Approaching mental illness and substance use disorders as conditions that should be screened for and treated in the primary care system.

“Integrated Behavioral Health” or “IBH” is a health care approach that treats mental illness and substance use disorders (SUD) as chronic conditions that should be screened and treated appropriately within the primary care system. It gives primary care practices new and more effective tools to address these behavioral health conditions, which is a top priority for communities across Montana. Because untreated, mental illness and SUD also adversely affect outcomes of chronic illnesses such as diabetes and high blood pressure, implementing IBH provides a powerful tool for primary care to improve health outcomes across the board.

Numerous studies have demonstrated that IBH can improve health outcomes and generate associated cost savings. For example, in a 10-year study, Intermountain Health in Utah demonstrated substantial increases in depression screening and treatment and increased adherence to diabetes care. Intermountain also found substantial reductions in emergency department visits and hospital admissions (23% and 11% respectively). Ultimately, over the 10-year period, Intermountain realized a savings of 3% (or $157 million) through reductions in overall costs to the health system.

In order to develop our understanding of behavioral health challenges in Montana, we commissioned a report that provided a baseline assessment of benefits, challenges, and opportunities for IBH in the state. We also met extensively with community mental health centers, substance use disorder treatment centers, hospitals, federally qualified health centers (FQHC), policy leaders, and advocacy groups. We found that very few primary care and behavioral health practices were implementing IBH.

Based on our findings, we decided to form an IBH steering committee, comprised of health leaders throughout the state to provide strategic guidance and development of the nine core elements of IBH, which provide a critical framework for implementing IBH in Montana. We also found opportunities to support the implementation of IBH through health education, which led to our investments in curriculum development and training. Finally, since our survey respondents posed important questions regarding IBH financing models, reimbursement, and coding, we developed resource guides for administrators, clinicians, and billing staff to help maximize revenue and fully account for the services provided. We have also found that organizations that are able to implement IBH generate a net income and demonstrate cost savings by reducing emergency department and inpatient admissions.

As part of this initiative, we found willing partners with large and small hospitals. Deb Anczak, CEO of Livingston HealthCare, provided the following reason that her health care system (one of the larger critical access hospitals in the state) is implementing IBH:

Behavioral health services were identified as a top priority in our community and we felt like the hospital needed to provide more leadership. Locally as well as nationally, there is a shortage of behavioral health workers, so we looked to IBH to effectively utilize existing resources and create access for our community and stretch thin resources. In addition, the IBH model has improved continuity of care, earlier and improved detection, and referral for patients with behavioral health concerns, and it allows us to look at the well-being of the whole patient.Deb Anczak,
Livingston HealthCare CEO

IBH provides a fantastic opportunity for hospitals and health centers to enter into formal partnerships with behavioral health organizations and maximize existing community resources. We found that these partnerships are rare but can be very successful. Intermountain (a behavioral health organization) and PureView Health Center (an FQHC), provide a notable example of how two organizations can leverage each other’s strengths and provide IBH through a partnership.

The science is in. IBH creates the rich medium for enhanced growth and practice with a multidisciplinary lens upon addressing client’s needs, optimizing outcomes, and achieving efficiencies. In our system of very limited resources, we believe strategic unions accelerate organizational learning, culture change, and strategic investments into integrated systems of care rather than yesterday’s silos.Jim Fitzgerald,
Intermountain CEO

Finally, primary care providers have a tool in their belt for helping patients with behavioral health and physical health needs. An FQHC and behavioral health organization collaboration makes perfect sense for IBH. Their skills and expertise and our skills and expertise under one roof meeting the patient’s needs as one care team.Jill-Marie Steeley,
PureView Health Center Executive Director

To support the transformation of the delivery system, in 2016, we launched an initiative to focus on planning for and implementing IBH. This two-pronged approach allows organizations to either dip their toe into the water by going through a planning process or jump in head first and begin implementation. As part of the initiative, we partnered with the Montana Department of Public Health and Human Services (DPHHS) to jointly fund training, technical assistance, learning communities, and webinars. Investing and collaborating with DPHHS demonstrates a shared vision and strategy for an integrated system, as well as the alignment of values and resources.

Our core strategies include:

• Fully implement IBH in the FQHC network.
• Implement IBH in large hospital’s primary care networks.
• Support critical access hospital primary care practices that serve our rural and frontier counties to implement IBH through partnerships with affiliates and health networks.
• Make targeted IBH investments in other settings, such as university and college student health clinics, tribal health departments, urban Indian health centers, and other nonprofit primary care practices.

IBH is a cost-effective approach to aligning and strengthening existing health services and resources in a community. Communities across Montana have clearly identified behavioral health as a top community concern. Implementing IBH offers a way to catch these conditions early and improve the effectiveness of primary care overall, rather than waiting until individuals are in crisis and end up in the emergency room.