Behavioral Health and the Comprehensive Primary Care (CPC) Initiative: Findings from the 2014 CPC Behavioral Health Survey

Zivin K, Miller BF, Finke B, Bitton A, Payne P, Stowe EC, Reddy A, Day TJ, Lapin P, Jin JL, Sessums LL
Source: BMC Health Serv Res
Publication Year: 2017
Patient Need Addressed: Behavioral health, Chronic Conditions
Intervention Type: Service redesign
Study Design: Other Study Design
Type of Literature: White

Incorporating behavioral healthcare into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation.

We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores.

One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers.

This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.

Insights Results

Overview of article/program

  • This article explores associations between practice characteristics and the extent of behavioral health integration (BHI) to illuminate factors that influence successful implementation
  • Given the high prevalence of both behavioral health conditions, and psychiatric comorbidities among individuals with chronic medical conditions, patient-centered medical homes (PCMHs) that address behavioral health care needs could improve patient health and care quality and reduce costs
  • CPC was a 4-year multi-payer initiative (2012-2016) of CMS in 7 regions across the US designed to strengthen primary care. CMS and other payers pay nearly 500 participating primary care practices with approximately 2,700,000 patients quarterly population-based care management fees in addition to usual fee for service payments, and provide shared savings opportunities to support providing a core set of comprehensive primary care functions. In 2013 (the first year of the initiative), CPC practices received sizable enhanced payments from CMS and other participating payers. In CPC’s second year, practices were required to engage in at least 1 of 3 advanced primary care strategies: 1) BHI; 2) Comprehensive medication management; and 3) Self-management support
  • Practices choosing to focus on BHI reported quarterly about their progress towards implementing BHI, and these questions provided implicit guidance to practices on BHI. Questions used to assess the reported data from sites on BHI included: 1) Who provides behavioral health services and what services they provide; 2) How practices identify and treat patients with Behavioral healths; 3) Which tools practices used to assess patients Behavioral healths and monitor care; 4) What evidence-based treatments practices provided; 5) Whether and how practices engaged in systematic case review and consultation; 6) How practices were building capacity for behavioral health; 7) How practices were currently tracking patients receiving behavioral health care; and 8) How practices measure their progress towards BHI

    Methods of article

    • The 2014 CPC Behavioral Health Survey was designed to assess progress towards implementing BHI in practices that chose BHI as their advanced primary care strategy. The survey is modeled after the Patient-Centered Medical Home Assessment tool and its precursor, the Assessment of Chronic Illness Care
    • Authors fielded survey to CPC participants that addressed 6 domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and 5 behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). All CPC practices that elected to focus on BHI or that had a behavioral health provider on staff were eligible for survey participation. Emails were sent to practice CPC points of contact, requesting that each eligible practice complete 1 survey. In total, 161 survey responses (86% response rate) were received
    • In addition to the BHI survey, authors linked survey data to CPC application data, which included information collected in 2012 from all practices that applied to become part of CPC: whether the practice was part of a multispecialty practice, practice ownership status (hospital, physician, or government/other owned), whether the practice qualified for National Center for Quality Assurance PCMH designation, metropolitan area (yes, no), patient mix (proportion of African American patients in the practice), and patients per full time equivalent (FTE) provider


    • Respondent scores for all survey domains ranged from 2.02 (communication and coordination) to 3.24 (depression), indicating that most practices had basic to good (but not full) support for BHI in each
      domain assessed
    • Practice characteristics associated with higher domain scores included: multispecialty practice, PCMH designation, availability of any behavioral health provider, and PCP/behavioral health provider communication
    • Scores varied significantly by region. Ownership status, patients/ FTE, and metropolitan area had limited relationship to domain scores
    • Within individual domains, practice characteristics had a variable impact on domain scores. Many substantive domains were sensitive to practice characteristics. Specifically, access, communication and coordination, and treatment planning were significantly positively associated with being a multispecialty practice, having PCMH designation, and having any behavioral health provider on staff
    • In the training domain, most practices reported that PCPs had been trained in principles of behavioral health care, with a mixture of those who reported feeling comfortable handling these issues and others not. In contrast, other clinical professionals and non-clinic staff in most practices did not address behavioral health issues or play a very limited role
    • In the access domain focused on scheduling, the preponderance of practices reported PCPs’ ability to accommodate addressing behavioral health issues, but a much more limited number of practices had the ability for behavioral health providers to accommodate addressing behavioral health issues
    • In the communication and coordination domain, respondents indicated that PCPs and behavioral health providers engaged in limited communication and did not regularly meet to review cases
    • In the treatment planning domain, shared care plans between PCP and behavioral health providers were rarely recorded and shared electronic health records were not routinely available
    • In the resource domain, most practices reported not having readily available resources for patients’ Behavioral healths, such as staff and time

    Key takeaways/implications

    • Overall, authors found that being part of a multispecialty practice, having a PCMH designation, having any behavioral health provider (especially a psychologist or social worker), and any communication between behavioral health providers and PCPs were each associated with significantly higher BHI domain and disease area scores. Conversely, practice ownership, metropolitan location, proportion of African American patients, and number of patients per FTE provider had almost no discernible impact on scores
    • Findings demonstrate 1) It may be easier for primary care practices to develop collaboration with a psychologist or social worker than a psychiatrist; and 2) Focusing on communication or securing access to any type of behavioral health provider may assist practices with successful behavioral health intervention implementation
    • Barriers to integrating behavioral health providers into primary care: 1) Payment; and 2) The extent to which primary care practices have integrated behavioral health implementations
    • Future studies should examine the impact of new payment models and billing practices on BHI to help achieve the value added proposition of BHI, and should assess BHI-related outcomes
    • Study limitations: cross sectional survey; no formal evaluation or validation of psychometric properties was conducted prior to study; lack of consistent definition of behavioral health intervention within primary care practices