A Blueprint for Including Behavioral Health in the Patient Centered Medical Home Model

patient centered medical home model

An individual’s mental health must be factored into any value-based care plan. This reality is starting to take hold as there is an increasing awareness that the Patient Centered Medical Home (PCMH) model must include a behavioral health component that is fully-integrated into the overall system. A group of experts recently released their 7-point strategy to include behavioral health as part of true “whole-person” care, which is the ultimate goal of any organization making the PCMH transition[1].

These experts included Roger G. Kathol, MD, Adjunct Professor of Internal Medicine and Psychiatry at University of Minnesota, and President of Cartesian Solutions, Inc, Frank deGruy, MD, Woodward-Chisholm Chair and Professor of Family Medicine for University of Colorado School of Medicine, and Bruce L. Rollman, MD, MPH, Professor of Medicine, Psychiatry, and Clinical and Translational Sciences for University of Pittsburgh. As one of the reasons behind this effort, the group cited the fact that over 40% of patients seen in primary care settings have behavioral health conditions, which include mental health and substance use disorders, disabling psychological symptoms and psychosocial stress, and unhealthy behaviors[2].

This is contrasted with the current financial environment that clinics currently face. With much of the saving from providing integrated care benefiting the payer, clinics feel that they cannot afford the investment in behavioral care. The result is that they refer patients to the mental health sector, but without proper integration, many patients never complete the referral or they experience extreme delays in actually being able to see a behavioral health clinician.

Another common issue is that primary care clinics hire counselors, social workers or staff with a similar background to offer counseling sessions in-house. But these experts point to the fact that research suggests that while these counseling sessions may bring higher patient satisfaction, evidence indicates that counseling short of evidence-based psychotherapy is not associated with long-term positive health outcomes or with lower total health care expenditures[3], [4].

Seven Components to Comprehensive Primary Care that Successfully Integrates Behavioral Health

To better integrate behavioral health services into comprehensive primary care, in a way that adds the value and sustainability of behavioral health care to the PCMH model, these experts recommend the following seven steps[5]:  

  1. Make behavioral clinicians part of “medical” clinician networks and pay for behavioral health through general medical/surgical benefits.
  2. Use consolidated medical and behavioral electronic health records (EHRs), registries, and claims data to proactively identify patients with greater health complexity for targeted assessment and treatment of behavioral health conditions.
  3. Assign geographic or virtual onsite behavioral “teams” with various levels of expertise, including nurses, social workers, PhD/PsyD psychologists, and psychiatrists as integral members.
  4. Match the level of behavioral health professional expertise to the clinical needs of the patient and escalate behavioral health treatment intensity when improvement fails to occur.
  5. Prospectively define desired medical and behavioral health outcomes and evaluate success towards these goals in real time, as treatment is given.
  6. Apply evidence-based treatment algorithms and protocols as standard behavioral health interventions.
  7. Use care coordinators trained in cross-disciplinary medical and behavioral support to create an integrated, comprehensive, whole-person personal care plan—to help patients with high health complexity overcome clinical and non-clinical barriers to improvement.

Overall, this group of experts recommends that the focus for behavioral health screenings should be on patients with chronic conditions, as well as those with high healthcare costs. The group also advises that a primary care clinic must ensure that behavioral clinicians involved in care have the expertise necessary to deliver the evidence-based behavioral treatments that are proven effective at improving long-term health outcomes. And they recommend that care efficiency should be enhanced with the latest evidence-based approaches.

While the components of this strategy may be debated, it is very encouraging to see that behavioral health is starting to be recognized as a critical part of any serious PCMH implementation. Only when comorbid conditions are treated as part of a truly comprehensive system, will the full benefits of value-base care start to be recognized.


[1]Roger G. Kathol, Frank deGruy, Bruce L. Rollman, “Value-Based Financially Sustainable Behavioral Health

Components in Patient-Centered Medical Homes,” Annals of Family Medicine, (March/April 2014), Vol. 12, No 2, http://www.annfammed.org/content/12/2/172.full.pdf

[2] Ansseau M, Dierick M, Buntinkx F, et al., “High Prevalence of Mental Disorders in Primary Care,” J Affect Disord. 2004;78(1):49-55.

[3] Bower P, Knowles S, Coventry PA, Rowland N., “Counselling for Mental Health and Psychosocial Problems in Primary Care,” Cochrane Database (2011), Syst Rev. (9):CD001025.

[4] Bower P, Rowland N, Hardy R., “The Clinical Effectiveness of Counseling in Primary Care: A Systematic Review and Meta-Analysis,” Psychol Med. (2003), 33(2):203-215

[5] Roger G. Kathol, Frank deGruy, Bruce L. Rollman, “Value-Based Financially Sustainable Behavioral Health

Components in Patient-Centered Medical Homes,” Annals of Family Medicine, (March/April 2014), Vol. 12, No 2, http://www.annfammed.org/content/12/2/172.full.pdf

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