A research team headed by Perelman School of Medicine Associate Professor and LDI Senior Fellow Chyke Doubeni has received a $3.7 million Health Resources and Services Administration (HRSA) grant to evaluate and disseminate effective methods for integrating behavioral health care into primary care settings.

The five year award underwrites the creation of a new National Center for Integrated Behavioral Health in Primary Care within the Department of Family Medicine and Community Health at Penn’s Perelman School of Medicine.

A clinical epidemiologist and Chair of the Family Medicine Department, Doubeni, MD, FRSC, MPH, will head a 15-member research team that will work collaboratively with the Department of Psychiatry and the School of Nursing.

Access to mental health services
“We’ll be looking at various targeted research questions throughout the five years but the one we need to tackle up front is access,” said Doubeni. “There is an epidemic of mental health disorders in the country at the same time access to behavioral health services is limited and we don’t even have enough providers to refer to at this point.”

The new program is the latest to explore the barriers that keep primary care and mental health services separated despite a 1999 U.S. Surgeon General’s report that made the integration of the two disciplines a national goal.

That landmark report concluded, “Primary care is generally not well equipped to treat chronic mental disorders such as depression or dementia. It has limited capacity to identify patients with common mental disorders and to provide the proactive followup that is required to retain patients in treatment… Many highly committed primary care providers do not know referral sources or do not have the time to help their patients find services… there is heightening awareness of the need for new models for mental health service delivery.”

Regulatory roadblocks
Seventeen years later, Doubeni noted that compensation procedures and regulatory roadblocks continue to make it difficult to seamlessly pair primary care and behavioral health services in a way that better serves both the patient and the goal of more effective population health practices.

“Health care payment models are procedure-based while psychiatry’s generally aren’t,” he said. “So health systems have not found it valuable to have psychiatric services. There are also laws that shield psychiatric information in a different compartment. So in a health system you have to have one information set excluded from the rest of the medical record. It creates a two-tier structure. It’s not that the two disciplines are incompatible but that payment systems and regulations have driven a wedge between them.”

“We need to solve this because a lot of the issues that drive poor utilization are deeply rooted in mental health and social issues and these are two issues that we’ve often chosen not to address — and that has resulted in a lot of poor outcomes,” Doubeni said.

Lost in the system
Currently, he said, even if the general medicine/primary care provider refers a patient to a behavioral health provider, the patient is often unable to navigate the complex health care system to actually find that remote provider and get the needed care.

“It creates an enormous barrier,” said Doubeni. “Another approach is the ‘warm hand-off’ where the primary care physician guides the patient to the behavioral health practice within the same clinic rather than at a clinic elsewhere in the city. The patient gets his or her needs met within that same setting.”

He noted that the project award is a Primary Care Training and Enhancement grant with the ultimate goal of disseminating best practices for both clinical and training settings. “In order to enable people to begin implementing a new model of care, you have to have it in place — because you can’t teach something that you don’t yet have,” Doubeni said.

Three other LDI Senior Fellows on the 15-member research team are Peter Cronholm, MD, MSCE, Associate Professor of Family Medicine and Community Health at Perelman; Julie Sochalski, PhD, FAAN, RN, Associate Dean of Academic Programs at Penn’s School of Nursing; and Anne Teitelman, PhD, CRNP, Associate Professor of Nursing.