At a typical primary care visit, medical providers routinely screen for common illnesses like high blood pressure, diabetes, and high cholesterol. Until recently, though, it was less common for primary care providers to screen or offer treatment for common behavioral health issues like depression, anxiety, and substance use disorders. Considering that mental illness and substance use disorders consistently rank among the top concerns in community health studies in Montana, and the leading causes of disability nationwide, this represents a missed opportunity to improve health in our state. The Montana Healthcare Foundation’s Integrated Behavioral Health Initiative helps primary care practices around Montana seamlessly add services for behavioral health issues into the care they offer.
“Integrated behavioral health” means providing primary care and behavioral health services together in the same place and at the same time.
Mental and physical health are intrinsically connected, and research consistently shows that primary care works best when it focuses on the whole person. The Integrated Behavioral Health Initiative uses a team-based model in which behavioral health issues are routinely screened for during primary care appointments. A person with a positive screening test for a problem like depression, anxiety, or substance misuse can now receive evaluation and appropriate care right away, often during the same visit. Each patient is also assigned a care coordinator to help them manage their treatment and navigate any barriers they may have to getting and staying well, like low-quality housing, hunger, and lack of transportation.
This model of care gives communities a practical way to address their leading health concerns while improving health outcomes and reducing health care costs. Studies show that integrated care improves outcomes for illnesses ranging from diabetes to depression. It reduces health care costs because early diagnosis and treatment can help lower the chances of a medical emergency down the road. It also helps make sure that specialty behavioral health services, which are in short supply in Montana, are available to those who need them most.
“The ability to provide integrated behavioral health is paramount to our role in fully serving our community. Understanding that both the Body and the Mind need to be cared for in a symbiotic fashion – as well as having the resources to do it – helps us furnish everything needed by our patients.”
– Burt Keltner, Prairie County Hospital CEO / Administrator
The Integrated Behavioral Health Initiative seeks to make this highly effective model of care a standard practice in primary care. To develop the Initiative, we listened to health leaders in communities across the state to understand their challenges and needs; we conducted a literature review on the integrated care model; we invested in and learned from community health assessments; and beginning in 2016 we funded pilot projects across the state. Based on what we learned, starting in 2017, we began a full-scale effort to bring integrated behavioral health to communities around Montana, and we contracted with the National Council for Behavioral Health to provide support and technical assistance to our grantees.
By the end of 2019, the Integrated Behavioral Health Initiative had helped integrate behavioral health services into 62 primary care clinics and hosted two statewide summits, which brought providers together to connect with and learn from each other. Together, the clinics in this initiative serve roughly 64% of adults covered by Montana Medicaid. You can learn more in our “First 5-Years Report.”
Practices Implementing Integrated Behavioral Health:
- 10 of the 11 large hospitals
- All 14 federally qualified health centers
- 32 of the 48 critical access hospitals
- 2 of the 7 tribal health departments
- 4 of the 5 urban Indian health centers
“Providence Montana sees the integrated behavioral health model as important to help patients improve access to care, decrease stigma, and promote overall well-being. Incorporating behavioral health into primary care can help us reach a larger population and address a person’s mental health, along with their physical health, in a holistic, collaborative way with a team of professionals to have the best outcome.”
– Joyce Dombrouski, Providence Montana Service Area Chief Executive
Is It Working?
Our early grants are reaching completion, and we are now starting to receive outcome data that will allow us to assess whether this model of care is improving health as we expect. As a start, we are using the Integrated Practice Assessment Tool (IPAT) to measure how well practices are implementing the integrated behavioral health model, and the Patient Health Questionnaire (PHQ-9) to assess whether our grantees are effectively treating depression and related mental health issues.
IPAT uses a scale from one-to-six. A score of four indicates the successful implementation of the major elements of the model. Over the course of a two-year grant, we aim to help each practice achieve at least an IPAT score of four. Of the 26 grantees working on integrated care for over a year, half have already reached an IPAT score of four or higher. The data also indicate that most are continuing to improve.
Alleviating depression and related mental illness is one of the primary goals of integrated care, and clinics measure clinical improvement using the PHQ-9. Of the eight sites that have completed their two-year grants so far, all reported improvement in PHQ-9 scores, and seven were statistically significant. 27% of patients improved by at least 50%, which is better than the rates of improvement reported in national studies of “usual care.” This statistically significant finding provides powerful early validation of the importance of the integrated care model for the health and lives of Montanans.
As more clinics fully implement integrated care in the coming years, we will continue to measure these outcomes and add measures that look at substance use disorders, emergency room use, and other clinical outcomes.
“Integrating behavioral health into the primary care clinics at KRMC has allowed us to provide a valuable ‘real-time’ resource to patients who are struggling with behavioral health illnesses. It has also allowed us to create training opportunities for other staff and providers to better support patients’ behavioral health needs.”
– Rhonda Tallman Kalispell Regional Healthcare Executive Director, Primary Care
The Work Ahead
Our investment in the Integrated Behavioral Health Initiative and the work our partners have accomplished to date has already significantly strengthened Montana’s health care system and offered access to screening and prompt, effective care to people around the state. In the coming years, we will continue to support past and current grantees through ongoing technical assistance opportunities. We will continue to add new practices that see a high share of low-income Montanans that would otherwise have difficulty accessing this care. In the long run, we seek to ensure that integrated care becomes recognized as the norm—as a new standard for primary care that gives providers an effective way to treat Montana’s most pressing health issues and ensures that patients ready access to behavioral health services when needed.