In 2019, mental health and opioid use disorders remain major public health issues. The most recent estimates suggest that 40 million adults experience mental illness in the U.S. and nearly 8 million adults experience both mental and substance use disorders at the same time. Individuals with mental illness also face higher risks of co-occurring chronic health conditions and early mortality, as well as social problems including unemployment, and homelessness.
Treatment for these issues requires an interdisciplinary approach. According to the current literature and the Substance Abuse and Mental Health Services Administration, the best treatments for mental health and substance use disorders combine both medical and behavioral health services. In supporting these findings and recognizing the growing need to codify the importance of behavioral health treatments, the federal government has passed laws to promote better access and higher quality. The 2008 Mental Health Parity and Addiction Equity Act requires health plans to provide mental health and substance use disorder benefits similarly to medical and surgical benefits. Health plans cannot impose special restrictions on behavioral health benefits such as lower annual/lifetime dollar limits, financial requirements, and limitations on treatment. Additionally, under Section 2703 of the Affordable Care Act (ACA), states have the option to provide “health home” services to Medicaid beneficiaries with serious mental illnesses (SMI) and other chronic health conditions. Health homes are managed by teams of providers and staff who coordinate preventive and primary health services and provide case management to patients.
Using these federal guidelines as an opportunity to improve population health outcomes, many states [pdf] have taken great strides to treat some of their most vulnerable patients through their versions of health homes, such as behavioral health home (BHH)s. BHHs seek to embed primary care services into specialty mental health settings, striving for a patient-centered and evidence-based approach to improve the lives of patients. Although the exact qualifications and covered benefits vary by state, BHHs generally include six core services: care management, care coordination, health and wellness promotion, transitional care, individual and family supports, and referrals to community supports.
In a recent Medical Care article, Daumit and colleagues investigated the capacity and limitations of BHHs in Maryland and discovered numerous organizational and structural challenges to integration. In the state of Maryland, BHHs are embedded within inpatient psychiatric rehabilitation programs to target high-risk populations and must include the six core services mentioned above. Maryland BHH programs must also be certified by the Maryland Department of Health, having completed accreditation processes and enrolled as a Medicaid provider with the state.
After collecting and analyzing survey responses from leaders and staff members from 46 Maryland BHH programs, the authors found that the challenges related to population health management and primary care integration included lack of experience managing and cultivating a BHH and lack of formal partnerships with primary care providers in the community.
It should not come as a surprise that health home models, such as BHHs, experience such barriers. To successfully integrate primary care within specialty clinics requires thoughtfully established collaboration both internal and external to the program. In one notable example, the state of Vermont implemented its Medicaid “hub-and-spoke” health home. This program was designed to treat patients with opioid use disorder within a highly integrated network of coordinated care such that patients can enter the network through various points, such as hospital emergency rooms, community mental health programs, and the state Department of Corrections. Patients can also be referred to other types of care through a streamlined referral process that allows providers and staff from external “spoke” locations to consult with internal “hub” behavioral health specialists.
Despite integrating successfully, the Vermont program also faced challenges. In a study of the hub-and-spoke, researchers found that progress was hindered by staffing shortages, lack of education for buprenorphine prescription by clinicians, and lack of data collection to properly evaluate and monitor the program outcomes. These challenges mirror the ones also faced by the Maryland BHH programs: low staff-to-patient ratios, difficulties with staff recruitment and retention, and lack of integrated health information technology (HIT).
So how can health home implementation leaders and staff work around these overlapping challenges? Daumit and colleagues suggest, at least for the Maryland BHHs, that health home programs should adopt a multifaceted approach that includes formalized care coordination protocols, additional staff training and support, improvements in HIT interoperability and communication, and changes in financial policies.
It will take time and resources to understand how successfully these solutions are implemented and what effects will be had on BHH quality and sustainability. For example, the U.S. Department of Health and Human Services recognizes that a strong HIT ecosystem will take ten years of collaboration between federal, non-profit, and private partnerships. And in my opinion, state and national policies to financially incentivize health home-related services will take several years to develop.
In the meantime, Maryland’s BHH programs are awaiting future evaluation. As our health care system continues to make modifications to improve health outcomes, we may witness programs go through several iterations before becoming successful. I am hopeful that the public health crises of today will be solved within our lifetime. For patients experiencing mental health and substance abuse disorders, home health models may be a worthwhile opportunity to address their physical, mental, and social wellness in a high-quality, evidence-based, and sustainable way.
