Increased recognition of the high comorbidity of depression and chronic medical disorders has led to the development of depression management programs that integrate mental health services into primary care settings. Collaborative depression care models in which mental health specialists are co-located within primary care settings have worked well in staff-model health maintenance organizations. However, few programs integrate medical and behavioral health services in an open-access system of care using independent providers, in which a carved-out behavioral health plan manages the mental health benefits separately from the health plans that manage the medical care.
United Behavioral Health (UBH), a large managed behavioral health organization, developed an integrated program in which the medical and the mental health care plans manage medical patients with comorbid depression concurrently and collaboratively. The High Risk Medical Intervention Program is an innovative program that provides case-finding, telephone outreach, and behavioral health services to medically ill patients. Medical patients at risk of mental health problems are identified by the health plan through claims and encounter data. Predictive modeling techniques are employed in which medical claims algorithms are programmed to identify individuals in 18 chronic-condition groups who have high costs and service use. In addition, patients are flagged during any period within a hospitalization episode, including preadmission counseling, inpatient care, discharge, or a hospitalization follow-up. Additional patients are flagged from chronic disease management programs, such as for diabetes or cancer.
Trained "health advocate" nurses from the health plan screen identified patients with mental illness by telephone. The goal is to detect individuals who, in addition to their medical problems, are experiencing untreated depression, anxiety, or psychosocial stress that might compromise their ability to cope with illness or comply with medical treatment. Criteria for referral include the presence of a chronic or acute condition or high use and cost of health care services and comorbid psychosocial issues, a positive screen for depression or anxiety, a history of mental health treatment, or high levels of distress or discord within the family.
The health advocate nurses refer patients to the program via a telephone call or a secure e-mail. Trained, licensed UBH counselors contact the referred patients by telephone. Outreach activities include a psychosocial assessment, including assessment of depression and anxiety symptoms; education about the patient's behavioral health condition; rapid referral to a range of work and life resources, such as financial and legal services, community organizations, and support groups for the patient or his or her family; and referral for focused treatment with specialty mental health clinicians as needed.
A preliminary feasibility evaluation examined referrals, outreach, and use of behavioral health services in a subcohort of 172 of 262 patients referred to the program in 2002. UBH outreach counselors reached 80 percent of the referred patients. Among those reached, 70 percent accepted a referral to some type of service—for example, to a mental health clinician or to financial or legal services. The first 104 members who accepted a referral were sent a satisfaction survey; 95 percent reported being satisfied with the services they received.
Thirty-four percent of the 172 patients (N=58) primarily accessed outpatient specialty mental health services in the year after the outreach intervention. This rate of use was nearly double the rate for this cohort in the year before the intervention. Rates of use of mental health specialist services approached levels expected on the basis of reported prevalence of depression among chronic medical patients—27 percent—compared with a 3.5 percent rate of use of behavioral health services in open-access health care systems.
Mental health services provided in the medical sector were examined by dividing the claims into three time periods: 12 months before the referral date, six months after the referral date, and 12 months after the initial six-month postreferral period to determine potential shifting of service use from medical to behavioral health sectors. "Medical-mental health" services were defined as medical claims with an ICD-9 code within the category of mental diseases and disorders—that is, medical claims with an attached mental health diagnosis. In the 12 months before the referral date, 38 percent of patients with a diagnosis of mental disease or disorder accessed medical services. In the six months after the referral date and the 12 months after that, use of mental health services in the medical sector decreased to 36 percent and 33 percent, respectively.
Cost data revealed a 47 percent decrease in total combined medical and behavioral health care costs for the patients in the program who were treated by a mental health specialist. Among patients who did not access mental heath services, costs increased by 53 percent. Although further analyses are needed, these preliminary findings support the feasibility of this behavioral health outreach program as a model for integrating medical and behavioral health care in open-access systems of care.
Dr. Azocar and Dr. Kelleher are affiliated with United Behavioral Health, 425 Market Street, 27th Floor, San Francisco, CA 94105 (e-mail: firstname.lastname@example.org), where Dr. Ciemins was affiliated when this work was done. Dr. Ciemins is now with the Sutter Health Institute for Research and Education, San Francisco.