF THE STUDY: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development. METHODS: We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included. RESULTS: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31). DISCUSSION: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes. LIMITATIONS: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care. IMPLICATIONS FOR HEALTH POLICIES: Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts. IMPLICATIONS FOR FURTHER RESEARCH: There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

Health and Aging Policy Fellows: Dementia and Mental Health Policy to Improve Lives of Older Adults.

The Health and Aging Policy Fellows (HAPF) Program has, since its inception in 2008, provided health policy training and mentorship for 113 gerontological professionals across a wide range of disciplines and stages of careers. The fellows' shared passion is the effective engagement of policy levers to improve the lives of older adults. This article briefly describes the HAPF Program and provides a sample of policies with which fellows have been engaged related to dementia and late-life mental health. Approximately 20% of the fellows have specifically addressed one of these areas during their fellowship year. This would be expected, given that 14% of older adults aged 71 and older have a diagnosis of dementia, and although new mental health diagnoses decline as adults age, mental health conditions remain prevalent. Thus, we conclude by describing opportunities for future advocacy and policy efforts in dementia and mental health in the areas of funding, translating science to practice, interprofessional education and innovative models of care for persons with these conditions.

The Case for Severe Mental Illness as a Disparities Category.

Extensive evidence documents that people with severe mental illness have higher rates of morbidity and mortality compared with the general population and receive lower-quality and higher-cost health care. These trends, at least in part, stem from discrimination, exclusion, widespread stigma, and criminalization of individuals with mental illness. As such, severe mental illness should receive formal, national recognition as a disparities category. Such a designation would have multiple important implications in health policy, services and quality research, and advocacy.

Measuring and improving the quality of mental health care: a global perspective.

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology-based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient-centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement-based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.

Health and Aging Policy Fellows Program: Shaping a Healthy Future for Older Americans.

As the size of the elderly population increases, so do the challenges of and barriers to high-quality, affordable health care. The Health and Aging Policy Fellows (HAPF) Program is designed to provide health and aging professionals with the skills and experience to help lead the effort in reducing these barriers and shaping a healthy and productive future for older Americans. Since its inception in 2008, the program has affected not only the fellows who participate, but also the field of health and aging policy. Work needs to be done to sustain this program so that more fellows can participate and sound policies for the elderly population can continue to be shaped and improved. This report describes the HAPF Program, including its background (rationale, description, partners, progress, effect), lessons learned, challenges and solutions, and policy implications.

Bringing Recovery and Consumers' Views Into the Mainstream of Mental Health Quality Measurement.

Health policies in the United States and elsewhere are moving to increase accountability of health care systems and providers for providing high-quality, efficient care and driving application of evidence-based improvement strategies. To support these efforts, a "quality measurement industrial complex" has been created to develop, endorse, and apply quality measures that incentivize these behaviors. Parallel to this development in mental health care is an emerging commitment to include recovery orientation approaches in treating serious mental illness. However, consumers have been only tangentially involved in quality assessment and improvement strategies of the mental health services that they are receiving. This Open Forum aims to advance the conversation about how to integrate recovery into mental health care quality assessment cohesively and how to involve consumers in this process in a more meaningful way.

Prioritizing quality measure concepts at the interface of behavioral and physical healthcare.

OBJECTIVE: Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care. DESIGN: We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures. SETTING: United States. PARTICIPANTS: Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates. MAIN OUTCOME MEASURES: Panelists rated measure concepts on importance, validity and feasibility. RESULTS: The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible. CONCLUSIONS: This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.

Carrots and Sticks on Opposite Sides of the Atlantic: Integration Incentives for People With Serious Mental Illness in England.

Integrating care pathways between primary and specialist mental health care is seen as integral to improving the health of people with mental illness. Multiple integration initiatives have been implemented, but few have tried to integrate care for people with serious mental illness. This column describes two such initiatives in the United States and in England. The two schemes are compared according to the population they target, payment mechanisms, accountability structures, service delivery, outcomes, and lessons learned.

A review of mental health recovery programs in selected industrialized countries.

The concept of recovery has gained increasing attention and many mental health systems have taken steps to move towards more recovery oriented practice and service structures. This article represents a description of current recovery-oriented programs in participating countries including recovery measurement tools. Although there is growing acceptance that recovery needs to be one of the key domains of quality in mental health care, the implementation and delivery of recovery oriented services and corresponding evaluation strategies as an integral part of mental health care have been lacking.

Challenges in the Operationalization of Mental Health Quality Measures: An Assessment of Alternatives.

Interest in measuring the quality of mental health services has increased, but challenges remain in moving from general standards of quality and best practices to specific, implementable quality measures. The International Initiative for Mental Health Leadership identified 656 mental health quality measures and then applied a modified Delphi approach to assess various available alternative quality measures. Panel members considered issues of data source, segmentation, and thresholds. Policy makers and organizations will need to make difficult choices about accountability, purpose, feasibility, and validity in order to operationalize quality measurement. Empirical data can help guide them in this process.

Quality Measures For Mental Health And Substance Use: Gaps, Opportunities, And Challenges.

Following up on its Crossing the Quality Chasm report, in 2006 the Institute of Medicine issued a report that included sweeping recommendations to improve the quality of behavioral health care in the United States. To date, few of those recommendations have been implemented, and there is little evidence that behavioral health care quality has improved significantly over the past ten years. However, the advent of health care reform, parity of insurance coverage, and growing recognition of the impact of behavioral health disorders on population health and health care costs have created new demands and opportunities for expanded and innovative strategies to assess the quality of care for this patient population. We provide an overview of the current state of quality measurement in behavioral health, identify key priorities for measure development, and describe the most important challenges. We recommend a coordinated plan that would boost investment in developing, evaluating, and implementing behavioral health quality measures; conduct research to develop the evidence necessary to support a more robust set of measures; overcome barriers to the improvement and linking of data sources; and expand efforts to build the capacity of the clinical workforce, in partnership with consumers, to improve quality.