My patient Andrew was brought to my office by his parents. They were concerned that his attention deficit hyperactivity disorder (ADHD) medication had not been as effective in the last few months as in the past. During the visit I learned that there had been recent changes to the parents' custody agreement and that Andrew's father was going through a second divorce. Andrew had become sullen and argumentative and less willing to do homework. His grades were faltering as well.

Primary care physicians deliver half of all mental health services (92 percent among the elderly),¹ perhaps in part because patients prefer to seek behavioral health care from their family physician to avoid the stigma and unfamiliarity of a therapist's office or mental health facility.² Whatever the reason, there is no shortage of cases like Andrew's in family medicine, where we find that a patient's mental health is directly linked to his or her physical health. Consider a case in which a patient is spiraling downward with depression despite medical intervention, or an adolescent shows the first signs of psychosis or mania, or a patient's substance abuse problem complicates treatment of other medical conditions. What do you do for these patients, and for Andrew?

Increasingly, family physicians are finding that the best answer to the above situations is to collaborate closely with a behavioral health specialist or integrate one into their practice.

Finding the right level of integration

The level of collaboration between a family physician and a behavioral health specialist can vary from rudimentary (e.g., developing a preferred referral relationship with a local caregiver) to fully integrated, which requires an operational, structural and financial transformation of the practice. Consider these five levels of collaboration:³

• Level 1: Minimal collaboration (referrals only),

• Level 2: Collaboration at a distance (referrals and some direct communication),

• Level 3: Basic on-site collaboration,

• Level 4: Close collaboration in a partly integrated system,

• Level 5: Close collaboration in a fully integrated system.

Many family physicians work in settings with level 1 or level 2 collaboration. Typically, these practices refer patients to a preferred behavioral health specialist, such as a psychotherapist. Minimal collaboration is often sufficient for cases that do not involve psychotropic medications, family therapy or specialty care such as court-mandated therapy or inpatient substance abuse treatment.

The advantages of level 1 and level 2 collaboration for family physicians are that treatment does not stray far from familiar physician skill sets and minimal resources are required. However, these levels of collaboration require extra work on the part of the patient, and they often result in high no-show rates and a disconnect in planning and coordinating care.

At the other end of the scale, highly integrated arrangements (i.e., those with level 4 and level 5 collaboration) are becoming increasingly common. While such arrangements were originally conceived for specialty clinics such as cancer and HIV treatment centers, many private practice physicians and their patients are now benefiting from them. Common characteristics of highly integrated systems include on-site, full-time mental health staff; integrated medical records and billing; universal screening for depression and substance abuse; and a focus on treatment approaches that encourage shared patient care. These arrangements also create opportunities for the family physician to personally introduce the patient to the behavioral health specialist and for “meet-in-the-hall” consults and shared appointments for more complex cases.

Issues of cost and space make it difficult for practices to move forward with level 4 or level 5 integration. Many family physicians find it most practical to pursue a basic collaboration (level 3), in which the behavioral health specialist conducts an independent practice in the physician office, simply entering into a contract with the practice for space and the use of its staff. Most behavioral health specialists are self-sufficient and require only one room and limited use of front-desk staff. (We realize that even this small amount of space may be more than a practice has available. You can see in the case example below that full integration did not happen for Primary Care Partners until the practice changed locations. This may be the case for many practices.) Collaboration occurs as the need arises. As the relationship grows, billing services and even patient records might be shared. Of course the financial impact on the family medicine practice is entirely dependent on the contracted arrangement.

Other considerations

Some physicians express concern that integrated systems may violate laws against self-referral. Federal Stark laws are the primary issue; however, Stark laws apply to a very specific set of services (i.e., laboratory, radiology and home nursing) that does not include mental health services. State laws may set a higher standard and should be consulted. Regardless, it is wise to maintain relationships with numerous behavioral health specialists because patients' needs and preferences may require services beyond what the provider you typically collaborate with can offer.

If a behavioral health specialist is working in the practice's space, it is important to address patient confidentiality. To ensure Health Insurance Portability and Accountability Act compliance, many offices choose to have shared patients sign a consent-for-treatment form that covers release of information and explains that the behavioral health specialist and the physician will share information for continuity-of-care purposes.

It is important for physicians to keep in mind that, while physicians are able to bill for almost all encounters that involve a behavioral health specialist, the reverse is not always true. Behavioral health specialists cannot always bill for services that involve a physician. This can make it more difficult to sustain a collaborative practice.

Finding the right specialist to collaborate with

Behavioral health specialists cover a variety of specialties and differ in their training and licensure. Professional counselors, family therapists and clinical social workers provide the majority of collaborative services with family physician practices. These professionals are typically trained at the Master's degree level and are qualified to treat conditions commonly found in a primary care setting, such as depression, anxiety, ADHD, relationship problems and insomnia. Depending on the demographics and health needs of your patients, professionals with different training may be a good fit. These include certified addictions counselors for patients with alcohol and drug problems, psychologists for diagnostic testing and other treatments that require advanced training, group therapists for co-leading group medical appointments for chronic illness or prenatal care, and case managers for assisting patients in accessing community resources, such as housing assistance, referral to specialists, legal aid, pharmaceutical assistance programs and applications for disability.

Weighing the benefits

The positive outcomes that an integrated behavioral health specialist can bring to you, your practice and your patients are plenty (see “A case example: Primary Care Partners”). We've experienced the following benefits of collaboration, but you may find additional benefits in your own practice:

Increased efficiency. Chronically ill patients with co-occurring somatic or mental health issues can be quickly sent to an in-house behavioral health specialist without a referral or scheduling a separate appointment. All the while, the physician is able to remain on schedule.⁴

Increased patient and physician satisfaction. Both patients and physicians report that they prefer the convenience, efficacy and support of on-site behavioral health specialists.^5,6

Improved health outcomes. Working as a team, the physician and behavioral health specialist assist the patient in managing chronic illnesses that often require changes in lifestyle and behaviors.⁷

Improved mental health outcomes. Research shows that patients with mental health conditions achieve greater symptom relief and have less need for costly emergent services when treated by an interdisciplinary team.⁸

Let them help you

Let's return to Andrew's case:

A behavioral health specialist can be a “helpful neighbor” who visits or shares space within a family physician's practice. He or she can assist with the treatment of patients' mental and behavioral issues, which might otherwise tie up a physician's time and detract from those aspects of care that a family physician finds most professionally, personally and financially rewarding.