MAY 14, 2015
New Models for
Integrating Behavioral
Health and Primary Care
Lessons from Six Colorado Health Care Providers
CHI sta members contributing to this report:
Anna Vigran, lead author
Brian Clark
Amy Downs
Cli Foster
Deb Goeken
Michele Lueck
Acknowledgements
Arne Beck, PhD, Director of Quality Improvement and Strategic Research, Institute for Health Research,
Kaiser Permanente Colorado
Ruth N. Benton, CEO, New West Physicians
Maribel Cifuentes, RN, Deputy Director of Advancing Care Together (ACT), University of Colorado School
of Medicine, Department of Family Medicine
Mindy Klowden, MNM, Director, Oce of Healthcare Transformation, Jeerson Center for Mental Health
Jonathan Muther, PhD, Director of Behavioral Health & Psychology Training, Salud Family Health Centers
Michael Pramenko, MD, Executive Director of Primary Care Partners, and practicing physician
at Family Physicians of Western Colorado, a division of Primary Care Partners
Pam Wise Romero, PhD, Chief Clinical Ocer, Axis Health System
Cheryl Young, MA, LMFT, Behavioral Health and Wellness
Our Funders
On the cover
Health Coach Gabriela Pena meets with a patient at Union Square Health Home in Lakewood. BRIAN CLARK/CHI
Table of Contents
4 Introduction
5 The Five Critical Success Factors
6 Integrated Care: Putting Health Together Again
8 What is Behavioral Health Integration?
9 Integrating Behavioral Health and Primary Care in Colorado
10 Taking the First Step
10 Success Factor One: Align the Level of Integration
With Patient Needs and Practice Capacity.
12 Success Factor Two: Innovate and Adapt Both the
Workforce and the Workplace.
14 Success Factor Three: Create New Funding Models
that Support Integration.
15 Success Factor Four: Recognize that Patient Numbers
Impact Integration Potential.
16 Success Factor Five: Lead Creatively and Learn Constantly.
17 Conclusion
19 Case Studies
20 New West Physicians
22 Primary Care Partners
24 Kaiser Permanente Colorado
26 Salud Family Health Centers
28 Cortez Integrated Healthcare
30 Union Square Health Home
32 Endnotes
New Models for Integrating
Behavioral Health and Primary Care
Lessons from Six Colorado Health Care Providers
4 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Introduction
Colorado is forging ahead with new models of care delivery that integrate the treatment
of behavioral health and physical health.
These evolving models combine physical health care with behavioral health care, often
in one setting and with one team of providers, instead of the traditional method of
providing these services separately.
By consolidating physical and
behavioral care, practices across
the state are aiming to make their
patients healthier while lowering
long-term costs in the process.
And as the Aordable Care Act
leads to more Coloradans with
insurance that covers mental
health and substance use needs,
health care organizations are
hoping to better meet increased
demand.
Colorado is placing a big bet on
the expected benets of blending
physical and behavioral health
care. Care integration is a focus
of Colorado’s $65 million State
Innovation Model (SIM) award
from the Centers for Medicare
& Medicaid Services (CMS).
The state’s goal is to have fully
integrated primary and behavioral health care
available to 80 percent of Coloradans by 2019.
This bet, however, builds on a solid foundation of
work underway in Colorado. Many practices already
are innovating around integration in both the private
and public sectors.
The Colorado Health Institute (CHI) studied six
practices that are testing an array of approaches to
integration, tailoring models to their locations, their
client populations, their workplace cultures and their
available resources, among other considerations.
These groundbreaking clinics are spread across
Colorado in both urban and rural areas. Some are
privately funded while others are supported by
public money. But they have at least two things in
common. Each demonstrates how communities
are developing local health care solutions to meet
local needs. And each has lessons for Colorado’s
policymakers, health care leaders and practices just
beginning the integration journey.
Based on our analysis of these practices, CHI
has identied ve critical success factors for
implementing an integrated approach to care
delivery.
While integration is a complex undertaking,
practices both inside and outside of Colorado
can consider these factors as part of a strategic
approach to the hard work of combining primary
care and behavioral health.
The hub of New West Physicians behavioral health initiative is its clinic in Golden. BRIAN CLARK/CHI
Colorado Health Institute 5
MAY 14, 2015
The Five Critical Success Factors
1. Align the Level of Integration With Patient
Needs and Practice Capacity.
Focusing on patient needs drives the most
eective integration models. Patient needs
exist along a continuum for both behavioral
health care and medical care, from prevention
and wellness services to complex and ongoing
care for chronic conditions. The complexity of
patient needs drove the integration models we
observed, ranging from primary care providers
consulting with mental health professionals
located in the same building to hiring mental
health clinicians to join the practice.
2. Innovate and Adapt Both the Workforce
and the Workplace.
Many of today’s clinicians have not been
trained to work on integrated primary care and
behavioral health teams. We observed that
new kinds of providers, or providers practicing
in new ways, are the linchpin to eective
integration. The best workplace cultures for
integration are exible, able to adapt quickly
but thoughtfully to a changing environment.
3. Create New Funding Models That Support
Integration.
The scale at which behavioral health care
can be combined with primary care services
will largely depend on how quickly payment
models that can sustain integration are
implemented. Demonstrating a return on
investment, both nancially and in improved
health outcomes, will help persuade insurers
to pay for more services that are critical to
providing integrated care.
4. Recognize that Patient Numbers Impact
Integration Potential.
Patient volume drives decisions regarding the
level of integration and the specialization of the
integrated team, according to our observations.
A practice must care for enough patients to
support the infrastructure and sta needed to
provide the range of needed behavioral health
and medical services.
5. Lead Creatively and Learn Constantly.
Integration is new. It presents many challenges.
And practice leaders must be creative and
exible to address them. The leaders we
observed are committed to the model,
attentive to providing the resources and
training to make it work and willing to make
midcourse corrections. Ongoing evaluation will
be essential to better understand the clinical
and business reasons for integration. While
necessary, it will be costly.
Colorado’s Denition of
Behavioral Health Integration
“The care that results from a practice team of
primary care and behavioral health clinicians,
working together with patients and families, using
a systematic and cost-eective approach to provide
patient-centered care for a dened population.
This care may address mental health, substance
abuse conditions, health behaviors (including
their contribution to chronic medical illnesses), life
stressors and crises, stress-related physical symptoms
and ineective patterns of health care utilization.”
CHI’s analysis highlights critical questions that
practices should ask as they decide on a care
delivery model, identies useful strategies for
advancing integration and provides lessons
from the eld for providers and policymakers
in a rapidly changing environment.
This is a rst look at a quickly evolving eld.
Many of these models are new, and evaluation
is, in many cases, just beginning. CHI will
continue to track progress, following up with
the clinics proled here to learn more about
what is working well and what challenges
remain.
6 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Integrated Care
Putting Health Together Again
1. Good behavioral health is key to good overall health.
Behavioral Health Includes:
The Connection
Mental Health
Concerns:
From temporary depression
and anxiety to severe
and persistent
mental illness.
Unhealthy
Behaviors:
Diet, not enough
physical activity,
smoking and more.
Substance Use
Disorders:
Problematic use
of alcohol, tobacco
and drugs.
Smoking, high blood
pressure, obesity and
inadequate physical activity
are all leading risk factors of
chronic disease and premature
death that can be improved
through behavior change.
1
About 1 of 10
Coloradans (10.6%)
Report poor mental health, dened as eight or more days in the
past month when their mental health was not good.
2
About 866,000
Coloradans (17.1%)
Needed behavioral health services at some point during the year,
according to the most recent estimates available (2009).
4
Of Coloradans reporting Good Mental Health 90.0% also report Good Physical Health.
3
Of Coloradans reporting Poor Mental Health 55.3% also report Good Physical Health.
3
Colorado Health Institute 7
MAY 14, 2015
2. But the traditional health care system treats behavioral health
and physical health separately.
3.
Integrating behavioral health care
and primary care treats the whole person.
Behavioral
Health Care
Lost in
the Middle
Primary
Care
Often the rst place
that behavioral health
needs are identied.
But when patients are
referred to a behavioral
health provider, many
don’t go.
5
Patients in the mental
health system often
don’t get physical
health care, which
can lead to premature
death from treatable
medical conditions.
8, 9
Most mental health conditions
aren’t treated at all or are
inadequately treated.
6
Nearly eight percent of
Coloradans – more than 337,000
people – report not getting
needed mental health services.
7
A Picture of Integrated Care
• One team of providers, both primary care and behavioral health
• A systematic and cost-eective approach
• Sharing information on a timely basis
• A dened group of patients and their families.
• Improved Health
Outcomes
• Lower Cost
• Better Experience of Care
The Goals
8 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
The patient has a care team consisting of both
primary care and behavioral health clinicians.
They collaborate to address physical health,
mental health, substance use, stress and
behaviors that contribute to chronic illness.
The care team also helps the patient to more
eectively use the health system.
An integrated model uses standard
procedures such as screenings and
consultations to identify needs and to provide
access to appropriate care. But it also has
exibility to serve varied populations. For
example, people with severe and persistent
mental illness often require a dierent care
team than those who are generally healthy.
There are a variety of ways to deliver care in a
more integrated way:
• Providers might work in separate locations
with established systems to refer patients
and communicate about their needs.
• Co-locating the physical health and
behavioral health providers in the same
building, or even in the same oce
space, could be the next step. This makes
communication easier and allows patients
to consult with both providers at the same
time.
• A care team that shares exam rooms, medical
records, scheduling and visits with patients,
represents an even more fully integrated
approach.
The Standard Framework for Levels of
Integrated Healthcare, published by the
SAMSHA-HRSA Center for Integrated Health
Solutions, provides detailed descriptions
of how key elements of integration —
communication, physical proximity and
practice change integration — dene
six levels of integration. These levels of
integration range from minimal collaboration
to a fully merged, integrated practice.
10
What is Behavioral Health Integration?
The State Innovation Models (SIM) initiative — a Centers
for Medicare & Medicaid Services Innovation Center
program – supports state-level testing of innovative
approaches to health care delivery and payment.
Colorado won a $65 million SIM award in December
2014, one of 17 states to receive this kind of funding.
Each awardee has detailed a “big idea” that will
accelerate movement toward the Triple Aim goals of
better health care, improved health outcomes and
lower costs.
Colorado’s big idea is to improve the health of
Coloradans by providing access to integrated primary
care and behavioral health services for 80 percent of
the state’s residents by 2019. The integrated care will
be delivered in coordinated community systems and
be supported by value-based payment structures.
The vision includes practice transformation,
population health and consumer engagement,
payment reform, robust IT infrastructures and quality
measurement.
Colorado’s Timeline
2015: Ramp up with practice assessment tools,
IT infrastructure and regional planning
2016: 100 practices on board; launch
regional population health transformation
collaboratives; ongoing evaluation
2017: 150 practices on board
2018: 150 practices on board
Colorado’s SIM Project
Colorado Health Institute 9
MAY 14, 2015
Integrating Behavioral Health
and Primary Care in Colorado
The six practices studied by CHI illustrate an array
of approaches to integrating behavioral health and
primary care. Three are safety net providers that focus
on serving low-income and vulnerable populations.
The other three are commercial market practices,
which rely primarily on payments from commercial
insurers. (See Map 1.) They were selected for the
diversity of settings and models they represent.
SAFETY NET
Cortez Integrated Healthcare
This clinic on Colorado’s Western Slope is part of Axis
Health System, which also operates a community
health center in Durango as well as community
mental health centers and school-based health
centers across southwest Colorado. The Cortez clinic,
designed specically for integrated care, opened in
January 2012. Primary care and behavioral health
providers work in tandem in shared exam rooms,
supported by new tools for screening and sharing
health information with both providers and patients.
Salud Family Health Centers
A community health center with 10 clinics across
north central Colorado, Salud Family Health Centers
has provided integrated care for nearly 20 years. Each
primary care clinic has at least one behavioral health
provider sharing exam rooms and electronic medical
records with the primary care providers. The behavioral
health providers screen new and high-risk patients,
provide consultation with medical providers and other
members of the care team, as well as provide ongoing
behavioral health care and therapy services.
Union Square Health Home
Serving adults with serious mental illness, Union
Square Health Home launched in early 2013 in a new
Lakewood building. Enrollees receive both behavioral
health and medical care at the same clinic. Care
coordination is the central component of this health
home approach, facilitating collaborative, team-
based care. It is a partnership between Jeerson
Center for Mental Health, a community mental
health center, Metro Community Provider Network,
a community health center, and Arapahoe House, a
substance use disorder treatment provider.
COMMERCIAL PRACTICES
New West Physicians
This is a primary care group practice with 18 locations
across metro Denver. New West refers patients to
therapists and a child psychiatrist who rent oce
space from New West and accept private insurance,
but are not employees. These behavioral health
providers communicate closely with primary care
providers to better coordinate care. New West
recently hired an adult psychiatrist who primarily
manages medication and collaborates closely
with primary care providers via a shared electronic
health record. New West accepts insurance for this
employed psychiatrist.
Primary Care Partners
A private practice with three locations in the Grand
Junction area, Primary Care Partners participates
in a variety of payment reform pilot projects that
support integration of behavioral health and primary
care. Behavioral health providers rotate through the
primary care clinic, so there is always a behavioral
health provider available for consultations, diagnoses
and referrals. The behavioral health providers are
employed by a behavioral health practice that shares
a building with Primary Care Partners.
Kaiser Permanente Colorado
A health care system with 32 medical oces along
the Front Range, Kaiser is both an insurer and a
provider. Because of this, medical records are shared
by primary care, behavioral health and specialist
providers, making Kaiser well situated to provide
integrated services. Kaiser has placed behavioral
health providers in primary care clinics to improve
communication and to promote patient acceptance.
Behavioral health providers are part of care teams
designed for patients with specic diagnoses, such
as those who have both depression and poorly
controlled diabetes.
Read our case studies beginning on page 19.
10 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Lessons from the practices CHI observed will be
useful as a guide for the initial strategic thinking
and the subsequent on-the-ground implementation
necessary to increase the integration of behavioral
health and primary care.
Each of these six practices began by answering basic
questions such as as the number of patients they
serve, the level of their physical and behavioral health
needs, the services that would be reimbursed and
available funding streams to cover unreimbursed
services.
They then delved into workforce decisions, training
options, data sharing and IT requirements, as well as
funding.
All of these considerations led to the most important
strategic decision: selecting the level and look of
integration appropriate for their practice.
Important thinking on this process has been done
by the federally funded SAMSHA-HRSA Center for
Integrated Health Solutions. Its Standard Framework
for Levels of Integrated Healthcare describes six levels of
integrated care, ranging from minimal collaboration
between a medical provider and a behavioral health
provider to a fully integrated practice where care is
merged and the approach to providing care has been
transformed. (Please see Figure 1.)
11
Several practices observed for this paper are
operating at high levels of collaboration, approaching
full integration.
The safety net organizations most closely meet the
criteria for full integration. They tend to be high-
volume clinics serving populations with more acute
behavioral health needs and they often have access
to grant funding to support integrated models of
care. Behavioral health and primary care providers
share clinic space, patients and clinical data.
Behavioral health is an integral part of the primary
care visit for all new patients as well as those who
need further behavioral health services.
Several clinics, both private and public, have
behavioral health and primary care providers in the
Taking the First Step
same location, sharing at least some clinical systems
and meeting regularly to discuss patient needs.
For some clinics, co-location with close collaboration
is the best model for now and may be sucient to
meet the needs of most of their patients, particularly
if their patient population is relatively healthy. For
others, it may be a step toward further integration.
This paper analyzes these important decisions
through the framework of the success factors we
observed at the six Colorado clinics.
Success Factor One:
Align the Level of Integration
With Patient Needs and Practice Capacity.
Focusing on patient needs drives the most eective
integration models that we observed. These needs,
Map 1. The six practices studied by CHI
New West Physicians (Denver Metro Area)
Primary Care Partners (Grand Junction)
Kaiser Permanente Colorado (Front Range)
Salud Family Health Centers (Northern/Central Colorado)
Cortez Integrated Healtcare (Cortez)
Union Square Health Home (Lakewood)
Colorado Health Institute 11
MAY 14, 2015
both for behavioral health care and medical care,
exist along a continuum from prevention and
wellness services on one end to complex and
ongoing care for chronic conditions on the other.
Poor physical health contributes to poor behavioral
health, and vice versa, so people with high physical
health needs often have signicant behavioral health
needs as well.
Still, it is challenging for practices to assess which
services are most frequently needed by their patients.
They must rst dene the client population and then
identify which services are needed and how often
they are needed.
Some services, such as screenings and preventive
care, are frequently provided because many people
can benet from them. More complex and specialized
services are needed less often — unless the practice
serves a specic population. For example, a clinic
that specializes in treating people with severe mental
illness will see greater need for long-term therapy.
All six clinics conduct screening for common
Based on the SAMHSA-HRSA Standard Framework for Integrated Healthcare
behavioral health conditions, such as depression
and anxiety. Based on the results, they may provide
access to short-term therapy, substance use disorder
treatment or longer-term therapy. The therapy is
either provided in the practice’s integrated setting or
through referral if the patient’s needs are better met
in a dierent setting.
Cortez Integrated Healthcare and Union Square
Health Home, two safety net providers where many
patients have high levels of behavioral health needs,
provide the most specialized services in an integrated
setting, including long-term therapy and psychiatric
medication management by a psychiatrist. Salud sees
patients with a range of behavioral health needs.
On the commercial side, New West provides more
limited integrated services — mostly screening
and referral — because its patients tend to have
fewer needs and it is not reimbursed for counseling
services. New West, however, recently hired a
psychiatrist to provide psychiatric medication
management and it has established a close working
relationship with therapists. Primary Care Partners
Figure 1. Six Levels of Integrated Care*
Coordinated Co-Located Integrated
Level 1 Level 2 Level 3 Level 4 Level 5 Level 6
Beginning
Collaboration
Basic
Collaboration
at a Distance
Basic
Collaboration
On-Site
Close
Collaboration
On-Site, Some
Systems
Integration
Close
Collaboration,
Approaching
Integrated
Practice
Full
Collaboration,
Transformed/
Merged/
Integrated
Practice
Key Element:
Communication
Key Element:
Proximity
Key Element:
Practice Transformation
12 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
oers more integrated services because it receives
funding from pilot projects.
The Kaiser Permanente Colorado system oers all
services, with screening and short-term therapy
provided in the primary care clinic and all other
services referred to other Kaiser departments. The
prevention and wellness department provides
behavior change education and coaching. The
behavioral health department provides more
intensive and longer-term behavioral health services.
Many of the practices started integration work with
a focus on mental health but are exploring ways to
expand into more behavior change coaching.
Success Factor Two:
Innovate and Adapt Both the Workforce and the
Workplace.
After identifying patient volumes and needs,
practices can begin to focus on assembling the
appropriate workforce, from care coordinators or
health coaches who have less specialized training,
to doctoral-level providers, such as psychologists or
psychiatrists. (See Figure 2.)
Practices Behavioral Health Services
Screening
Behavior
Change
Education
Short-Term
Therapy
Substance Use
Treatment
Long-Term
Therapy
Psychiatric
Medication
Management
New West Yes
For patients
with diabetes,
pre-diabetes
Referred Referred Referred
Psychiatrist or
primary care
provider w/
consultation
Primary
Care Partners
Yes Yes Yes
Some
services
Referred
Primary care
provider w/
consultation,
referred as needed
Kaiser
Permanente
For higher
risk
patients
Some in
primary care
clinic; some
referrred to
prevention
department
Yes
Some
services;
referred as
needed
Referred to
behavioral
health
department
Some in
primary care clinic;
some referred to
behavioral health
department
Salud Family
Health Centers
Yes Yes Yes
Some
services;
referred as
needed
Referred
Primary care
provider w/
consultation,
referred as needed
Cortez
Integrated
Healthcare
Yes Yes Yes Yes As needed As needed
Union Square
Health Home
Yes Yes No* Yes All clients Yes
Figure 2. The Six Practices: Behavioral Health Services Integrated with Primary Care
* All patients need long-term therapy
Colorado Health Institute 13
MAY 14, 2015
Many of the practices we observed have contracts
with other organizations or providers instead of
hiring all members of the care team. Some of the
practices have hired sta to help navigate social
support resources such as housing or applications for
public benets. (See Figure 3.)
Patient care teams vary based on need. Union Square
Health Home, for instance, has highly specialized
providers because it has many patients with acute
needs. But New West Physicians relies more on
referral relationships with counselors, while a New
West psychiatrist maintains communication with
primary care doctors through a shared electronic
health record.
Generally, a primary care provider and a master’s
degree-level counselor make up the core care team.
Many practices have a psychologist on sta, but fewer
have sta psychiatrists. Many of the practices we
studied provide some substance use treatment from
mental health counselors with special training.
The practices often assign care coordinators to
patients with specic needs, such as diabetes, or
people with depression who also have diabetes
or heart disease. Some clinics have added peer
specialists, health coaches or transitional case
managers.
Although many of the practices do not have
specialists on sta, they all have referral relationships
with organizations that can provide those services.
For example, Salud Family Health Centers has ties
with community mental health centers where it can
refer patients.
Existing relationships often guide how care teams
are developed. When Primary Care Partners decided
to bring behavioral health providers into its clinic, it
turned to providers already working in its building.
Union Square Health Home grew out of many years
of collaboration between organizations specializing
in medical care, mental health and substance abuse
treatment.
Even after these stang decisions are made,
implementing team-based care is challenging. Many
providers do not have training or experience in
these new models of care. Each team member must
learn to work with the rest of the team, coming to
Practice Types of Care Providers
Primary Care
Care
Coordinator
Counselor/ Clinical
Social Worker
Substance Use
Disorder Specialist
Psychologist Psychiatrist
New West Yes
For diabetic,
pre-diabetic
patients
Referred Referred No As needed
Primary Care
Partners
Yes As needed Yes As needed As needed Referred
Kaiser
Permanente
Colorado
Yes
For patients
with certain
diagnoses
Referred to
behavioral
health
department
Referred to
behavioral
health
department
Yes
Referred to
behavioral health
department
Salud Family
Health Centers
Yes
For many
Medicaid
patients
Yes As needed Yes
Consultation and
referral
as needed
Cortez Integrated
Healthcare
Yes As needed Yes As needed As needed As needed
Union Square
Health Home
Yes Yes Yes As needed Yes Yes
Figure 3. The Six Practices: Providers on Integrated Care Teams
14 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
consensus regarding clinical decisions. The team
must continually evaluate what is working and what
is not and make changes to support the integrated
model.
Creating an adaptive clinic culture is crucial to
ensuring that teams work well.
Enhanced communication is also a crucial component
of successful integration. Both the sharing of clinical
data and direct communication, in person, over the
phone or by other means, is necessary.
Where an organization stands on communication —
from sharing some information between providers
via a printed care plan to a fully shared electronic
medical record to regular team meetings — depends
on the structure of the organization, available
resources and how long the integration project has
been in place. (Please see Figure 4.)
Implementing new technologies to improve data
sharing can be expensive, and larger practices are
often better able to cover the up-front costs. Kaiser
and Salud are large organizations with fully integrated
electronic medical record systems that include
behavioral health information. Providers have access to
patient records — with the exception of therapy notes
that are protected by law — at any time.
Union Square Health Home is much smaller and
newer. It is working to create a system of electronic
medical records between behavioral health
providers and medical providers and is now sharing
some information electronically, but this work is
complicated and only possible at this smaller scale
due to a grant.
Cortez Integrated Healthcare also used grants to
develop a way to share information between the
electronic medical record systems used for behavioral
health services and the systems used for medical
services.
Success Factor Three:
Create New Funding Models
that Support Integration.
Historically, behavioral health care and medical
care have been paid for separately, with dierent
billing requirements. Because of this, most of today’s
insurance payment models are not designed to
support integrated care.
12,13, 14
And some aspects of
integrated care, such as brief consultations between
providers, aren’t reimbursed at all.
Any viable business needs to be paid for its work.
Identifying a sustainable source of funding is key to
implementing behavioral health integration. It’s also
a signicant obstacle to large-scale integration in
Colorado.
15, 16, 17
The safety net practices we observed have been
successful in obtaining grant funding to help support
the higher costs of integration. (See Figure 5.)
For example, workforce training grants support about
a third of the behavioral health sta at Salud Family
Health Centers. Cortez Integrated Healthcare received
grants to build its clinic and launch the new approach
to care.
Pilot programs may be funded without a long-term
commitment. For example, Primary Care Partners is
participating in a pilot program funded by the Center
for Medicare & Medicaid Innovation and another by
the Colorado Health Foundation. Both are testing the
cost eectiveness of new payment models.
Figure 4. The Progression of Data Sharing
Information
Shared on
Paper:
• Union
Square
Health Home
• New West
• Primary Care
Partners
Electronic
Sharing of
Some
Information:
• Union
Square
Health Home
• Cortez
Integrated
Healthcare
• Primary Care
Partners
• New West
Fully
Integrated
Electronic
Medical Record:
• Salud Family
Health
Centers
• Kaiser
Permanente
Colorado Health Institute 15
MAY 14, 2015
But private practices generally fund the integrated
services internally. They will need to demonstrate
a return on investment to private insurers in order
to scale up a sustainable integration model in the
private market.
New West Physicians, for example, has no additional
funding for integrated care. Most private insurers
have separate contracts for behavioral health and
physical health services. New West plans to hire
therapists within the next year who are credentialed
with their insurers, which would allow New West to
bill for behavioral health care on a fee-for-service
basis.
This will strengthen integration at New West because
the sta therapist will share the practice’s electronic
health record system with medical providers. Still,
New West doesn’t expect fee-for-service payments to
cover the cost of providing behavioral health services.
To address this gap, New West hopes to negotiate a
contract that includes capitated payment for both
medical and behavioral health services.
Kaiser Permanente Colorado, as both the insurer
and provider of care, has a capitated model based
on a per member per month payment for all care,
including physical and behavioral health. While this
avoids the need to bill separately for services, it is still
challenging to design a budget that funds dierent
departments and supports integrated care.
Kaiser’s providers are paid out of their departmental
budgets. But the costs of integration and savings
from more eective care are often seen across
departments. For example, better integrated
care may result in fewer visits to the emergency
department, but that integration requires more
services from the behavioral health department.
Success Factor Four:
Recognize that Patient Numbers
Impact Integration Potential.
Serving a critical mass of patients is an important
starting point for integrating care. While practices of
any size can move toward increased integration, the
question of how many patients are served must be
considered as the integrated model is developed.
Hiring new providers will be more cost eective if
there are enough patients to keep their schedules
full. So having teams that always include at least one
medical provider and one behavioral health provider
is only feasible if the practice is seeing enough
patients with these needs.
Primary Care Partners, for example, generally sees
the same group of patients on an ongoing basis. It
found that over the course of a year, most patients
had been in for an appointment, and many of their
behavioral health needs had been addressed. Primary
Care Partners still believes that having a behavioral
health provider working in the primary care clinic is
benecial for both patients and providers, but pent-
up demand has largely been met.
The number of patients served also aects the
nancial viability of some approaches of behavioral
health integration. If a per capita payment is
available for integrated care, that funding will only
cover the costs of the additional time, workforce
and infrastructure to support integration if there
are enough patients. Smaller practices may not
see enough patients for a per capita payment for
integrated care to cover the costs.
Figure 5. The Spectrum of Funding Models
No Additional
Funding for
Integration:
• New West
Grant Funding,
Pilot Programs
or Partnerships:
• Union
Square
Health Home
• Cortez
Integrated
Healthcare
• Primary Care
Partners
• Salud
Family Health
Centers
Combined
Payment for
Behavioral
Health, Medical
Care, Costs of
Integration:
• Kaiser
Permanente
16 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Success Factor Five:
Lead Creatively and Learn Constantly.
All of the leaders of the practices described in this
paper believe in the promise of integration and are
nationally recognized in this eld. And each is a
creative and supportive manager, which is critical in
leading a team toward a new model of care.
They repeatedly emphasize the importance of
having partners at all levels of the organization
who understand, value and promote integration.
This new model of care needs to be woven into the
fabric of the practice.
Ruth Benton, CEO of New West Physicians, says that
New West began working toward a more integrated
model of care because primary care providers saw
that their patients needed these services. New West
continues to move forward with a more integrated
approach even though the organization isn’t
making a prot on this model. She is committed
to a more integrated approach, and hopes that in
the future payment reforms will make it nancially
sustainable.
Tillman Farley, medical director of Salud Family
Health Centers, has championed integration of
behavioral and physical health care. Having the
medical director focusing on the need for behavioral
health helped establish it as a priority among the
sta.
Bern Heath and Pam Wise Romero have led the
development of Cortez Integrated Healthcare,
transforming a community mental health center into
an integrated health care system. Acknowledging
that their integrated model of care is new and
dierent, they developed a series of trainings
for clinic workers to make sure the model is fully
understood and implemented.
Each practice we studied also values ongoing
learning and evaluation. But some have more
resources than others to take this on. (See Figure 6.)
The larger organizations and those with grant
funding are more likely to have robust evaluation
plans. But even then, evaluations tend to focus
on current needs of the organization or a funder’s
research interest.
Some evaluations are anecdotal. Others explore how
integrated care is being implemented. Some are
also looking at the patient and provider experience,
gathering qualitative data about integrated care from
those perspectives. And several are looking at health
outcomes, measuring whether patients become
healthier after receiving integrated care.
For example, Salud is assessing how integrated care
aects pregnant women and new mothers. Union
Square Health Home is including all patients enrolled
in the health home in its evaluation in order to
understand the eect of integrated care on the health
of those with serious and persistent mental illness.
As payers seek evidence that integrated care
improves quality and helps contain costs, large-scale
evaluations will be essential.
Provider
feedback
Qualitative data on
patient and provider
experience of care
Quantitative process
measures (e.g. screening,
follow-up treatment)
Health outcomes
New West Physicians x
Primary Care Partners x x x x
Kaiser Permanente Colorado x x x x
Salud Family Health Centers x x x x
Cortez Integrated Healthcare x x x x
Union Square x x x x
Figure 6. Evaluation Approaches
Colorado Health Institute 17
MAY 14, 2015
Examining specic examples of behavioral health
integration takes the leap from theory to practice,
illustrating both the challenges and the rewards for
patients, care providers and health care organizations.
Practices are trying dierent approaches to integrate
behavioral health and primary care based on the
number of patients served, the needs of those
patients and reimbursement. They are reporting
benets to increased integration. Providers
appreciate the ability to consult with their behavioral
health or medical counterparts and they believe
it is helping patients get the care they need. Early
ndings indicate that patients appreciate integrated
services as well and show improvements in health.
While each situation is unique, an overview of the six
Colorado practices provides themes and lessons that
can be useful as health leaders seek to strengthen
behavioral health integration.
Integration is happening quickly. Part of the
challenge is identify the balance of services that are
both helpful to patients and nancially sustainable,
and to identify the most ecient and eective team
to deliver those services.
Conclusion
Dr. James Bachman, MD, left, and Dr. Deborah Casuto, PsyD, right, discuss a patient’s health at Kaiser Permanente’s Skyline Medical Oces in Denver. BRIAN CLARK/CHI
18 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Colorado’s State Innovation Model (SIM):
Colorado has been awarded a federal innovation
grant to implement a transformation of the state’s
health system. Integration of behavioral health
and primary care is one of the major goals. More
information is available at https://sites.google.com/a/
state.co.us/sim-colorado
Advancing Care Together (ACT):
This ve-year program provided funding to 11
demonstration projects in Colorado to identify and
test promising models of integrating behavioral
health and primary care, to evaluate processes
and outcomes of these models, and to actively
disseminate results and best practices. Funded by the
Colorado Health Foundation and led by the University
of Colorado Department of Family Medicine, ACT
began in 2011. Funding to demonstration sites ended
in August 2014. Evaluation results will be available
in the fall of 2015. For more information, please visit
www.advancingcaretogether.org
Sustaining Healthcare Across Integrated
Primary Care Eorts (SHAPE):
This project is a collaboration between Rocky
Mountain Health Plans, the University of Colorado
Department of Family Medicine, the Colorado Health
Foundation and the Collaborative Family Healthcare
Association. The objectives are to determine if a
global payment method will support and sustain
the integration of behavioral health in primary care,
understand how dierent payment models aect
clinical models of care and related costs and test the
real world application of a global payment model to
inform future policy. SHAPE is working with six family
practices on Colorado’s Western Slope to accomplish
these objectives.
This is a three-year project, which began in
spring of 2013. More information is available at
www.sustainingintegratedcare.net
Colorado Medicaid’s Accountable Care
Collaborative Payment Reform Pilot Initiative:
In July 2013, the Colorado Department of Health Care
Policy and Financing selected a payment reform pilot
program, as required by legislation passed in 2012
(HB12-1281). The selected proposal was developed
by Rocky Mountain Health Plans, in collaboration
with a number of community partners, including
mental health centers. This program, called Medicaid
PRIME, is being implemented in seven Western Slope
counties.
Colorado Behavioral Health Integration Projects
Colorado Health Institute 19
MAY 14, 2015
New West
Physicians
PAGE 20
Primary Care
Partners
PAGE 22
Kaiser Permanente
Colorado
PAGE 24
Case Studies
Salud Family
Health Centers
PAGE 26
Cortez Integrated
Healthcare
PAGE 28
Union Square
Health Home
PAGE 30
A sign directs patients at New West Physicians, which is integrating behavioral health and primary care. BRIAN CLARK/CHI
20 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
New West Physicians is a private practice group with
18 locations in the metro Denver area. Primary care
physicians founded the group 20 years ago to deliver
high-quality, cost-eective, patient-centered care in a
physician-owned practice.
The idea of adding mental health care to the mix took
shape a few years ago. New West Physicians estimated
that more than half of its patients suered from
depression or anxiety that could not be adequately
addressed in a primary care visit and that most
weren’t seeking treatment. So, the practice formed
a partnership with three mental health counselors,
adding a new dimension to its care.
New West does not have additional funding to support
behavioral health integration. Counselors are not
employees of New West. As independent providers,
they do their own billing for services, though New
West requires that they accept private insurance from
at least the four biggest carriers. Many mental health
providers in private practice don’t accept insurance,
but New West wants to accommodate patients with
coverage.
New West also works with two psychiatrists. One,
specializing in child and adolescent psychiatry,
contracts with New West and bills private insurance.
The other psychiatrist, who works with adults, is a
full-time New West employee. This psychiatrist mostly
oversees medication management for patients with
complex needs and works closely with the counselors
and primary care providers. New West bills insurance
for the psychiatrist’s services for adults. The practice
is planning to hire a mid-level psychiatric provider
very soon, as well as a neurologist who will work at
the same location. New West plans to hire counselors
within the next year, once it has nalized an agreement
with insurers so New West can bill for those services.
Approach to Integration
The hub of New West’s behavioral health initiative is
its clinic in west Denver, although it will soon expand
into a new space as the number of behavioral health
providers continues to grow. Both psychiatrists
are based at the clinic. As an employee, the adult
psychiatrist uses the same medical record system as
primary care providers, allowing information to be
easily and securely shared.
Currently, three counselors, each with a master’s
degree, rent space in the west Denver location,
and collaborate with primary care providers. Two
counselors maintain other oce locations; the third
works exclusively out of the New West space.
The counselors mostly provide short-term treatment
— three to six sessions on average. They do not have
access to New West electronic medical records, but
do share notes with primary care providers if the
patient agrees. Medical care is not provided at the
west Denver counseling oce.
Initially, it was a challenge to get patients who might
benet from therapy to make an appointment with a
counselor. Primary care providers would give patients
an informational brochure, but that approach had
limited success; only about 40 percent of patients
referred actually saw a counselor. So, New West tried a
pilot program at a couple of clinics, creating a release
form that patients could sign to allow the counselor
to call them. The number of referrals that led to
counseling appointments increased to approximately
60 percent.
Lessons Learned
New West is not formally evaluating this model of
care. But primary care providers say they are more
likely to refer patients to mental health services now
that they have a specic place to send them. The fact
that more referrals lead to appointments suggests
that New West patients nd these services helpful.
The adult psychiatrist’s schedule is now booked for
several months, and New West plans to hire a mid-
level psychiatric provider to handle demand.
New West Physicians
Critical Decisions: Patients Served, Patient Needs and Funding
CASE STUDY
Colorado Health Institute 21
MAY 14, 2015
Over the next year or so, New West intends to make
counselors employees instead of contract workers.
This would allow them to use the New West medical
record system, which would improve communication
and coordination with primary care providers.
Counselors could potentially work out of several New
West locations, making behavioral health services
more convenient for patients.
But rst New West must nd a way to pay for such a
move.
The stumbling block is the way insurers pay for
behavioral health services. Generally, an insurance
company contracts with a single provider
organization and pays a set amount for each
policyholder — a capitated rate. Even though New
West is a large practice, it doesn’t yet have sucient
scale with any one insurer to get a capitated payment
to hire counselors. That could change as New West
continues to grow and negotiates with insurers on
more sophisticated reimbursement approaches that
reward integration of services and quality of care.
A more immediate step is hiring counselors who
are credentialed by the organization that has the
behavioral health contract, so New West can bill
that organization for behavioral health services. This
would allow New West to hire the counselors, likely
within the coming year.
New West is committed to integrating behavioral
health care. Ruth Benton, CEO of New West, says
although the practice is losing money on these
services, the value in providing better, comprehensive
care is worth the expense.
Dr. Lindsey Harrison, left, meets with a patient at the New West Physicians oce in Golden, the hub of New West’s behavioral health initiative. BRIAN CLARK/CHI
22 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Grand Junction, the largest city in western Colorado,
is known for spectacular vistas, oil and gas
development and an innovative health care system.
The Grand Junction health care model has attracted
national attention for the way physicians, hospitals
and insurers work together to provide low-cost,
high-quality care using a variety of approaches,
including data-sharing and new models of payment.
Researchers have identied leadership by the primary
care community as one of the key features of Grand
Junction’s health care success.
18
Grand Junction’s largest provider of primary care is
Primary Care Partners, a physician-owned private
practice with more than 50 clinicians serving about
60,000 patients in three clinics. The partners use a
medical home model, which is designed to provide
comprehensive, patient-centered, team-based,
coordinated care.
To better serve patients, the group agreed to try new
payment structures to support behavioral health
integration. Central to this approach is the long-
standing relationship the practice has with Behavioral
Health and Wellness, a group of independent
providers that has shared a building with Primary
Care Partners’ largest family practice for a decade.
Three programs are supporting Primary Care Partners’
behavioral health integration. The Comprehensive
Primary Care initiative (CPC), a multi-payer program
designed to strengthen primary care, provides a per
patient per month payment, which is adjusted based
on the health status of the patient. Primary Care
Partners uses a portion of the CPC money to contract
with Behavioral Health and Wellness, which places
counselors in primary care clinics. Another program,
Advancing Care Together (ACT), is evaluating the
expansion of the patient-centered medical home
model to include behavioral health. The third
program, Sustaining Healthcare Across Integrated
Primary Care Eorts (SHAPE), is testing a global
payment methodology — paying one lump sum
instead an amount for each service.
Approach to Integration
Counselors spend a couple of days a week in a
primary care clinic. They may be called in by a primary
care clinician to provide brief interventions. For
example, a doctor treating someone who wants to
get o opiates may enlist a counselor to help the
patient. Or a counselor may coach a patient on how
to manage stress or make healthy lifestyle changes.
This “warm hand o” approach better meets the
patient’s need and lets medical providers focus on
what they are trained to do. If there has been a “warm
hand o,” the counselor will often be present at a
follow-up medical appointment.
Besides such interventions, counselors also provide
follow-up visits, up to four half-hour sessions a day.
Patients who need more than a half-dozen follow-ups
are referred to someone at Behavioral Health and
Wellness or elsewhere based on their condition and
insurance coverage.
The counselors have a variety of specialties and most
hold master’s degrees. Psychologists are available
to participate in joint visits with a medical provider
for patients with complex needs. At the two largest
clinics, a behavioral health provider works with a
dozen primary care providers. The ratio is one-to-
seven in the smaller clinic. Primary Care Partners
also employs one care coordinator for every four or
ve primary care physicians, plus one who works
with patients coming out of the hospital. Patients
can reach their care coordinator by phone, and the
care coordinator can make referrals to either primary
care or behavioral health services. A behavioral
health provider is part of the team that oversees care
coordination plans for high-risk patients.
To enhance communication, behavioral health
providers enter notes in the Primary Care Partners’
Primary Care Partners
Critical Decisions: Patients Served, Patient Needs and Funding
CASE STUDY
Colorado Health Institute 23
MAY 14, 2015
electronic medical record, which can be agged
as condential. There is currently no sharing of
electronic medical records between Primary Care
Partners and Behavioral Health and Wellness, but
patients can approve information exchange to
improve coordination of care.
Lessons Learned
Primary Care Partners has found integrating medical
and behavioral care to be challenging. Some
counselors don’t take to the rhythms and demands
of primary care. Every time a new counselor comes in
to a primary care clinic, relationship building starts all
over again. The team approach is new for everyone,
and establishing rapport between providers takes
time.
The behavioral health providers work part time with
Primary Care Partners, allowing them to continue
practicing in a traditional mental health setting.
Those with extensive experience tend to be most
comfortable in the clinics. The practice has found
that these veterans can more easily adapt to the
faster pace of a primary care oce and have the
background to quickly assess a situation and refer the
patient to appropriate resources in the community.
This integrated model of care is expensive, mostly
due to personnel costs. Primary Care Partners
believes a fee-for-service model doesn’t work for
integrated care. That’s why it likes the model currently
being tested — a per patient per month payment
to cover services such as care coordination and
behavioral health integration. The model allows the
practice to keep evaluating how best to provide
holistic care in a nancially sustainable way.
Despite challenges, Primary Care Partners reports
promising results. Physicians have seen an increase
in completed behavioral health referrals, lower
rates of hospital readmission and no change in the
generally low rates of emergency department use.
That said, it’s unknown whether these results are due
to behavioral health integration, care coordination,
or both. The payment model is being evaluated, but
results are not yet available. Evaluators are looking
at changes in utilization, patient satisfaction and
improvement in physical and behavioral health as
well as changes in overall cost of care, projected cost
and nancial sustainability. Details of the evaluation
plans are available from SHAPE, CPC and ACT.
19, 20,
21
Behavioral
health clinician
Cheryl Young,
M.A., LMFT,
talks to a patient
at Primary Care
Partners in Grand
Junction, a medical
home designed
to provide
comprehensive,
patient-centered,
team-based,
coordinated care.
SPECIAL TO CHI
24 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Kaiser Permanente Colorado is the state’s largest
not-for-prot health plan, serving 623,000 Coloradans
from Fort Collins to Pueblo. It is both the insurer and
the provider of primary and specialty care, including
behavioral health services. Kaiser Permanente
Colorado does contract with providers in some
communities, though most members see clinicians
employed by the Colorado Permanente Medical
Group.
Integrating behavioral medicine specialists into
primary care started about three years ago, initially
to collaborate with primary care teams in managing
patients with mental health needs who frequently
visited the emergency department.
As insurer and provider, Kaiser Colorado’s premiums
cover all costs — it doesn’t bill an outside payer
for specic procedures, although providers do
record standard diagnosis (ICD-9) and procedures
codes (CPT) in a patient’s electronic medical record.
Integrating behavioral health with primary care can
trim overall costs. Addressing patients’ behavioral
health may reduce their need for more expensive
emergency or inpatient services. On the other hand,
the cost of care may increase if patients are referred
to behavioral health for treatment that they may not
have received before.
Approach to Integration
The Kaiser model simplies many aspects of
integration. For example, Kaiser Colorado has a
shared electronic medical record system that all
its providers can access. It has several integration
projects underway and is evaluating dierent
approaches to serve dierent populations.
The basic approach is this: Clinical psychologists,
called behavioral medicine specialists, have an oce
in the primary care department. They consult with
primary care providers, but also have appointments
of their own. Patients may be referred by their
primary care provider or as a result of an automated
screening that identies a behavioral health problem
such as depression or anxiety.
Behavioral medicine specialists encounter a range
of conditions, including depression, anxiety, ADHD
and severe mental illness. They don’t have their own
panel of patients and typically see a patient two or
three times to provide assessment, diagnosis and
brief interventions such as behavioral activation or
cognitive behavioral therapy. Behavioral medicine
specialists can refer patients to the prevention
department, which provides a variety of psycho-
educational material via classes, webinars and online
resources, or to the behavioral health department for
ongoing therapy and/or psychotropic medications.
Kaiser Colorado has 11 behavioral medicine
specialists, all with doctorate degrees. Most split
their time between two clinics because there is not
sucient funding for a full-time behavioral medicine
specialist at all 22 primary care clinics.
Behavioral medicine specialists are part of a larger
approach to integration. Some serve on Kaiser’s many
care management teams, such as those for patients
with chronic conditions, complex health needs or
frequent visits to the emergency room.
All providers, behavioral medicine specialists,
and members of the care management teams,
communicate through Kaiser’s electronic medical
record system, which is a key component of
integration. For example, a care manager may use the
system to recommend a larger dose of depression
medication for a patient. The primary care provider
would review the suggestion and either approve it via
the medical record system or follow up with the care
manager with questions or concerns. Mental health
information that is protected by law is not shared
through the medical record system.
To be enrolled with a care management team,
a patient must have a qualifying diagnosis, or a
Kaiser Permanente Colorado
Critical Decisions: Patients Served, Patient Needs and Funding
CASE STUDY
Colorado Health Institute 25
MAY 14, 2015
combination of conditions. In a pilot project, Kaiser
Colorado is providing integrated care management
to patients who have depression as well as poorly
controlled diabetes or cardiovascular disease.
The project is called Care of Mental, Physical, and
Substance Use Syndromes (COMPASS) and is funded
by the Center for Medicare & Medicaid Innovation,
with the goal of improving patient outcomes
and reducing unnecessary hospitalizations. Initial
results demonstrate improvements in depression
symptoms, diabetes control and blood pressure.
Results for hospitalizations are not available yet.
Lessons Learned
Kaiser Colorado is studying the reach and impact of
having behavioral medicine specialists in primary
care, using qualitative feedback from providers
and patients, as well as tracking data on visits,
assessments and referrals. Kaiser has already
found that primary care providers are more likely
to screen for depression and anxiety because
they know behavioral medicine specialists are
ready to help. Some
primary care providers
have also reported
referring patients to a
behavioral medicine
specialist instead of
simply prescribing
medication. The
team approach helps
primary care providers
and patients become
more familiar with
the behavioral health
department, increasing
communication and
minimizing stigma that
may be a barrier to
seeking treatment.
That said, there
are challenges to
integration. The clinical
settings for primary care
and behavioral health
are dierent, requiring orientation and adjustment
for new behavioral medicine specialists joining
primary care clinics. The primary care focus
is on assessments, brief consultations and
interventions. The pace is faster and there is more
focus on immediate problem-solving. Behavioral
health assessments can take longer than many
primary care visits. Kaiser Colorado is still working
to overcome these cultural dierences.
The COMPASS evaluators are looking at whether
this model is a sustainable way to improve the
health and care experience for patients with
complex medical and behavioral health needs and
to trim costs by reducing unnecessary emergency
and inpatient services. Complete evaluation
results for COMPASS will be available in fall 2015.
Other evaluations are looking at the eects
of screening, therapy groups and telephonic
coaching on particular populations (for example,
pregnant women with depression), as well as the
use of electronic medical record data to identify
high-risk groups for mental health care needs.
Dr. Denise Hunter, MD, left, consults with Dr. Deborah Casuto, PsyD,
at Kaiser Permanente’s Skyline Medical Oces in Denver. BRIAN CLARK/CHI
26 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Salud Family Health Centers opened its rst clinic in
a Fort Lupton apartment in summer 1970 to serve
migrant laborers in southern Weld County. It soon
converted an onion warehouse across the street
into a medical and dental facility. Today, Salud is
a federally qualied health center with 10 clinics
serving 10 Colorado counties, plus a mobile health
unit that provides care to migrant and seasonal
farmworkers and does community outreach.
The majority of patients are low-income rural
residents with access to few, if any, other health
services. Many are uninsured, prefer services in a
language other than English and lack transportation.
Salud uses a medical home approach, providing
comprehensive and integrated medical, dental and
behavioral health services and promoting prevention
and early intervention. Salud served 70,000 patients
in 2014 through 280,000 visits.
Salud’s Director of Medical Services, Dr. Tillman Farley,
led the integration of behavioral health and primary
care beginning in 1997. Farley, who had worked with
an integrated model before, saw that many of Salud’s
patients had behavioral health needs brought on by
stress related to immigration and poverty. Integration
has been incremental. A big step came in 2009, when
Salud hired a director of integrated services to ensure
that both a patient’s mental and physical well-being
were considered in all health and administrative
decisions. A year later, Salud created a mission
statement reecting its approach to integration. It
says the organization will strive to “deliver stratied,
integrated, patient-centered, population-based
services utilizing a diverse team of behavioral health
professionals who function as primary care providers
(PCPs), not ancillary sta, and who work shoulder-to-
shoulder with the rest of the medical team in the same
place, at the same time, with the same patients.”
22
Salud is not reimbursed by insurance for behavioral
health services. About a third of the cost is covered
by grants, including funding for a psychology training
program; a third by Salud’s general budget; and a
third by in-kind services from community partners
whose behavioral health sta work exclusively at a
Salud clinic. Patients are not charged for behavioral
health services provided in the context of a medical
appointment. There is a sliding fee scale, based
on family size and income, for uninsured patients.
Colorado Medicaid contracts with behavioral health
organizations (BHOs), so while Salud does provide
behavioral health services to Medicaid clients, it does
not bill for those services.
Approach to Integration
Behavioral health and medical providers work in
tandem at Salud clinics. Patients have an initial
medical screening, including measures of blood
pressure, weight and height. Next, a behavioral
health provider evaluates the patient for depression,
anxiety, trauma, tobacco, alcohol, and drug use. The
provider also asks about the safety of the patient’s
living environment. If there are concerns, the
behavioral health provider inquires further and, if
necessary, provides immediate intervention, referral
and consultation with the medical provider.
The goal is for each Salud patient to have a behavioral
health screening once per year, or more often if
needed. A patient with a persistent problem can
meet again with a behavioral health provider when
returning to a clinic for a medical reason or make
an appointment for a traditional therapy session.
This continuing care is solution-focused with an
average of ve visits and rarely more than a dozen.
For substance use disorders, Salud provides limited
individual outpatient treatment and often refers to
outside providers.
Behavioral health providers only spend about a third of
their time doing traditional therapy. They hold master’s
degrees in disciplines such as social work, counseling
and psychology, or doctoral degrees in psychology.
Each provider works at only one clinic to strengthen
Salud Family Health Centers
Critical Decisions: Patients Served, Patient Needs and Funding
CASE STUDY
Colorado Health Institute 27
MAY 14, 2015
the team approach. Salud’s larger clinics have three or
four behavioral health providers while smaller clinics
have one. Depending on the size of the clinic sta, the
ratio of behavioral health providers to primary care
clinicians ranges from one to three to one to six.
Behavioral health providers typically see patients
with mental health problems but their role may
expand beyond this. Salud would like them to
provide more coaching on health behavior changes,
including pain management, eating and exercise
patterns, medication compliance and more. But
expanding those services is dicult. For one thing,
behavioral health providers are busy serving patients
with mental health needs. Some may lack training
or interest to take on health behavior roles. Also,
medical providers may not realize how a counselor
or psychologist can help a person achieve healthier
behaviors and often feel limited by time constraints
and other workow considerations.
Lessons Learned
Salud’s data collection and analysis mostly focuses
on physical health.
There is still work to
be done in tracking
behavioral health
over time. Salud has
recently adopted a
measurement system
for mental health
outcomes, degrees
of integration
(i.e., collaboration
between members of
care team), as well as
social determinants
of health and the
impact on physical
and mental health
outcomes.
Salud is evaluating
a program that
provides behavioral
health screening and treatment for high-risk
pregnant women. Those who need ongoing support
work with a psychologist regularly through the
pregnancy and for six weeks postpartum. If the
patient needs additional care, she is referred for
follow-up services. The evaluation looks at screening,
follow-up treatment and changes in severity of
symptoms. It also includes qualitative data on
the patient experience and feedback from the
psychologist. This evaluation is part of the Advancing
Care Together (ACT) program, which is testing
promising models of integrating behavioral health
and primary care across Colorado.
The Salud experience with integrated care
underscores the importance of building relationships
between dierent kinds of providers, clinic sta,
clinic managers and with community organizations.
The impetus for integration came from the medical
director, not outside entities. This was important in
establishing the culture and leadership to support
the partnership between behavioral health and
primary care.
Physician Assistant Tara Clemens, PA-C, visits with a access to health services. SPECIAL TO CHI
28 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
Axis Health System opened Cortez Integrated
Healthcare in January 2012 in a new building in
Cortez, a small city in the far southeast corner of the
Colorado, minutes from Mesa Verde National Park.
The clinic embodies six years of thinking on how to
provide health care that meets all the patient’s needs
— for both body and mind.
This was such a signicant change that the
organization renamed itself to reect the new
approach to care. For 50 years it had been the
Southwest Colorado Mental Health Center and had
provided mental health and substance use treatment
to residents of ve counties. Axis added primary care
services starting at the Cortez location; it also operates
La Plata Integrated Healthcare, two School-Based
Health Centers in Durango and three clinics that only
provide mental health and substance use treatment.
Axis CEO Bern Heath and the Chief Clinical Ocer,
Pam Wise Romero, led the transition from traditional
mental health center to integrated health care
system. They knew that many people treated for
mental health problems or substance use disorders
did not receive sucient medical care and vice
versa. Initially, they embedded behavioral health
providers in medical oces that partnered with Axis.
Though helpful, the approach didn’t reach the level
of integration they wanted. So, Heath and Romero
started from scratch. As Heath describes it, they
decided to “bake a new cake” with all the ingredients
of holistic care — mental health, primary care,
substance use disorder treatment and wellness.
Three years after opening, the Cortez clinic is serving
nearly 2,700 patients. The goal is to serve more than
twice that many when the clinic is operating at full
capacity.
The clinic receives separate reimbursements for
behavioral health services and medical care. As the
Medicaid behavioral health provider in the area,
Axis Health Systems is paid on a capitated basis for
Medicaid patients. Medicaid insures about half of
the clinic’s patients, a number that increased after
Colorado expanded eligibility in January 2014.
Slightly less than a third of patients have private
insurance, just under 10 percent are enrolled in
Medicare and nearly 18 percent are uninsured and
pay on a sliding fee scale.
For medical care, the clinic bills Medicaid, Medicare
and private insurance on a fee-for-service basis.
Those without insurance pay a sliding fee scale.
Care provided by therapists who are teamed
with a primary care clinician is billed dierently,
depending on the situation. Sometimes it is classied
as a complex physical health visit, sometimes as a
behavioral health visit and sometimes it is not eligible
for insurance reimbursement.
The Cortez clinic is still guring out how to nancially
sustain its version of integrated care. A global
capitated model of payment would better support
its operations, but insurers currently won’t reimburse
that way. Becoming a federally qualied health center
— which has already happened for the Axis La Plata
clinic in Durango — would also help, because such a
designation would allow the Cortez clinic to receive
an enhanced Medicaid payment and grant money to
subsidize care for the uninsured.
Approach to Integration
Patients can make an appointment for behavioral health
care, medical care or both. About 80 percent receive
integrated care; the rest receive behavioral health
services but stay with their outside medical provider,
though more are turning to the Cortez clinic for their
physical health needs. The clinic continues to accept
behavioral health referrals from other medical providers.
New patients complete a variety of screenings. They
use a digital tablet to ll out a questionnaire about
their physical and behavioral health. The results are
scored electronically and reviewed by the provider
and patient on an electronic “Health Tracker” that
shows a graphical representation of the data. This
Cortez Integrated Healthcare
Critical Decisions: Patients Served, Patient Needs and Funding
CASE STUDY
Colorado Health Institute 29
MAY 14, 2015
system, developed by Axis, merges information from
medical and behavioral electronic records to provide
comprehensive, “real time” information to guide care
decisions. It is available at touch screen monitors in
exam and consultation rooms. Patient screening is
repeated regularly.
At the rst medical appointment, the patient is
introduced to a therapist who teams with the primary
care provider. This therapist might briey talk with the
patient about, say, changing their habits to improve
health or setting up a series of counseling sessions.
Patients who need longer-term therapy, beyond
a half-dozen visits, may be referred to a dierent
behavioral health provider at the clinic.
The number and composition of the medical sta
has uctuated. The Cortez clinic currently has four
primary care providers, most working part time.
There is a family practice physician, a physician’s
assistant and two pediatric providers. There are nine
behavioral health providers, most with master’s
degrees. They are employed by Axis at the Cortez
clinic, although a few split their time between Axis
clinics or work part time. There is one psychologist
at the Cortez clinic. A psychiatrist works in the clinic
part time for consultation and to see patients. A
full-time psychiatric nurse
practitioner provides
consultation and follow-
up care, and a child
psychiatrist is available
via teleconference for
consultation.
Lessons Learned
The Cortez clinic is
participating in two
Colorado studies on
implementing and funding
integrated behavioral
health care. The Advancing
Care Together (ACT)
program supported
development of Health
Tracker and is evaluating
how it helps guide care
decisions. The Sustaining
Healthcare Across
Integrated Primary Care
Eorts (SHAPE) is evaluating the impact of dierent
payment models on integrated clinics and if a global
payment approach — paying one lump sum instead
of individually for each service provided — would
nancially sustain integrated care.
Internally, the clinic tracks a patient’s health status.
For adults, it records information on body mass index
(BMI), blood pressure, depression, alcohol use and
health-related quality of life. Similar measures are
tracked for adolescents and children. Axis has seen
improvement on most of these measures. Notably,
early analysis suggests patients treated for depression
in the integrated clinic make as much progress as
patients treated for depression in the traditional
mental health clinics Axis runs, even though the
treatment in the integrated care setting is less
intensive.
The Cortez clinic illustrates the complexity of moving
from the concept of integrated care to practice.
23
Transitioning to an integrated care clinic required
collaboration between behavioral health and medical
providers. It took quite some time and a good deal of
turnover before Axis assembled a full team ready to
work together. The time, energy and eort required
to fundamentally change how care is delivered
should not be underestimated.
Dr. Whitney Pack, a pediatrician at Cortez Integrated Healthcare, interviews a young patient before
beginning a physical exam. BRIAN CLARK/CHI
30 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
The Union Square Health Home is a program at the
Union Square Health Plaza building in Lakewood. The
building, owned and operated by Jeerson Center
for Mental Health, houses mental health emergency
and wellness services on the rst oor and integrated
medical and behavioral health services on the
second. The Jeerson Center, a community mental
health center, has served the metro area west of
Denver and mountain communities in Jeerson, Clear
Creek and Gilpin counties for more than 50 years.
Jeerson Center partners with Metro Community
Provider Network (MCPN), a federally qualied
health center providing medical care, and with
Arapahoe House, which oers substance use disorder
treatment.
Jeerson Center bought the Union Square Health
Plaza building in September 2012. This new space
allowed the center to expand a successful pilot
project it started a couple of years earlier. Jeerson
Center developed the pilot after a review found
that 2,000 of its adult Medicaid enrollees who were
receiving behavioral health services did not have a
regular source of medical care. So, Jeerson Center
and its partners deployed primary care and substance
use treatment providers to three of Jeerson Center’s
largest clinics, making it easier for patients to access
treatment for substance use disorders, hypertension,
high cholesterol, diabetes and more. Those clinics
were designed to be entry points to primary care and
had very limited capacity. Jeerson Center applied
for a grant from the Substance Abuse and Mental
Health Service Administration (SAMHSA) to develop
a more fully integrated, long-term program for adults
with serious mental illness. This led to the creation of
Union Square Health Home.
The Health Home serves roughly 450 people with
serious mental illness, providing both behavioral and
medical care. To qualify, patients must be residents
of Jeerson County and not have a primary care
provider. They have been diagnosed with a serious
mental illness, agree to receive all their care at that
clinic and allow various measures of their health to be
tracked. Jeerson Center expects to have 600 patients
enrolled by the end of 2015.
Behavioral health and medical services are
reimbursed separately. For behavioral health,
Jeerson Center receives capitated Medicaid
payments — about 65 percent of Health Home
enrollees are covered by Medicaid. That proportion
grew due to eligibility expansion. Private insurance
and Medicare are billed for patients with those kinds
of insurance. They account for about 15 percent
of Health Home patients. Local, state, federal and
foundation grants cover behavioral health care for
uninsured individuals, who account for just over
20 percent of enrollees. Substance use treatment
is paid for through a contract between Arapahoe
House and Jeerson Center. The Metro Community
Provider Network is reimbursed for medical
services by private insurance and receives Medicaid
payments as a federally qualied health center.
Some of the SAMHSA grant supports primary care
for the uninsured who can’t pay for services and for
some specialist care when there is no other payer
sources. Mostly, the SAMHSA grant supports services
that currently are not reimbursable by any payer,
including care coordination, health coaching, data
management and evaluation.
Approach to Integration
Collaborative care planning is key to the model. Care
coordination is provided by a registered nurse or
social worker. The coordinator explains the program
to patients, helps them enroll if they choose to do
so and works with them to develop a care plan that
includes their health goals. In addition to hallway
consultations, every week all providers meet to
discuss patient needs and identify areas of concern
or follow-up. The coordinator maintains patients’
integrated collaborative care plans in each of four
domains (physical health, mental health, substance
use and wellness) and shares these documents
Union Square Health Home
Critical Decisions: Patients Served, Patient Needs and Funding
CASE STUDY
Colorado Health Institute 31
MAY 14, 2015
with providers for review and update as needed.
The Health Home is exchanging continuity of care
documents electronically and hopes to expand
its participation in electronic health information
exchange through the Colorado Regional Health
Information Organization (CORHIO) in the future.
The care coordinator regularly telephones patients,
answers their questions and handles scheduling.
Patients often come to the Health Home for one
reason — a regular therapy appointment, for
example. But if they need medical care as well, the
care coordinator makes appointments as close to
the therapy session as possible. In addition, a peer
health coach generally meets with the patient once a
month, although these meetings can be more or less
frequent depending on the needs of the patient.
Most Union Square mental health therapists have
master’s degrees and are licensed. The Health Home
sta also includes psychiatrists, a psychiatric nurse
and a psychiatric medical assistant. Substance
use treatment is provided by a licensed addiction
counselor. Medical care is provided by a family nurse
practitioner and a medical assistant. More medical
providers will be added as the number of patients at
the Union Square Health Plaza grows.
All providers, including the care coordinator, peer
health coach, and primary care and behavioral
health clinicians, meet once a week to
discuss patient needs in a holistic way.
Approximately ve cases are taken
up per meeting and usually involve
patients with more complex health
care conditions.
Health Home enrollees receive other
services: Members of Jeerson
Center’s navigation team help patients
with benets enrollment, housing,
vocational assistance and connects
them to other community resources.
Wellness services, including nutrition,
exercise and individualized health
coaching, are provided by the wellness
team. Peer specialists are also part of
the Health Home team.
Lessons Learned
Jeerson Center hired an independent evaluator to
assess Union Square Health Home’s eectiveness.
The evaluator is looking at individual outcomes for all
Health Home patients, including measures of physical
health, such as blood pressure, BMI and blood
sugar, as well as hospital admissions and emergency
room visits, nights spent in jail or homeless shelters,
tobacco and other substance use and how patients
perceive their own health. At the population level,
evaluators are measuring whether patients are
using more or fewer high-cost services such as
hospital admissions, readmissions or emergency
room visits. The evaluators will provide progress
updates to Jeerson Center; the nal evaluation
will be completed in 2017. Early results show that
the Health Home has been eective at reducing
depression and suicidal thoughts. They also show
improvement in physical health, with fewer patients
at risk of metabolic syndrome after being enrolled in
the Health Home for six months. Although data are
limited, there has been a decrease in hospitalizations,
use of detox services, jail time and emergency room
visits for behavioral health needs.
Creating infrastructure to support integration, such as
sharing electronic records and an electronic care plan,
has been challenging and time consuming. Union
Square Health Home has grant funding to continue
development of this integrated approach over the
next couple of years.
Health Coach Gabriela Pena meets with a patient at Union Square Health Home in Lakewood.
BRIAN CLARK/CHI
32 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
1
Danaei G, Ding EL, Mozaarian D, Taylor B, Rehm J, Murray CJL, et al. (2009) “The Preventable Causes of Death in the United States: Comparative Risk Assessment of
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2
Colorado Health Institute analysis of the 2013 Colorado Health Access Survey
3
Colorado Health Institute analysis of the 2013 Colorado Health Access Survey
4
TriWest Group (2011). “The Status of Behavioral Health Care in Colorado – 2011 Update. Advancing Colorado’s Mental Health Care.” Caring for Colorado Foundation, The
Colorado Health Foundation, The Colorado Trust and The Denver Foundation: Denver, CO.
5
Colorado’s State Health Innovation Plan. (2013)
Available at: http://www.coloradohealthinstitute.org/key-issues/detail/new-models-of-health-care/colorado-state-innovation-model-sim
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Wang, P.S. et al. (2005) “Twelve-Month Use of Mental Health Services in the United States: results from the National Comorbidity Survey Replication.”
Archives of General Psychiatry Jun; 62(6): 629-40. http://www.ncbi.nlm.nih.gov/pubmed/15939840
7
Colorado Health Institute analysis of the 2013 Colorado Health Access Survey
8
De Hert, M. et al. (2011) “Physical Illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care.”
World Psychiatry, Feb; 10(1): 52-77. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048500/
9
National Association of State Mental Health Program Directors (NASMHPD) (2012) “Reclaiming Lost Decades: The Role of State Behavioral Health Agencies in
Accelerating the Integration of Behavioral Healthcare and Primary Care to Improve the Health of People with Serious Mental Illness.”
http://www.nasmhpd.org/docs/publications/docs/2012/Reclaiming%20Lost%20Decades%20Full%20Report.pdf
10
SAMHSA-HRSA Center for Integrated Health Solutions. Standard Framework for Levels of Integrated Healthcare.
Available at: http://www.integration.samhsa.gov/resource/standard-framework-for-levels-of-integrated-healthcare
11
SAMHSA-HRSA Center for Integrated Health Solutions. Standard Framework for Levels of Integrated Healthcare. Available at:
http://www.integration.samhsa.gov/resource/standard-framework-for-levels-of-integrated-healthcare
12
Colorado’s State Health Innovation Plan.
13
Center for Improving Value in Health Care (CIVHC). (2013) “Paying for Integrated Primary Care and Behavioral Health:
Identifying Barriers and Developing Strategies to Overcome Them.”
14
The Colorado Health Foundation. (2012) “The Colorado Blueprint for Promoting Integrated Care Sustainability”.
Available at: http://www.coloradohealth.org/studies.aspx
15
Colorado’s State Health Innovation Plan.
16
Center for Improving Value in Health Care (CIVHC). (2013)
17
The Colorado Health Foundation. (2012)
18
Bodenheimer, T. and West, D. (2010) “Low-Cost Lessons from Grand Junction, Colorado.” The New England Journal of Medicine. Oct 7;363(15):1391-3.
http://www.ncbi.nlm.nih.gov/pubmed/20925540
19
Colorado Beacon Consortium. (2012) “Issue Brief: Tear Down this Wall: Rocky Mountain Health Plans embarks on a mission to bring together
behavioral health and primary care.”
20
Centers for Medicare & Medicaid Services. Comprehensive Primary Care Initiative.
Available at: http://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/
21
Advancing Care Together. Primary Care Partners PC, Grand Junction, Colorado.
Available at: http://www.advancingcaretogether.org/innovators-primary-care-partners-gj.php
22
Auxier, A., Farley, T., and Seifert, K. (2011). “Establishing an Integrated Care Practice in a Community Health Center.”
Professional Psychology: Research and Practice. Advanced online publication. doi:10.1037/a0024982
23
Axis Health System. (2014) “Creating an Integrated Healthcare Facility: The Challenges, Missteps and Solutions.”
http://67.230.212.99/wb/Our_Care_Model/Creating_An_Integrated_Healthcare_Facility.pdf
Endnotes
Colorado Health Institute 33
MAY 14, 2015
Union Square Health Home in Lakewood.
BRIAN CLARK/CHI
34 Colorado Health Institute
New Models for Integrating Behavioral Health and Primary Care: Lessons from Six Colorado Health Care Providers
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The Colorado Health Institute is a trusted source of independent and
objective health information, data and analysis for the state’s health care
leaders. The Colorado Health Institute is funded by the Caring for Colorado
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