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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25927.
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Caring for People with Mental Health and Substance Use Disorders in Primary Care Settings PROCEEDINGS OF A WORKSHOP Laurene Graig, Kaitlyn Friedman, and Joe Alper, Rapporteurs Forum on Mental Health and Substance Use Disorders Board on Health Care Services Board on Health Sciences Policy Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by Purchase Order No. 75FCMC19P0036 with the Cen- ters for Medicare & Medicaid Services, Contract No. HHSN263201800029I, Order No. HHSN26300025 with the National Institutes of Health, and by Alkermes, Ameri- can Board of Family Medicine, American College of Clinical Pharmacy, American Psy- chiatric Association, American Psychiatric Nurses Association, American Psychological Association, Association for Behavioral Health and Wellness, Centers for Disease Control and Prevention, Council on Social Work Education, Education Development Center, Health Resources and Services Administration, Janssen Research and Develop- ment, National Academy of Medicine, National Association of Addiction Treatment Providers, Optum Behavioral Health, Think Bigger Do Good Policy Series (a partner- ship of the Scattergood Foundation, Peg’s Foundation, Patrick P. Lee Foundation, and Peter and Elizabeth C. Tower Foundation), U.S. Department of Veterans Affairs, and Well Being Trust. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25927 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Caring for people with mental health and substance use disorders in primary care settings: Proceedings of a workshop. Washington, DC: The National Academies Press. https:// doi.org/10.17226/25927. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technol- ogy. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of ­ ciences, S Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The state- ments and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National A ­ cademies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING COMMITTEE ON CARING FOR PEOPLE WITH MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN PRI- MARY CARE SETTINGS1 DEIDRA ROACH (Co-Chair), Medical Project Officer, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health RUTH SHIM (Co-Chair), Luke and Grace Kim Professor in Cultural Psychiatry, Associate Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis JEFFREY A. BUCK, Senior Advisor for Behavioral Health, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services W. PERRY DICKINSON, Director, Practice Innovation Program; Professor, Department of Family Medicine, University of Colorado (Representing the American Board of Family Medicine) RICHARD G. FRANK, Professor of Health Economics, Department of Health Care Policy, Harvard Medical School HOWARD H. GOLDMAN, Professor of Psychiatry, University of Maryland School of Medicine PAMELA GREENBERG, President and Chief Executive Officer, Association for Behavioral Health and Wellness CAREN HOWARD, Advocacy Manager, Mental Health America R. KATHRYN McHUGH, Director, Stress, Anxiety, and Substance Use Laboratory; Associate Psychologist, SUDs Division, McLean Hospital; Assistant Professor of Psychology, Department of Psychiatry, Harvard Medical School (Representing the American Psychological Association) KATHY PHAM, Director of Policy and Professional Affairs, American College of Clinical Pharmacy MARTIN ROSENZWEIG, Chief Medical Officer, Optum Behavioral Health ALEXANDER ROSS, Senior Behavioral Health Advisor, Office of Planning, Evaluation, and Analysis, Health Resources and Services Administration MATTHEW TIERNEY, Associate Clinical Faculty, University of California, San Francisco, School of Nursing (Representing the American Psychiatric Nurses Association) 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speak- ers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. v PREPUBLICATION COPY—Uncorrected Proofs

Project Staff LAURENE GRAIG, Director, Forum on Mental Health and Substance Use Disorders, and Senior Program Officer KAITLYN FRIEDMAN, Research Associate ANESIA WILKS, Senior Program Assistant SHARYL NASS, Senior Director, Board on Health Care Services ANDREW M. POPE, Senior Director, Board on Health Sciences Policy Consultant JOE ALPER, Writer vi PREPUBLICATION COPY—Uncorrected Proofs

FORUM ON MENTAL HEALTH AND SUBSTANCE USE DISORDERS1 COLLEEN L. BARRY (Co-Chair), Johns Hopkins Bloomberg School HOWARD H. GOLDMAN (Co-Chair), University of Maryland School of Medicine MARGARITA ALEGRÍA, Harvard Medical School DARA BLACHMAN-DEMNER, Office of Behavioral and Social Sciences Research, National Institutes of Health CARLOS BLANCO, National Institute on Drug Abuse, National Institutes of Health DARLA SPENCE COFFEY, Council on Social Work Education W. PERRY DICKINSON, University of Colorado (Representing the American Board of Family Medicine) ROBERT FORMAN, Alkermes RICHARD G. FRANK, Harvard Medical School CHELSEY GODDARD, Education Development Center ALTHEA N. GRANT-LENZY, Centers for Disease Control and Prevention PAMELA GREENBERG, Association for Behavioral Health and Wellness LARKE NAHME HUANG, Substance Abuse and Mental Health Services Administration KRISTIN KROEGER, American Psychiatric Association LAUREN B. LOWENSTEIN, Centers for Medicare & Medicaid Services HUSSEINI K. MANJI, Janssen Research and Development, LLC R. KATHRYN McHUGH, McLean Hospital and Harvard Medical School (Representing the American Psychological Association) BENJAMIN MILLER, Well Being Trust ANNIE PETERS, National Association of Addiction Treatment Providers KATHY PHAM, American College of Clinical Pharmacy JOE PYLE, Scattergood Foundation (Representing Think Bigger Do Good Policy Series) DEIDRA ROACH, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health MARTIN ROSENZWEIG, Optum Behavioral Health ALEXANDER ROSS, Health Resources and Services Administration RUTH SHIM, University of California, Davis 1 The National Academies of Sciences, Engineering, and Medicine’s forums and round- tables do not issue, review, or approve individual documents. The responsibility for the pub- lished Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

MATTHEW TIERNEY, University of California, San Francisco, School of Nursing (Representing the American Psychiatric Nurses Association) MICHAEL TOEDT, Indian Health Service Forum on Mental Health and Substance Use Disorders Staff LAURENE GRAIG, Director, Forum on Mental Health and Substance Use Disorders, and Senior Program Officer KAITLYN FRIEDMAN, Research Associate ANESIA WILKS, Senior Program Assistant MICAH WINOGRAD, Senior Finance Business Partner SHARYL NASS, Senior Director, Board on Health Care Services ANDREW M. POPE, Senior Director, Board on Health Sciences Policy viii PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in mak- ing each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: KIRSTEN BERONIO, National Association for Behavioral Healthcare LYDIA CHWASTIAK, University of Washington BETH McGINTY, Johns Hopkins Bloomberg School of Public Health GREGORY E. SIMON, Kaiser Permanente Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings, nor did they see the final draft before its release. The review of this proceedings was overseen by KENNETH B. WELLS, University of California, Los Angeles. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. ix PREPUBLICATION COPY—Uncorrected Proofs

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Acknowledgments The National Academies of Sciences, Engineering, and Medicine’s Forum on Mental Health and Substance Use Disorders wishes to express its sincere grati- tude to the planning committee co-chairs Deidra Roach and Ruth Shim for their valuable contributions to the development and organization of this workshop. The forum wishes to thank all the members of the planning committee, who collaborated to ensure a workshop complete with informative presentations and rich discussions. Finally, the forum wants to thank the speakers and moderators, who generously shared their expertise and their time with workshop participants. Support from the many sponsors of the Forum on Mental Health and Sub- stance Use Disorders is critical to the forum’s work. The sponsors include the Centers for Medicare & Medicaid Services and the National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, and Office of Behavioral and Social Sciences Research of the National Institutes of Health with Alkermes, American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric Association, American Psychiatric Nurses Association, Ameri- can Psychological Association, Association for Behavioral Health and Wellness, Centers for Disease Control and Prevention, Council on Social Work Education, Education Development Center, Health Resources and Services Administration, Janssen Research and Development, National Academy of Medicine, National Association of Addiction Treatment Providers, Optum Behavioral Health, Think Bigger Do Good Policy Series (a partnership of the Scattergood Foundation, Peg’s Foundation, Patrick P. Lee Foundation, and Peter and Elizabeth C. Tower Founda- tion), U.S. Department of Veterans Affairs, and Well Being Trust. xi PREPUBLICATION COPY—Uncorrected Proofs

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Contents PROCEEDINGS OF A WORKSHOP  1 INTRODUCTION  1 Overview of the Proceedings, 3 MODELS OF CARE FOR PEOPLE WITH MHSUD  4 Key Elements of Integrated Care, 13 Policies to Support Integrated Care, 13 Panel Reactions and Discussion, 16 Question and Answer Session with the Webinar Participants, 19 Closing Remarks of the First Webinar, 21 ESSENTIAL COMPONENTS OF CARE FOR THREE MHSUD CONDITIONS IN PRIMARY CARE SETTINGS  21 Exploring the Essential Components of Care for Alcohol Use Disorder in Primary Care Settings, 21 The Case for Integrating MHSUD into Primary Care, 23 Implementing Collaborative Care Treatment for Depression, 26 Sustaining Successful Interventions in Primary Care Practices, 29 Panel Reactions and Discussion, 31 Question and Answer Session with Webinar Participants, 34 IMPLEMENTATION OF ESSENTIAL COMPONENTS OF CARE IN PRIMARY CARE SETTINGS  37 Implementing the Essential Components of Care in Primary Pediatric Practices, 37 xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv CONTENTS Successful Strategies for Implementing Alcohol SBIRT into Adult Primary Care, 41 Integrating Primary Care and Behavioral Health, 43 Breaking Down Silos to Improve Integrated Care, 45 Panel Reactions and Discussion, 47 Question and Answer Session with Webinar Participants, 50 Closing Remarks of the Second Webinar, 52 IMPROVING THE WORKFORCE TO SUPPORT PROVIDING ESSENTIAL COMPONENTS OF CARE  53 Developing the Workforce to Support Health Centers, 53 The Role of Peer-Support Services in Delivering Collaborative Care to Treat Mental Health and SUDs, 54 Behavioral Health Workforce to Optimize Medication Outcomes, 56 Digital Enhancement of the Primary Care Workforce, 58 Supporting a Workforce for the Provision of the Essential Components of Care, 60 Panel Reactions and Discussion, 62 Question and Answer Session with Webinar Participants, 64 ADDRESSING FINANCING, PAYMENT, PRACTICE, AND SYSTEMS-LEVEL ISSUES, POLICIES, AND INCENTIVES TO SUPPORT PROVISION OF ESSENTIAL COMPONENTS OF CARE  68 Can Primary Care Afford Behavioral Health?, 68 Delivery System Considerations for Integrating Addiction and Mental Health Treatment into Primary Care Settings, 70 Medicare and Medicaid Opportunities and Challenges for Integrating Behavioral Health Care in General Medical Settings, 72 The Addiction Recovery Medical Home Model, 75 Panel Reactions and Discussion, 76 Question and Answer Session with Webinar Participants, 81 CLOSING REMARKS  83 REFERENCES  84 APPENDIX A WORKSHOP STATEMENT OF TASK  93 APPENDIX B VIRTUAL WORKSHOP AGENDA  95 PREPUBLICATION COPY—Uncorrected Proofs

Boxes, Figures, and Tables BOXES 1 Suggestions Made by Individual Participants to Improve Care of People with Mental Health and Substance Use Disorders (MHSUDs) in Primary Care Settings, 5 2 The 5Ds: How Children Differ from Adults in Behavioral Health Care, 39 3 The 10 Guiding Principles of the Addiction Recovery Medical Home Alternative Payment Model, 77 FIGURES 1 Collaborative care, a model for primary care and mental health care integration, based on Wagner’s Chronic Care model, 11 2 Principles of collaborative care for effective implementation, 27 3 Percentage of depression, anxiety, and behavior disorders, by age, 38 4 Core components of the Common Elements Treatment Approach (CETA), 45 5 Mental health care professional shortage areas: Percent of need met, 57 6 The treatment gap for mental health and substance use disorders, 59 7 Delivery and payment systems must be considered together, 71 xv PREPUBLICATION COPY—Uncorrected Proofs

xvi BOXES, FIGURES, AND TABLES TABLES 1 Core Tenets of the Collaborative Care Model, 11 2 Key Elements of Integrated Care, 13 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations ACO accountable care organization CETA Common Elements Treatment Approach CMMI Center for Medicare & Medicaid Innovation CMS Centers for Medicare & Medicaid Services CPC+ Comprehensive Primary Care Plus CTMS clinical trials management system DBSA Depression and Bipolar Support Alliance ED emergency department FQHC federally qualified health center EHR electronic health record HRSA Health Resources and Services Administration IBH-PC integrated behavioral health in primary care MAT medication-assisted treatment MHSUD mental health and substance use disorder OBAT Office-Based Addiction Treatment xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii ACRONYMS AND ABBREVIATIONS OTP opioid treatment program OUD opioid use disorder PCMH patient-centered medical home PharmD doctor of pharmacy PHQ-9 Patient Health Questionnaire major depressive disorder module SAMHSA Substance Abuse and Mental Health Services Administration SBI Screening and Brief Intervention SBIRT Screening, Brief Intervention, and Referral to Treatment SUD substance use disorder PREPUBLICATION COPY—Uncorrected Proofs

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Behavioral health conditions, which include mental health and substance use disorders, affect approximately 20 percent of Americans. Of those with a substance use disorder, approximately 60 percent also have a mental health disorder. As many as 80 percent of patients with behavioral health conditions seek treatment in emergency rooms and primary care clinics, and between 60 and 70 percent of them are discharged without receiving behavioral health care services. More than two-thirds of primary care providers report that they are unable to connect patients with behavioral health providers because of a shortage of mental health providers and health insurance barriers. Part of the explanation for the lack of access to care lies in a historical legacy of discrimination and stigma that makes people reluctant to seek help and also led to segregated and inhumane services for those facing mental health and substance use disorders.

In an effort to understanding the challenges and opportunities of providing essential components of care for people with mental health and substance use disorders in primary care settings, the National Academies of Sciences, Engineering, and Medicine's Forum on Mental Health and Substance Use Disorders convened three webinars held on June 3, July 29, and August 26, 2020. The webinars addressed efforts to define essential components of care for people with mental health and substance use disorders in the primary care setting for depression, alcohol use disorders, and opioid use disorders; opportunities to build the health care workforce and delivery models that incorporate those essential components of care; and financial incentives and payment structures to support the implementation of those care models, including value-based payment strategies and practice-level incentives. This publication summarizes the presentations and discussion of the webinars.

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