When a patient calls for an appointment at the new Carolina Advanced Health practice in Chapel Hill, N.C., a questionnaire is sent by email that screens for depression and other factors that may affect health status.

Depending on the score, the patient receives a more elaborate depression screen at the time of the appointment, counseling from an on-site behavorial specialist, care management to help identify and manage psychosocial problems at home and support in accessing other resources in the community, if needed.

The practice just opened in December, but when its first-year data is analyzed, Director Thomas Warcup, D.O., expects to see that the proactive approach to behavioral health issues translates into fewer emergency department visits and inpatient days — and healthier patients. "We firmly believe that behavioral health is intertwined in people who have chronic medical conditions, and that treating both allows us maximum success," he says.

Integrating behavioral and medical health services is just one of several approaches that forward-thinking providers are taking to address America's growing mental health and substance abuse problems. While the strategies differ, they all involve collaboration among various stakeholders that are designed to increase access to behavioral health services while holding down the overall costs of patient care.

The transformation of the nation's health care delivery model provides an opportunity to increase mental health and substance abuse treatment, says Bruce Schwartz, M.D., deputy chairman of the department of psychiatry at Montefiore Medical Center in New York City. "In the world we are going into — with health homes and accountable care organizations — it is imperative that there be an alignment of the goals of providing high-quality, empirically validated and efficient care," he says. "That becomes very important as we deal with how the health system is evolving."

H&HN's editorial team discuss new articles on the growing linkages between medical and mental health services, the rise of hospital engagement networks and growing concerns about alarm fatigue among clinicians. Running Time: 4:26.

Lay of the land

Although behavioral health disorders — which include mental illness, substance abuse and such addictive behaviors as compulsive gambling — have been treated as an afterthought in America's care delivery system, they account for one of the nation's biggest health care burdens.

Nearly half of Americans will develop a mental illness and 27 percent will suffer from a substance abuse problem during their lifetimes, according to the American Hospital Association's "TrendWatch: Bringing Behavioral Health into the Care Continuum," released in January. In any given year, 25 percent of the American population experiences either a mental illness or a substance abuse problem.

Frequently, behavioral health problems occur in tandem with medical problems. A recent Robert Wood Johnson Foundation report  found that 17 percent of American adults suffer from both mental health and medical conditions each year. Those coexisting problems exacerbate one another, making them difficult — and expensive — to treat.

Most of the higher costs associated with comorbid mental health and medical conditions come from treating the medical condition, rather than the behavioral health issue. That's because patients who suffer depression or other mental health conditions are less likely to comply with treatment recommendations than their peers who have no behavioral health problems. And they are more likely to be readmitted to the hospital after a discharge.

Treating a chronically ill patient with comorbid depression costs $560 more per month than treating a patient with the same chronic disease but no depression, according to the Robert Wood Johnson report. Despite how much economic sense behavioral health care makes, a number of obstacles stand in the way.

For starters, treatment capacity for behavioral services is in critically short supply and getting worse. The National Alliance on Mental Illness  reports that more than half of all U.S. counties have no practicing psychiatrists, psychologists or social workers — and only 27 percent of community hospitals have an inpatient psychiatric unit.

Meanwhile, many states have cut their mental health budgets dramatically, and that trend is intensifying. States are closing their government-funded psychiatric hospitals and reducing payment rates for mental health providers and residential treatment.

Increasing capacity via telemedicine

South Carolina has a serious shortage of behavioral health providers, with only about 10 to 12 psychiatrists per 100,000 residents. That shortage is being countered by a statewide telemedicine program that connects patients with psychiatrists for emergency diagnosis and treatment decision-making.

Some 25 hospitals are participating in the program, which started in 2009 as a joint effort of the South Carolina Department of Mental Health, the University of South Carolina School of Medicine, the South Carolina Hospital Association and Medicaid. Since then, more than 9,700 telepsychiatric consults have occurred via videoconferencing available around-the-clock in hospital emergency departments.

"It has gone beyond our expectations," says Meera Narasimhan, M.D., chairman of the department of neuropsychiatry and behavioral science at the medical school and director of research initiatives for the state's mental health department.

The program addresses a problem that most hospital leaders know well: psychiatric patients boarded in the ED while hospital staffers frantically search for an inpatient bed. Between 2006 and 2009, the number of ED visits nationwide involving a primary diagnosis of mental illness or substance abuse increased by 19 percent to more than 5 million visits, according to the "TrendWatch."

Through telemedicine, patients can be connected quickly to a psychiatrist for a visit that typically lasts 30 to 45 minutes. After the session, the clinician electronically transmits notes about the diagnosis and a signed consultation recommendation to the ED physician, allowing the patient to be discharged, admitted to an inpatient bed or transferred to another facility.

"So, you don't end up clogging the ER bed, which could be used for a person who is having a medical emergency such as a heart attack," Narasimhan says.

A comparison of care delivered at EDs showed that telepsychiatry reduces admissions, reduces length of stay for patients who are admitted and increases compliance with recommendations for outpatient follow-up care.

In South Carolina, the admission rate for patients triaged by telepsychiatrists was 10 percent, compared with 18 percent for patients receiving standard emergency care, Narasimhan says. Meanwhile, the length of stay for admitted patients was four days, compared with five days for patients who did not have access to telepsychiatry.

"And, if you look at the cost savings, that's mighty significant between the two groups," she says. "It is about $2,500 in cost savings per patient who is seen via telehealth."

The program appears to increase the amount of post-discharge care — which may decrease the number of ED visits in the future. The proportion of patients receiving outpatient follow-up within 30 days of their emergency teletreatment was 51 percent, compared with 28 percent of patients in a control group.

Those numbers convince Narasimhan that her maxim — if you do it alone, you go faster, but if you do it together, you go further — is right. "This is a great example of that. Public, private and academic partners came together, and we made it work," she says. "We have not only made mental health services available to patients who come to the ER, but we also have made a very strong business case that this can have a great deal of cost savings down the road. For a hospital administrator, it makes perfect sense."

Collaborating to reduce readmissions

Meanwhile, a collaboration between a health plan and eight psychiatric hospitals in Florida led to a significant decrease — from 17.7 to 10.4 percent — in readmissions over a two-year period.

Once each quarter, officials from Amerigroup Florida meet with hospital executives to show them utilization data and discuss strategies for improvement. "We have a lot of the same goals that the insurance companies have, such as reducing unnecessary care, decreasing recidivism and decreasing inpatient stays," says Jonathan Smith, director of quality management and health information at Personal Enrichment through Mental Health Services, an inpatient facility in Pinellas Park, Fla.

The initiative started in 2008 when Amerigroup Florida examined utilization data for the 47 hospitals in its network to identify those with higher-than-average readmission rates. It began meeting quarterly with the hospitals that had the highest readmission rates.

"Obviously, they don't have that type of data, and they are very interested in how they stack up to other facilities," says Diane Smeltzer, R.N., vice president of health care management services for Amerigroup.

Amerigroup shares the comparative readmission data and three other data points for patients treated at a given hospital: ED use, and the rates of both 7-day and 30-day outpatient follow-up visits. Taken together, that information often shows the need for better discharge planning to make sure patients get the outpatient care they need.

To improve its discharge planning, PEMHS developed a "bridge" program that helps transition its patients from inpatient to outpatient care. Its staff identifies inpatients who would benefit from outpatient therapy and, on the day of discharge, PEMHS provides at least one session of one-on-one counseling to prepare the patient for outpatient treatment.

"That helps on multiple levels," Smith says. "It helps to improve the compliance of these clients in going to their outpatient appointments. It also meets our statutory requirement to have clients seen within seven days upon discharge."

Amerigroup is one of the private insurers that reimburses PEMHS for the bridge service. An analysis of data for a 17-month period ending in September 2010 found that patients who received the day-of-discharge visit had 21 percent fewer readmissions than patients who did not.

"Because we did see some positive outcomes, we're working on growing that program now with many of our other providers," Smeltzer says.

Integrating care, North Carolina-style

The big goal, of course, is to keep patients out of the emergency department and the inpatient bed, whether it is a behavioral health issue or a medical issue that sends them there. Integrating behavioral health services into primary care may be the best way to do that, Schwartz says.

One reason: Many patients who have psychiatric or substance abuse disorders are reluctant to seek specialty mental health services; therefore, providing access in the primary care setting increases the likelihood they will be treated.

Beyond that, treating behavioral health problems has been found to improve outcomes for patients' chronic medical conditions.

For that reason, Schwartz says emerging care delivery models that hold providers accountable for the total costs of patient care encourage them to address behavioral health problems. "It's a very important model, and I think it becomes a model that more and more health systems and practices are going to decide to implement," he says.

Carolina Advanced Health is a good example. The primary care practice, which opened in late 2011, is jointly owned by University of North Carolina HealthCare and BlueCross BlueShield of North Carolina.

The practice serves employees covered by the state health plan and BCBSNC members who have diabetes, high cholesterol or high blood pressure, asthma, chronic obstructive pulmonary disease, heart disease or congestive heart failure.

About 30 percent of patients have a behavioral health issue, Warcup says. A much smaller percentage screen positive for depression, he says, but if a patient has any psychosocial issue that affects medical well-being, he or she is referred to the on-site behavioral health specialist.

"We're finding that having an embedded behavioral health person makes it far easier," he says. "Some of the barrier tends to be the preconceptions of a patient toward behavioral health therapy, and whether or not they need it. When we focus on that as a piece of the overall care for someone with chronic illness, it is better received."

Integrating care, Minnesota-style

In Minnesota, depression treatment is integrated into 60 primary care practices that participate in a disease management program called DIAMOND, or Depression Improvement Across Minnesota Offering a New Direction.

When a physician diagnoses major depression or dysthymia — a chronic low mood that is less severe than major depression — the patient is referred to an on-site behavioral health care coordinator, who enters the patient's information into a depression registry and performs an intake interview.

That information is shared with the on-site psychiatrist, who advises the coordinator and primary care physician on the patient's treatment. Some patients are referred for psychotherapy or prescribed medication; all are contacted each week by a behavioral specialist who conducts a depression screen.

"For the people enrolled in DIAMOND, it's very hard to fall through the cracks unless you intentionally do not answer phone calls," says David Katzelnick, M.D., chair of the division of integrated behavioral health for the Mayo Clinic.

That close monitoring pays off: Katzelnick says about 45 percent of DIAMOND patients go into remission by six months, compared with just 5 percent of patients who receive standard primary care. And 61 percent of DIAMOND enrollees experience at least a 50 percent reduction in the severity of their symptoms.

The key to the program's success, Katzelnick says, is true integration of care. The behavioral health specialists must be embedded in the flow of the primary care practice — using the same electronic medical record, being available for informal hallway consults and helping physicians respond to psychiatric emergencies — in a team approach to patient care. "A lot of places have dropped mental health providers into primary care clinics, and that actually does not work," he says. "They tend to act the way they always do in specialty care and not be truly integrated."

Lola Butcher is a freelance writer in Springfield, Mo.

A formula for success: Targeting niche patients

Low reimbursement rates, intense scrutiny from payers and a high rate of uninsured patients have long made running an inpatient hospital for behavioral health patients an even tougher job than leading an acute care community hospital.

So, why is Rob Simpson, M.D., president and CEO of the Brattleboro Retreat, so upbeat? Because the 177-year-old psychiatric and addiction hospital in Brattleboro, Vt., is on a roll. Five years ago, the hospital had fewer than 2,000 admissions per year; in 2011, that was up to nearly 3,000. "We've increased admissions 53 percent and our average daily census 46 percent," Simpson says. Total capacity expanded to 109 available beds in March and is expected to expand to 124 beds in 2013.

That growth stems from a strategic plan that kicked into action in 2007. The Retreat upgraded its facilities, added staff, increased bed capacity and conducted a market assessment throughout New England to find out what people needed.

"They want specialty programming, what we might call niche programming, addressing specific patient needs," Simpson says.

The Retreat delivered. In addition to treating adults, adolescents and children and providing programming for adults who suffer both addiction and mental illness, the hospital opened two new programs. The Uniformed Services Program provides trauma and substance abuse treatment for individuals in the military, law enforcement and other services who have suffered emotional wounds in the line of duty. The hospital also opened a 15-bed unit to serve lesbian, gay, bisexual or transgender adults with mental illness or addiction in an affirming environment. Next year, a program will be started specifically for young adults.

Today, 40 percent of the Retreat's patients come from outside Vermont. "The addition of the program for uniformed service personnel — policemen, firemen, EMTs, veterans — has increased our reach considerably," Simpson says. "People come from all over the country and even Germany for that specialty program."

The Retreat recently began admitting high-intensity patients who would have been treated at the Vermont State Hospital until Tropical Storm Irene demolished the facility last year. Vermont Gov. Peter Shumlin has recommended that the Retreat add another 14 beds as part of a new statewide system of care instead of rebuilding the state-run facility.

A care model grows in Brooklyn

In Brooklyn, N.Y., Maimonides Medical Center and nearly 50 partner organizations are using medical home concepts and health information exchange technology to address the needs of one of the most challenging populations: low-income patients with schizophrenia, bipolar disorder and other serious and persistent mental illnesses.

The Southwest Brooklyn Health Home Consortium, which began enrolling patients this year, was inspired by a successful care model developed by Maimonides and South Beach Psychiatric Center, Staten Island, N.Y. In that program, mental health and primary care services are co-located at the South Beach site, where weekly case conferences improve care coordination.

"The patients' care got better, and the result was a dramatic reduction in inpatient hospitalizations," says Maimonides CEO Pamela Brier.

With funding from state grants, Maimonides joined with its partner hospital Lutheran Medical Center, behavioral health providers, social service agencies and other stakeholders to create a network of medical, social support and behavioral health services for the 15,000 patients with severe mental illness in southwest Brooklyn.

"The interdisciplinary care team will be connected electronically to continually updated patient records, so we can track where patients are and how they are doing," Brier says.

Care managers are tasked with coordinating resources efficiently to reduce avoidable emergency and inpatient utilization. Care navigators work with patients to make sure they get the specific services they need. "In the short run, this is doing a better job of caring for patients," Brier says. "As we progress, we hope to develop ways of sharing in the savings."

CMS tests benefits of paying psych hospitals for emergency services

The Centers for Medicare & Medicaid Services will provide up to $75 million in federal Medicaid matching funds to 11 states and the District of Columbia to test whether reimbursing private psychiatric hospitals for emergency services improves care while reducing costs and the burden on general acute care hospital emergency departments. Alabama, California, Connecticut, Illinois, Maine, Maryland, Missouri, North Carolina, Rhode Island, Washington state, West Virginia and Washington, D.C., will participate in the Patient Protection and Affordable Care Act demonstration, which will reimburse inpatient psychiatric facilities for emergency care provided to Medicaid enrollees ages 21 to 64. "This new demonstration will help to ensure that patients receive appropriate, high-quality care when they need it most, and save states money," said CMS Acting Administrator Marilyn Tavenner.


Behavioral health patients may benefit from several emerging developments.

• Productivity

Employers are making the connection between behavioral health issues and their bottom line. "There are more days of work lost by employees who are working with mental illness than back pain, diabetes or asthma," says Rebecca Chickey, director of the American Hospital Association's Section for Psychiatric and Substance Abuse Services. That means investing in employee assistance programs and increased coverage for behavioral health services is money well spent.

• Parity

The Mental Health Parity and Addiction Equity Act of 2008 means private-payer coverage for behavioral health services is improving over time. "With parity now being the law of the land, I have some hope that the picture will begin to change," says Bruce Schwartz, M.D., deputy chairman, department of psychiatry at Montefiore Medical Center in New York City. "It's conceivable that fewer patients will fall into the safety net of Medicaid and public funding and that private insurers will no longer be able to discriminate in terms of their coverage for mental illness or substance abuse problems, as they have historically."

• Part of the package

When state insurance exchanges created by the Affordable Care Act come on line, their package of "essential benefits" will include mental health and substance abuse services.

• Providers as partners

The ability to coordinate care has never been better. The increasing prevalence of electronic health record technology makes it possible to "inform the behavioral health providers of medical problems, and vice versa," says Schwartz, the 2012 chair of AHA's Section for Psychiatric and Substance Abuse Services Governing Council.