Integrating Telemental Healthcare with the Patient-Centered Medical Home Model

Abstract

Objective:

The purpose of this article is to discuss how telemental healthcare and the patient-centered medical home (PCMH) can be integrated to improve the quality of mental healthcare available.

Methods:

This article outlines the components of a PCMH, and how the needs of this type of system of care can benefit from telemental healthcare.

Results:

The princples of PCMHs are being increasingly promoted in a variety of settings. In order to fulfill these principles, mental heathcare must be a integral part of the care provided to patients within the PCMH. The mental healthcare workforce is inadequate to provide care for patients, particularly in rural and high-poverty areas. Telemental healthcare provides a means to extend mental health services to the PCMHs using a variety of models.

Conclusions:

Telemental healthcare offers unique opportunities to bridge the need for mental healthcare integration in the PCMH for all patients.

Introduction

The United States healthcare system is in a time of dynamic change. At the same time that emerging technologies and medical advancements are becoming a new reality, the healthcare system is facing an increasing demand to curb costs and improve the outcomes for all patients. In 2008, Berwick and colleagues described the “triple aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care” (Berwick et al. 2008). Primary care is at the core of this dynamic drive to achieve these triple aims and the patient-centered medical home model (PCMH) is being widely promoted to address the necessary system changes (Jackson et al. 2013). The PCMH model recognizes the interdependence of mental health and physical health and, therefore, includes the provision of mental health and behavioral healthcare. However, access to an expert mental and behavioral healthcare workforce is limited in many parts of the country, making the integration of mental and behavioral health practices into the PCMH difficult. Telemental health is one approach to achieving integration (Comer and Barlow 2014).

The American Telemedicine Association (ATA) defines telemedicine as the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status (American Telemedicine Association 2014). Telemental healthcare is one of the most active telemedicine applications rendered in the United States. The term “telemental healthcare” is intentionally broad, referring to the provision of mental health and substance abuse services from a distance (American Telemedicine Association 2013), and including mental health services delivered through patient portals, e-mail, and other forms of electronic media. As telemental health services provided through real-time, interactive videoteleconferencing represent a rapidly growing segment of mental healthcare with implications for psychiatrists' future practices, this medium will be the main focus of this article. Both psychotherapy and medication management are provided via telemental healthcare, with increasing evidence of their effectiveness in improving patients' care and outcomes (Richardson et al 2009; Hilty et al. 2013; Shore 2013). However, most of the discussion on telemental healthcare integrated into PCMHs has focused on telepsychiatry and medication management. With that said, there is a significant role for psychotherapy in achieving optimal health outcomes in the PCMH. Likewise, although much of the research regarding telemental healthcare has focused on the adult population, there is a growing body of literature supporting the relevance of telemental healthcare for improving the care and outcomes for children and adolescents (Comer et al. 2014). Telemental healthcare offers unique opportunities to bridge the need for mental healthcare integration in the PCMH for all patients.

Patient-Centered Medical Home

Although there has been a great deal of discussion about PCMHs, and the principles of the PCMH are being encouraged as part of the Affordable Care Act (Milleson and Macri 2012) and within accountable care organizations (ACOs) (Jackson et al 2013), many patients, providers, and policy makers have only a limited understanding of what differentiates PCMHs from other types of clinical practice. The “medical home” concept was introduced in 1967 by the American Academy of Pediatrics as a way to centralize the care and the medical records for children with special healthcare needs (Sia et al. 2004). Since then, the concept of PCMH has expanded and evolved. Currently, there are a variety of definitions of what constitutes a PCMH, but the general principles consistently include a team-based approach toward improving the organization of healthcare delivery, and developing a sustained partnership with patients. More specifically, the Agency for Healthcare Research and Quality (AHRQ) has defined PCMHs as having five components: 1) Comprehensive care, 2) patient-centered care, 3) coordinated care, 4) accessible services, and 5) quality and safety improvement (Agency for Healthcare Research and Quality 2014).

In order to qualify as a PCMH, primary care practices must provide comprehensive care and be responsible for the majority of patients' healthcare needs. This includes prevention and wellness care, acute and chronic care, and physical and mental healthcare. Multidisciplinary teams are necessary to successfully accomplish this holistic focus on the patient. Some PCMH practices form these teams within the walls of the actual practice, employing primary care physicians, some specialists, advanced practice nurse practitioners, physician assistants, nurses, social workers, and care managers. Other, smaller PCMHs form remote or virtual teams by working closely with other providers and resources in the community. For example, a pediatrician practicing in a rural community may form alliances with a pediatric psychiatrist who sees patients via videoteleconferencing. Regardless of how the team is formed, good communication and coordination of care are vital to meet the principles of the PCMH.

The next component, patient-centered care, revolves around the ability of the PCMH teams to form partnerships with patients and their families. By actively engaging patients and integrating them and their families into the PCMH team, the team can more easily make decisions and develop care plans that are aligned with the patients' individual needs, values, cultures, and goals. Tools and processes such as care conferences, needs assessments, and shared decision-making instruments can assist with this communication. For example, the care manager at a PCMH who is working with an overweight adolescent with new-onset bipolar disorder could coordinate a meeting between the physician, the nutritionist, the patient and the patient's family to discuss the various options for a treatment plan, including the pros and cons of each option and necessary lifestyle modifications that might need to be implemented.

Although a primary component of the PCMH is to provide comprehensive care, inevitably patients will require care outside of the medical home. Whether this is care with an outpatient specialist, in an inpatient acute care setting, with a home health service, or with other community supports, the third defining component of the PCMH model is care coordination within the broad spectrum of the healthcare system. It is the responsibility of the PCMH team to ensure that there is open communication and cooperation between the various entities involved in the patient's care. This is particularly vital at times of transition, such as when a patient is discharged from one level of care to another.

Improved communication also extends to the patients themselves, with enhanced access to care. This could take multiple forms, including urgent appointment times, extended office hours, on-call availability of a team member, or accessibility via electronic communications such as e-mail or telephone care. Novel forms of communication, such as patient portals through electronic medical records, are also evolving, and will have a growing role in access to care (Goldzweig et al. 2013)

The final component of the PCMH is the implementation of quality and safety programs. PCMH teams are encouraged not only to use evidence-based practices, but also to measure, assess, and improve their healthcare processes and outcomes on a routine basis (Agency for Healthcare Research and Quality 2014). For example, biological outcomes, such as HgA1C values, patient-reported health status assessments, and patient satisfaction reports are frequently collected outcome measures used to examine the efficacy of PCMHs (Jackson 2013). Increasingly, providers will be encouraged, and eventually required, to report outcomes data, as well as describe their quality improvement programs. This transparency is highly encouraged among PCMHs as a sign of commitment to improvement at the system level. Considering the reciprocal effects of patients' mental and physical health, ACOs and accreditation/recognition agencies, such as the National Committee for Quality Assurance may mandate assessment of patients' mental and behavioral health status in quality care measures (National Committee for Quality Assurance 2011).

The five components that comprise the PCMH do not stand in isolation; each helps promote the others. For example, Palfrey and colleagues found a positive association between care coordination and improved outcomes, including increased patient and family satisfaction and decreased school absences and emergency department visits (Palfrey et al. 2004). Quality improvement processes such as monitoring patients in a registry can assist with care coordination (McAllister et al. 2009), and building effective teams can ease the burden and facilitate the offering of increased access (Council on Children with Disabilities 2014).

Mental and Behavioral Healthcare Integration

At the same time that the body of research supporting the efficacy of PCMHs is growing, there is also an increasing understanding of the need to integrate mental and behavioral healthcare with physical healthcare. As noted in a 2008 National Institute of Mental Health (NIMH) report, ∼26% of American adults have a diagnosable mental health disorder in any given year (National Institute of Mental Health 2008). These disorders often start early in life, with up to 50% of patients reporting symptoms by 14 years of age (National Institute of Mental Health 2005). The majority of patients seek treatment with their primary care providers rather than mental health providers. Williams and colleagues reported in 2004 that 75% of children with mental health concerns were seen in primary care, whereas only 2% were seen by mental health providers (Williams et al. 2004). Not only are primary care providers frequently tasked with addressing these mental health concerns, but these concerns often consume the bulk of their day. Some estimates are as high as 70% for the number of primary care visits that are prompted by psychosocial concerns (Robinson and Reiter 2007).

The high rate of mental health disorders in primary care has a profound impact on patients' physical health as well. Patients with chronic physical health conditions frequently have more medical complications if their comorbid mental health conditions are not adequately treated (Blount and Miller 2009). Beyond the obvious physical burden, a financial burden also exists. For example, patients with depression and anxiety have medical costs that are up to twofold greater than their peers who do not have mental health concerns (Simon et al 1995; Katon et al. 2003). Patients with mental health disorders frequently present to their primary care providers with physical health complaints rather than mental health complaints (Katon and Unutzer 2011), which can lead to unnecessary tests and procedures in an attempt to evaluate the physical concerns. In short, mental and physical healthcare must be integrated to optimize patient outcomes. Given that the PCMH goals are to provide comprehensive, coordinated care and to improve outcomes, this integration makes logical sense for PCMH teams.

Multiple strategies for integrating mental healthcare into primary care have been described. In 1996, Doherty and colleagues identified five levels of integration.

• Minimal collaboration – mental health and primary care providers work completely separately from each other and only communicate on a very limited basis.

• Basic collaboration at a distance – mental health and primary care providers work completely separate from each other, but communicate regarding common patients periodically.

• Basic collaboration on site – mental health and primary care providers work independently from one another, but are located in the same facility. As a result, communication is facilitated by proximity.

• Close collaboration in a partly integrated system – mental health and primary care providers are in the same facility and share some systems, such as medical records. Communication is facilitated by these shared resources as well as by proximity.

• Close collaboration in a fully integrated system – mental health and primary care providers are part of the same care team and are not differentiated as separate entities by patients.

As Collins and others noted in the 2010 Milbank report, most programs for integration have characteristics of two or three of the levels, creating a continuum of integration (Collins et al. 2010). The authors also noted that although PCMH are not specifically defined by integration, the philosophies of the PCMH and mental health/primary care integration are complementary.

The Role of Telemental Healthcare

Despite the need for PCMHs to integrate mental and behavioral healthcare into their practices, a significant limitation exists. The workforce shortage of qualified mental and behavioral health providers, particularly in rural and poverty-stricken areas, limits access to needed care (Thomas and Holzer 2006; Thomas et al. 2009). This, in turn, seriously restricts the availability for integration of a mental health provider into the PCMH. Telemental healthcare provides one viable mechanism to mental health integration. By using technology, mental health providers can join as “remote” team members. A variety of models have been piloted, and occupy various positions along Doherty's collaboration continuum. The models for integrating telemental healthcare into primary care generally fall into three categories.

Direct service models

The first category involves direct care of patients by the mental health provider. This clinical arrangement is common in telemental health practices. Patients are seen for initial evaluation and ongoing management by the mental health provider via a secure videoteleconference network. This type of telemental health treatment has shown to be effective for multiple adult populations in multiple settings and is comparable to in-person care (Hilty et al. 2013; Shore 2013). If the telemental health site and appointments are located within the PCMH's clinical space and the mental health provider is an active participant in the PCMH team care and treatment for patients, the provider helps the PCMH meet the goals of offering comprehensive care using a multidisciplinary team and improving access to services.

Multiple benefits have been cited for providing this direct care model through telemental health. Patients may be more comfortable being seen by a specialist, but within the familiar environment of their PCMH clinic. Patients may be more willing to seek mental healthcare if the care is not associated with the stigma of being seen in a mental health setting. Finally there are often financial implications, as patients can often be seen closer to their homes and places of employment or education, with limited travel costs and fewer of the costs associated with time off work or school (Rabinowitz et al. 2010; Loh et al. 2013).

One of the limitations of using telemental healthcare to provide direct care is that it does not necessarily expand the access to mental health services. Although it may be more convenient for patients to be seen at the PCMH site, they may have to wait just as long to see a provider via telemental healthcare as they would in person. By providing direct services, telemental healthcare may only redistribute the mental health workforce.

Consultation models

The second category of integrating telemental health services into the PCMH seeks to more directly address the workforce issue by promoting consultation care. In this model, the mental health provider does not offer ongoing care of the patient. The mental health provider may evaluate the patient via the videoteleconference network and then provide the primary care provider treatment recommendations via a consultation report. Alternatively, the mental health provider may discuss the case with the primary care provider as a “curbside” consultation either via telephone or videoteleconferencing. Several programs employing either one or both of these methods are being developed around the country, and research in this area is growing (Katon and Unutzer 2011; Hilt et al. 2013; Keller and Sarvet 2013). Most models incorporate training and education for the primary care teams regarding mental healthcare assessment, diagnosis, and treatment. For example, the Child and Youth Psychiatric Consult Project of Iowa (CYC-I) offers monthly webinars on mental health topics of interest to primary care providers in addition to being available for phone consultation regarding specific patient-related questions. Ultimately, the success of a telemental health consultation model depends upon the strength of the relationships between the mental health providers and the primary care providers (Kriechman and Bonham 2012). Mental health providers can strengthen these relationships by fostering respect and trust between the providers by acknowledging the unique skill sets and knowledge the primary care providers have, and by taking the time to learn about the community and patients that the primary care providers serve. Over time, primary care providers often become more confident in managing common psychiatric problems in their patients, and the role of the psychiatrist evolves into assisting with more challenging cases (Massachusetts Child Psychiatry Access Project 2012).

Depending upon how these relationships are structured, the telemental health consultation model can easily fill the need for mental health integration in the PCMH. In some instances, the consulting mental health provider could be considered a virtual part of the PCMH team and assist in providing comprehensive care. For example, Hilty et al. (2006) described programs in California in which they worked closely with primary care providers in delivering care. Some strategies included providing written reports within 10 minutes of seeing a patient, being readily available by phone for “curbside” questions, and encouraging primary care providers to participate in the patients' videoteleconference appointments (Hilty et al. 2006). In other arrangements the consulting mental health provider acts as a specialist with whom the PCMH team coordinates care. An example includes Project Extension for Community Health Outcomes (ECHO) in New Mexico. Various specialists, including mental health providers, provide consultations to primary care providers in addition to regularly scheduled didactic sessions. In the didactic sessions, the Project ECHO team helps promote local providers who have developed expertise in certain topics in order to build community resources (Arora et al. 2011). In another example, Dobbins described a year-long case conference-based course led by a psychiatric consultant, which was designed to replace more traditional didactics in a family medicine department and help build the primary care providers' confidence and clinical skills in treating children with mental and behavioral health concerns (Dobbins et al. 2011). Finally, consultation programs that provide ongoing didactics on evidence-based practices and standards of care can be an instrumental component in quality and safety improvement programs within PCMHs.

Reimbursement is a limitation of consultation models. Whereas consulting mental health providers can be reimbursed on a fee-for-service basis for consultations in which the patient is seen, subsequent follow up discussions or other “curbside” consultations with primary care providers cannot be billed. ACOs and other payment reform models may address this limitation, but are not yet readily available or widespread enough to have a meaningful impact at this time.

Collaborative care models

The final category of integrating mental health into primary care using telemental health strategies can be described as the collaborative care model. The collaborative care model has demonstrated comparable effectiveness with in-person care (Unutzer et al. 2002; Katon et al. 2010). In this model, the mental health provider treats the patient collaboratively with the primary care provider, primarily by providing weekly supervision of an on-site care manager. The collaborative care model relies on a care manager who administers screening tools, tracks treatment response through a patient registry, monitors patients to ensure adequate follow-up and identify challenges to treatment adherence before they become problematic, and identifies when patients may need a referral to the consulting psychiatrist or other specialized care. Implementation of this model requires considerable effort to establish relationships, build clinical processes, and, particularly, to support the care manager's role. The additional work needed to implement the model through telemental healthcare is starting to be examined (Fortney et al. 2007; Kriechman and Bonham 2012; Fortney et al 2013). Fortney and colleagues at the University of Arkansas have shown positive outcomes with decreases in remission rates for depression, increases in medication adherence, and increases in quality of life ratings when collaborative care models are implemented using telemental healthcare (Fortney et al. 2007, 2013).

Of the three categories, the collaborative care model is most consistent with the principles of the PCMH. By its very definition, the collaborative care model seeks to provide comprehensive care by utilizing a multidisciplinary team approach, including mental healthcare. Not only does using a shared treatment plan helps ensure care coordination, but tracking and monitoring patients through a care manager leads easily to quality and safety measures as well as improvement projects.

Much like the consultation model, reimbursement in traditional fee-for-service environments does not readily support the collaborative care model. At the current time, this model is most likely to be sustainable in settings such as federally qualified health centers that receive additional funding to provide specialty healthcare or through contractual arrangements (Fortney 2013; AIMS Center 2014), but the model has the potential to become more widespread as different payment models are utilized with ACOs. Furthermore, extensive work must be done to establish the relationships and build the clinical processes for this model to be implemented.

Conclusion and Clinical Significance

Although it is widely recognized that the United States healthcare system faces incredible change in the next several years, no one can predict for certain what form the evolving system will ultimately take. It seems clear, however, that the “triple aim” will be at the foundation. Patients, providers, and policy makers are demanding a system that improves access to care while improving outcomes and reducing total healthcare costs (Berwick et al. 2008). PCMHs have been accepted as a standard of care for patients with chronic and/or complex medical problems, and the inclusion of PCMHs as part of the Affordable Care Act indicates a growing role for PCMHs in the future. Including mental healthcare will be vital to the success of PCMHs, or any other model addressing chronic, complex conditions, and telemental healthcare is uniquely poised to address the limited access to mental health services that many patients and providers in PCMHs face. Telemental healthcare has a growing database of research supporting its feasibility, acceptability, and effectiveness as a service model for delivering mental healthcare. The improved accessibility to mental healthcare that is created via telemental health will strengthen the novel approaches to population health and team-based care that have been implemented in PCMHs, making telemental health and PCMHs ideal partners. Although research is still needs to be done on this partnership, the early results are promising.

Disclosures

No competing financial interests exist.

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