A consensus has formed across five large health systems: Clinical integration of behavioral health is instrumental to improving outcomes across specialties and reducing overall utilization.
Elicia Bunch, vice president of behavioral health at Aurora, Colo.-based UCHealth, told Becker’s true clinical integration starts with dismantling the idea that behavioral health is a separate lane.
“Integration isn’t about sharing space. It’s a shared perspective that effective and comprehensive healthcare includes mental health,” she said. “It’s about shared care plans. It’s about shared data within the medical record and really shared accountability for outcomes.”
Ms. Bunch described a model in which behavioral health clinicians are woven into every care discipline.
“When a patient’s depression, anxiety, substance use or trauma is addressed alongside their medical conditions, we really see better outcomes for both,” she said. “Episodic models where behavioral health is treated separate from medical risks intervening too late, fragmenting care and straining emergency departments and inpatient settings”
At UCHealth, the infrastructure backing that vision includes a virtual behavioral health center that gives patients 24/7 access to behavioral health clinicians.
Here is how four other health systems are further integrating behavioral health and clinical care.
Mass General Brigham: Embedding alongside medicine and surgery
At Somerville, Mass.-based Mass General Brigham, clinical integration has deep institutional roots and is expanding in new directions as leaders move Mass General, Brigham and Women’s in Boston, McLean Hospital in Belmont, Mass., and other sites toward a more unified behavioral health service line.
“There’s always been a tradition, both at Mass General and the Brigham, of psychiatry serving departments like medicine and surgery and having faculty embedded in departments and providing critical consultation services to those departments,” said Maurizio Fava, MD, chair of psychiatry at Mass General Brigham. “This tradition, which was established in the 1930s, has persisted over time.”
That includes medicine-psychiatry units, which are specialized inpatient environments designed to care for patients with significant medical and psychiatric comorbidity simultaneously.
“Some psychiatric patients don’t simply have psychiatric illnesses. They have significant medical comorbidity, and when they need to be hospitalized, they need to be hospitalized in what we call med-psych units, meaning units that are comfortable in delivering both acute medical and acute psychiatric care,” Dr. Fava said. “Those med-psych units are by definition tertiary care, and it’s very hard to see that level of care outside of [academic medical centers] that can have multi-disciplinary teams serving the patients.”
Bernard Jones, vice president for behavioral and mental health and the psychiatry department at Mass General Brigham, said the system’s clinical integration has become self-reinforcing.
“Without prompting, two of our most vocal advocates for investments in psychiatry are leaders of medicine and surgery, not because of the adjacency of those services, but how integral they are,” he said. “It isn’t that we need to knock on people’s doors to remind them about our value, but they know it from the care that they’ve been delivering for years.”
He pointed to transplant and cancer care as areas where that dynamic is especially visible.
“Transplant is a perfect example,” Mr. Jones said. “We think about the procedure itself, but our clinical leaders on the transplant center side understand the psychiatric and psychological implications of that transplant for the patient and their families, and so they’re actively seeking our services to embed in. In cancer, I don’t even need to explain to you the psychiatric and psychological implications of that.”
Dr. Fava noted that a dedicated Center for Psychiatric Oncology has been established within the MGB Cancer Institute, a signal of how seriously behavioral health is taken within the broader clinical enterprise.
Providence: The importance of screening
At Renton, Wash.-based Providence’s Well Being Trust, CEO Arpan Waghray, MD, has focused on making behavioral health a standard part of clinical encounters across the system’s almost 300 primary care clinics in seven states.
“When we’re trying to care for patients across primary care, pediatrics, OB, cancer care settings, we’re treating every patient as a whole person, and being able to meet their needs as a whole person is fundamental to our mission,” he said.
Providence uses two integrated care models: collaborative care and the patient-centered behavioral health model. Both embed psychologists directly into primary care, obstetric and pediatric clinics, he said.
“What happens is the primary care doctor is visiting with a patient, and through the course of the visit, they have a conversation about something that might be hard. It’s not only necessarily behavioral health — it could also be health behaviors,” Dr. Waghray said. “These very well trained psychologists in primary care clinics are able to help the patient navigate some of those terms, help them adapt, and help them get to a much better place where they’re able to stay with the treatment plan and get the health outcomes needed.”
In some markets, psychiatrists join primary care physicians for informal peer learning sessions.
“In addition to caring for the patient, they’re always there in the clinic, interacting with each other. They go for brown bag lunches, where they talk about the most common reasons why patients are referred, and it’s not an academic presentation, but it’s a very practical discussion,” Dr. Waghray said. “When you talk about integration, it’s much more than just having a psychiatrist or social worker available in a model across the city. They truly become a part of the care team.”
That integration extends to perinatal care, an area Dr. Waghray said remains underserved.
“Perinatal mood and anxiety disorders are the most common complication of childbearing, more so than gestational diabetes,” he said. “Yet every new mom gets a glucose test, but every new mom does not get an Edinburgh depression rating scale. That should change.”
Providence’s model addresses this gap by embedding screening into well-baby visits rather than waiting for an OB appointment. New mothers who might be struggling with clinical depression might not have their first OB appointment for eight to 12 weeks, leaving them to suffer in silence, he said.
“What we do know is that they all will come in for their well-baby visit at week four,” Dr. Waghray said. “When the individual comes for their well-baby visit, we work with the pediatrician to incorporate screening tools, and then having a therapist available if they were to score high to get them seamlessly connected, is a core part of integration.”
The impact of getting integration right showed up in depression treatment outcomes. Over 18 months, Providence moved from the 25th percentile nationally to the top quartile on the HEDIS depression treatment response metric across all its clinics — a shift Dr. Waghray attributed directly to the integrated model.
“The level of improvement at that scale for 200-odd clinics across seven states could not happen only with a few behavioral health providers,” he said. “It had to be true integrated models.”
Sentara: Building a whole-person care model in real time
At Norfolk, Va.-based Sentara, vice president of behavioral health services Tracey Izzard is leading what she describes as a true horizontal service line.
“We’re combining our health plan, our ambulatory and our acute care, and we are embedding behavioral health along the way,” she said. “We are embedding them alongside medical and physical healthcare. We’re also making sure we are collectively addressing social determinants of health, so that you’ve got your full population health initiatives going at once.”
On the ambulatory side, Sentara has expanded patient health questionnaire screening to every specialty, not just primary care.
“You go to your orthopedic doctor and you’ll get a PHQ,” Ms. Izzard said. “You go to the cardiologist and you get a PHQ, and then they can engage and refer on to behavioral health if necessary.”
In the emergency department, Sentara has launched buprenorphine treatment for opioid use disorder patients when appropriate and is now moving to expand that to medical floors, incorporating a whole-person care approach.
The system is also developing a transition of care coordinator role; these staff would be stationed on medical floors and aim to address a stark reality: Patients admitted for medical conditions often have co-occurring behavioral health needs that go unaddressed. The goal is to reduce avoidable readmissions, decrease length of stay and maintain days in the community.
“It’s a core strategy,” Ms. Izzard said. “It’s not a service line expansion. It really is a philosophy that behavioral health could and should be embedded into all of the components of healthcare. It’s taking a different approach that behavioral health belongs here in the treatment planning phase, even if somebody’s in the hospital for a broken leg.”
Geisinger: Building integrated virtual care at scale
At Danville, Pa.-based Geisinger, which serves a 23-county rural footprint, clinical integration has required building a virtual backbone, said Dawn Zieger, vice president of psychiatry and behavioral health.
Health system leaders there have focused on combining in-person integrated care providers with virtual clinicians organized around specific communities, ensuring patients see providers who know their geography, their systems and their neighbors.
“We believe from a workforce strategy perspective that that mix of integrated care and virtual care is going to be our path forward to continue to build capacity in the communities that need us,” Ms. Zieger said. “We took a concept from Harvard Business Review and we kind of turned it on its head. The concept is to organize resources around the patient, and so a psychologist, a psychiatrist, a social worker will all be serving that same community, whether they’re in person or whether they’re virtual.”
On the specialty integration front, the system has found particular success in oncology, where introducing the behavioral health provider before the first appointment dramatically improves patient follow-through.
“[Oncology has] been able to really integrate in practice and be able to be there to initiate that conversation as they’re being referred,” she said. “That makes a huge difference with show rate when you’re able to introduce that provider prior to the appointment.”
The system also has learned that virtual integration into specialties falls short without in-person relationship building.
“We tried virtual integration with specialties, and we’ve done in-person integration,” Ms. Zieger said. “This really is important to be in person, to have that warm handoff, to have the team know each other.
This story is the third and final installment for Becker’s series covering what behavioral health integration looks like financially, operationally and clinically.
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