People with Behavioral Health Conditions Guide

Improving the health of individuals and populations is only possible with adequate behavioral healthcare. Research indicates behavioral health factors moderate all components of the quadruple aim: patient experience, health outcomes, healthcare costs, and the experience of those providing care. Conservative estimates demonstrate 40% of the Medicaid population has a mental health and/or substance use disorder.^[1] California Health Home data indicate that approximately 40% to 50% of Medi-Cal patients have behavioral health needs. Mental health and addictive disorders are among the top 10 most frequent diagnostic conditions among Medi-Cal beneficiaries whose health challenges lead them to be in the top 5% of healthcare costs. Additionally, data demonstrate that psychosocial problems, a primary cause of frustration for primary care providers in safety net settings, drive 70% of all medical visits.

Primary care systems are the de facto mental health system in the United States, with more than 80% of psychotropics prescribed by primary care providers. Separating behavioral health from primary care has many challenges, including a 10% follow-through rate when patients are referred off-site for behavioral healthcare. Further, research in California indicates six in 10 patients would rather discuss behavioral health issues with a professional at their primary care facility than with one located off-site.^[2]

These factors and other robust research on healthcare outcomes have driven the growth of integration of behavioral health services with primary care. Currently, all federally qualified health centers (FQHCs) in California have some level of integrated behavioral health services. The largest barrier to robust integrated behavioral healthcare (IBH) services and improvements in population behavioral health for most health organizations is the wide gap between behavioral health (BH) needs and available resources. The BH provider shortage is severe^[3][4] and most practices are understaffed to meet the practice’s population health needs. Additionally, the clinician workforce does not reflect the population serviced by most safety net organizations. The workforce is overwhelmingly white and monolingual English-speaking: psychologists are 88% white,^[5] licensed marriage and family therapists are 79% white;^[6] licensed clinical social workers somewhat more diverse at 58% white.^[7]

Integrating behavioral health and primary care has been shown to increase access to services by providing BH services^[8] in a lower stigma environment and addressing childcare and transportation barriers with a “one-stop shop” model. IBH research demonstrates significant improvements in patient experience,^[9] health outcomes^[10] and health equity.^[11]

According to the Centers for Disease Control and Prevention (CDC), depression is a major contributor to mortality, morbidity, disability and economic costs in the United States. In 2021, 8.3% (21 million) of adults in the U.S. experienced at least one major depressive episode; 5.73% (14.5 million) experienced a major depressive episode with severe impairment.^[12] Approximately 50% of those diagnosed with depression in the United States are also diagnosed with anxiety.^[13]

Depression and other behavioral health conditions can often go undetected and unaddressed in primary care.^[14] Black and Hispanic or Latino/a and, when they do, the services are of poorer quality compared to that of white patients.^[15][16]

Developing, implementing and continually improving integrated care delivery within your practice is critically important; multidisciplinary, team-based care can increase equitable access to behavioral healthcare, improve patient health outcomes, enhance quality of life, and improve job satisfaction of medical providers and staff.

This guide is designed to help your practice enhance and deepen integrated behavioral healthcare and screen for and manage depression. It includes guidance on how to approach the activities of population health management in trauma-informed ways. In addition to the body of this guide, find more strategies in the resource on Trauma-Informed Population Health Management.

This guide provides practices with detailed guidance, examples, resources and tools to effectively screen for and manage depression and engage patients in integrated behavioral health services. This document uses existing evidence, bright spots and examples from the field to offer practical guidance on improving the effectiveness of your behavioral health protocols, keeping in mind that it will be adapted to your practice’s unique context.

Key activities in this guide are organized into three categories:

• Foundational activities: The core activities that all practices must implement to enhance integrated care delivery and engage adult patients in depression screening and treatment to achieve depression remission.
• Going deeper activities: More advanced activities that build off the foundational activities and help ensure your practice can achieve equitable improvement in depression screening and engage adolescents in depression screening and treatment.
• On the horizon activities: Additional activities focused on improving care delivery with people with severely impacting mental illness.

Where to Start: While we recommend following the sequence of the key activities in this guide, the activities can be used individually or adapted to fit your practice’s priorities.

Trying it Out then Making it Habit: For each activity, we provide guidance on how to plan, try, and implement the activity along with links to other resources, technology considerations and examples. Consider trying different versions of the action steps and roles with a smaller group before fully implementing at your practice.

Maintaining Progress: Ongoing review and continual improvement are important for your practice to maintain your progress in population health management and to help you stay nimble in adapting to changing patient demographics, new clinical best practices, new payment policies, workforce changes and other changes at your practice. For many activities, we have also provided tips for periodically reviewing and making improvements to key workflows even after initially implementing the change.

If you implement the Foundational Activities in this guide, your practice should be able to achieve the following objectives:

1. Engage patients served by your practice to validate any of your proposed process improvements and to propose alternative methods to improve quality in your focus area.
2. Analyze core quality measures to identify disparities and improvement opportunities for achieving universal depression screening among all attributed adolescents and adults.
3. Integrate behavioral health follow-up services as needed (e.g., for positive depression screens).
4. Identify and engage behavioral health partners.
5. Create a health-related social needs screening process that informs patients’ treatment plans.
6. Assess current capabilities and develop a plan for ongoing improvement in data utilization, care team workflows and efficiency that includes sustainable health information technology (HIT) strategies and continuous staff training in technology.

This guide also includes sections on measurement, equity, social health, behavioral health integration and an appendix including helpful tools and resources. We have included information about California Medi-Cal covered benefits and services that were up-to-date at the time of publishing, but benefits and billing guidance change over time. Nothing in this guide should be considered formal guidance, and anyone using this guide should check with the appropriate authorities on benefits and billing guidance.

This is a living document and will change based on continued learning on this topic and may include additional activities, examples, resources and sections in the future.

Additional Information can be found in Getting Started: Introduction to the PHMI Implementation Guides, and Aligning PHM Principles with Community Health Clinic Strategic Planning.

Improving the health of a population impacts everyone in a practice. Critical roles needed to engage in the work outlined in this guide and support practice change, include:

• Chief behavioral health officers (CBHOs), chief medical officers (CMOs) and other clinical leaders.
• Operation leaders, such as chief operating officers (COOs) and practice managers.
• Quality improvement leadership, like a director of quality improvement (QI), to support cultural changes.
• Coaches or practice facilitators who are partnered with teams to help identify areas for improvement and support change through change management strategies.

PHMI’s approach emphasizes four foundational areas for PHM: a reimagined care team, empanelment, the business case, and data quality and reporting (DQ&R). These areas provide the foundation for the sustainable delivery of person-centered, population-based care and improving outcomes for a population of focus; see Building the Foundations for Population Health Management: Talking Points for Engagement for a concise overview and talking points for why these areas are important.

In addition, practices can reference specific Building the Foundations key activities to go deeper into specific challenges related to advancing equity, social health, behavioral health integration, and access and outreach for their population of focus:

Equity

• Business Case Guide: Advancing Equity Through Your Business Case
• Empanelment Guide: Advancing Equity Through Empanelment
• Data Quality and Report Guide: Advancing Equity Through Data Quality and Reporting
• Care Teams and Access Guide: Advancing Equity Through Care Teams and Workforce
• In this guide: Key Activity 15: Use a Systematic Approach to Address Inequities within the Population of Focus and Key Activity 27: Strengthen a Culture of Equity

Social Health

• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure
• In this guide: Key Activity 14: Develop a Social Needs Screening Process that Informs Patient Treatment Plans

Behavioral Health

• People with Behavioral Health Conditions Guide
• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure and Key Activity 2: Identify gaps in staffing and decide how to address them

Access and Outreach

• Empanelment Guide: Going Deeper: Connecting Empanelment with Patient-Centered Access
• Care Teams and Workforce Guide: Key Activity 2: Identify Gaps in Staffing and Decide How to Address Them
• In this guide: Key Activity 5: Enhance Inreach and Outreach to Engage People in Behavioral Healthcare and Key Activity 22: Provide Proactive Inreach and Outreach to Help Adolescents Engage in Behavioral Healthcare