Providing primary care to patients with mental illness is a challenging task that requires highly skilled and experienced practitioners comfortable with the full array of biopsychosocial problems with which these patients present. For example, understanding the side-effect profiles of psychiatric medications and their impact on problems such as diabetes and other complex endocrinopathies requires highly evolved clinical skills.

Optimally, the successful care of these patients is best provided in close collaboration among the entire health team, including the prescribing psychiatrist and the primary care provider. Indeed, integrated care models are becoming more prevalent with patients being cared for by primary care and behavioral health teams, collaborating and/or collocated in the same practice using a single electronic health record (EHR).

Many behavioral health practices are considering adding primary care services to better address these whole-person health care needs. In the NextGen® Advisors’ conversations with behavioral health and physician groups across the country, we find several challenges that groups are universally grappling with.

Staffing requirements

Establishing primary care services requires a decision as to the skill sets of the primary care providers that will staff the practice, such as:

• Should this team be physician-led?
• Should the team include advanced practice providers (APPs)?
• Will the APPs be physician assistants (PAs) or nurse practitioners (NPs), or a combination of these skill sets?
• What is the optimal ratio of APPs to medical doctors (MDs)?

These are not easy decisions, as the differences between the foundational skill sets of these providers are nuanced and often somewhat opaque to a behavioral health leadership team.

A physician-led team will require recruiting family physicians, general internists, or medicine and pediatrics board-certified providers. Staff planning is further complicated by a shortage of primary care practitioners of all skill sets in many areas of the country, especially rural communities. Our experience that many groups will often not have the luxury of very detailed resource planning; they often must build teams by recruiting the resources available rather than the ideal combination of resources and skills.

Introducing these new medical practitioners into a behavioral health practice challenges many areas of the organization. For example, from a human resource perspective, recruiting, interviewing, and onboarding primary care team members is different from the process for behavioral health practitioners. Pay scales are different, and guidelines around practice sharing and part-time work may pose new frontiers. Leadership and governance issues such as privacy and HIPAA rules pose an interesting challenge as leaders of the behavioral health practice likely have not had prior experience managing a primary care practice where these issues are handled differently from behavioral health.

A common electronic health record (EHR)

One of the biggest challenges facing groups adopting an integrated care model by adding primary care services to a behavioral health practice is that their current technology infrastructure does not support behavioral health and physical health workflows well.

A common EHR is essential since true integration is virtually impossible unless both behavioral health and primary care providers can access a single clinical record for the patients they share. We see groups that have done so much work to start and sustain a primary care practice but have not implemented a single common EHR. It is clear that despite their best efforts, care continues to be disparate and disconnected as providers in both disciplines are unable to fully access each other’s notes, and critical information regarding their common patients is not easily shared. Groups must consider the implementation of a single integrated EHR platform capable of seamlessly and fully supporting both behavioral health and physical health workflows and regulatory requirements.

Cross referral workflows

In conversations with behavioral health leaders about their vision for the integrated model in their organizations, they often cite their hope that any patients receiving behavioral health in their organization also receive primary care and that the same holds for patients receiving primary care who might need behavioral health services. These cross-referrals are at the core of the integrated, whole-person model’s viability and sustainability.

Achieving this cross-referral is often difficult to operationalize. There are practice-driven barriers, such as the absence of clear workflows for both teams to engage patients at every opportunity to seek mental health treatment and primary care in the same organization. We observe that to be successful, these referral workflows need to be formalized, trained, reinforced, and incentivized by the leadership of the practice. There are also patient factors at play where patients already have a primary care provider or with patient reluctance to engage with primary care. It is important to implement a process that establishes primary care an easy and seamless step for patients. Many successful integrated practices describe a workflow whereby the behavioral health provider actually walks down the hall with the patient to the primary care office to make their first primary care appointment. Electronic workflows that support this task are easily supported if the providers share the same EHR platform.

Billing and revenue cycle management (RCM)

The integrated, whole-person practice’s financial viability can be threatened unless organizations carefully prepare for the initiation of primary care billing. If internal expertise in this area is not readily available or cannot be hired easily, the practice should consider outsourcing the primary care billing operations to an outside entity with deep expertise in this area. This is so important as it could make the difference between financial viability or failure of the primary care practice.

Integrated care is in sight

It is encouraging to see the integrated, whole-person care model gaining momentum across the country. Continued study and research will be required to refine the model further to ensure high quality, cost-efficient, and compassionate care is offered to this highly vulnerable segment of the population. Fortunately, the aforementioned deployment of truly integrated health IT platforms in these practices will also generate the clinical, quality, and cost data that can provide the insights needed to further refine and scale this essential care model.

Many behavioral health practices have successfully integrated primary care services, providing their patients with enhanced, comprehensive, whole-person care for their behavioral health and physical health issues. Careful planning and attention to the common challenges will help practices avoid some preventable pitfalls.

Betty Rabinowitz is chief medical officer, NextGen Healthcare. She can be reached on Twitter @DrBettyR.

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