So, what does this mean for the Clinical Health Coach?
It is nearly impossible to work in today’s health care arena – especially primary care – and not hear about health care integration. This is occurring in many areas but especially in behavioral health and primary care. There are varying methodologies and models in place throughout the country, with promising results. So, what exactly is behavioral health integration?
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines it the following way: “Behavioral health” is a general term that encompasses the promotion of emotional health; the prevention of mental illnesses and substance use disorders; and treatments and services for mental and/or substance use disorders. For some, the definition goes a bit further and encompasses those behaviors or conditions that can be impacted by behavioral changes that are impacting a patient’s ability to manage their health, such as exercise, tobacco use, stress, and chronic pain.
Behavioral health integration, then, is “the care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.” Agency for Healthcare Research and Quality (ARHQ), Academy for Integrating Behavioral Health and Primary Care.
There are many factors leading to this emphasis in integrated care, one of which is prevalence. The World Health Report 2001- Mental Health: New Understanding, New Hope, issued by the World Health Organization cites that: “Mental and behavioral disorders are common, affecting more than 25% of all people at some time during their lives. They are also universal, affecting people of all countries and societies, individuals at all ages, women and men, the rich and the poor, from urban and rural environments. They have an economic impact on societies and on the quality of life of individuals and families.”
Further, the Centers for Disease Control and Prevention reports that mental illness is associated with increased occurrence of chronic diseases such as cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer. Mental illness is associated with lower use of medical care, reduced adherence to treatment therapies for chronic diseases, and higher risks of adverse health outcomes. Exacerbating this issue is a nation-wide shortage of mental health professionals. According to the Health Resources and Services Administration (HRSA), as of September 2017, there are 4,781 Mental Health Professional Shortage Areas in the US. Health Professional Shortage Areas (HPSAs) are designations that indicate health care provider shortages in mental health and other disciplines. To learn more about the availability of mental health professionals in your area, go to this link for the latest HPSA map: https://datawarehouse.hrsa.gov/ExportedMaps/HPSAs/HGDWMapGallery_BHPR_HPSAs_MH.pdf
Given what we know about prevalence, disease burden, and the shortages of mental health professionals, it quickly becomes clear that behavioral health concerns are not something that primary care can ignore or refer away. Indeed, in order to reach the Institute for Healthcare Improvement’s Triple Aim of improving care, improving population health, and reducing per capita costs, the healthcare system needs to consider the health disparities in this patient population and respond with more effective treatment strategies. Thus, we arrive at behavioral health integration.
Behavioral health integration does not diminish the need for, and value of, traditional mental health or substance abuse services. Rather, it speaks to a shift toward using limited behavioral health resources more selectively, for those patients who cannot be effectively maintained in primary care and/or who need long term therapy or other behavioral health services and supports. In effect, traditional mental health services are becoming viewed more as specialty mental health care rather than the first stop for services for patients with behavioral health concerns.
Health coaching, either as a strategy or a formal role, is a valuable component in behavioral health integration. Initial interviews, using coaching communications, may uncover opportunities for specific screenings, particularly for depression, anxiety and/or substance use. Should this support additional behavioral health interventions, the development of a trusting relationship between patient and provider is crucial. Health coaching and motivational interviewing facilitate a collaborative relationship that encourages the “spirit” of partnership, acceptance, compassion and evocation of motivations and goals. Managing patients with a behavioral health diagnosis often requires a multidisciplinary team and systematic follow-up to support treatment, medication management and lifestyle behavior change. Health coaching addresses the all-important underlying motivation for a more positive health future, especially when facing depression and/or substance abuse. In fact, the efficacy of motivational Interviewing was researched initially in the addictions field. Its use has since been broadened to many issues (not limited to healthcare) where behavior change is desired. Health coaching in the clinical environment integrates these patient-centered approaches with best practice care management.
The Centers for Medicare and Medicaid Services (CMS) acknowledges the importance of behavioral health integration (BHI) into primary care. For reasons previously listed and an estimate that currently only 10% of patients with depression receive guideline-concordant treatment (NEJM, May 2017), this is a timely and urgent opportunity that actively utilizes health coaching. CMS has created four new codes to the 2017 Physician Fee Schedule that allows providers to bill for BHI services. Health coaches, or care managers using health coaching skills, are particularly valuable in providing initial assessments and screens, creating care plans that focus on behavioral health and goal setting and maintaining a consistent and continuous relationship with the patient. They can also monitor the progress of behavioral health management as well as co-morbid chronic condition management. Additional information about the Behavioral Health Codes may be found at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-Fact-Sheet.pdf
And finally, to address the question in the title of this article: What does behavioral health integration mean for the Clinical Health Coach? Coaching is an important strategy in any system of care that includes a focus on eliciting behavior change in the patient. The population of focus may shift and evolve, but coaches have the skill set needed to tackle the challenges of patient engagement and activation. More than that, a coaching strategy is critical to building a patient’s confidence and commitment to successful health management, be it a physical or behavioral health issue.
By Deb Kazmerzak and Kathy Kunath
Clinical Health Coach Faculty
This is the first in a series of articles related to clinical health coaching and behavioral health integration. Look for additional topics and perspectives in future newsletters.