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

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

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This activity was supported by Purchase Order No. 75FCMC19P0036 with the Centers for Medicare & Medicaid Services, Contract No. HHSN263201800029I, Order No. HHSN26300025 with the National Institutes of Health, and by Alkermes, Inc., American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric 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 & Development, LLC, 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 & Elizabeth 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: 978-0-309-68268-8
International Standard Book Number-10: 0-309-68268-1
Digital Object Identifier: https://doi.org/10.17226/25927

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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.

PLANNING COMMITTEE ON CARING FOR PEOPLE WITH MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN PRIMARY 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 at Baltimore 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, Center of Excellence in Alcohol, Drugs, and Addiction, 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 speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

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

FORUM ON MENTAL HEALTH AND SUBSTANCE USE DISORDERS¹

COLLEEN L. BARRY (Co-Chair), Johns Hopkins Bloomberg School of Public Health

HOWARD H. GOLDMAN (Co-Chair), University of Maryland at Baltimore 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, Inc.

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 & 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 roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

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

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 making 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:

Although the reviewers listed above provided many constructive comments 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.

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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 gratitude 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 Substance Use Disorders is critical to the forum’s work. The sponsors include the Centers for Medicare & Medicaid Services and 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 and Alkermes, Inc., American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric 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 & Development, LLC, 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 & Elizabeth Tower Foundation), U.S. Department of Veterans Affairs, and Well Being Trust.

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Contents

PROCEEDINGS OF A WORKSHOP

INTRODUCTION

Overview of the Proceedings

MODELS OF CARE FOR PEOPLE WITH MHSUDs

Key Elements of Integrated Care

Policies to Support Integrated Care

Panel Reactions and Discussion

Question and Answer Session with the Webinar Participants

Closing Remarks of the First Webinar

ESSENTIAL COMPONENTS OF CARE FOR THREE MHSUD CONDITIONS IN PRIMARY CARE SETTINGS

Exploring the Essential Components of Care for Alcohol Use Disorder in Primary Care Settings

The Case for Integrating MHSUDs into Primary Care

Implementing Collaborative Care Treatment for Depression

Sustaining Successful Interventions in Primary Care Practices

Panel Reactions and Discussion

Question and Answer Session with Webinar Participants

IMPLEMENTATION OF ESSENTIAL COMPONENTS OF CARE IN PRIMARY CARE SETTINGS

Implementing the Essential Components of Care in Primary Pediatric Practices

Successful Strategies for Implementing Alcohol SBIRT into Adult Primary Care

Integrating Primary Care and Behavioral Health

Breaking Down Silos to Improve Integrated Care

Panel Reactions and Discussion

Question and Answer Session with Webinar Participants

Closing Remarks of the Second Webinar

IMPROVING THE WORKFORCE TO SUPPORT PROVIDING ESSENTIAL COMPONENTS OF CARE

Developing the Workforce to Support Health Centers

The Role of Peer-Support Services in Delivering Collaborative Care to Treat MHSUDs

Behavioral Health Workforce to Optimize Medication Outcomes

Digital Enhancement of the Primary Care Workforce

Supporting a Workforce for the Provision of the Essential Components of Care

Panel Reactions and Discussion

Question and Answer Session with Webinar Participants

ADDRESSING FINANCING, PAYMENT, PRACTICE, AND SYSTEMS-LEVEL ISSUES, POLICIES, AND INCENTIVES TO SUPPORT PROVISION OF ESSENTIAL COMPONENTS OF CARE

Can Primary Care Afford Behavioral Health?

Delivery System Considerations for Integrating Addiction and Mental Health Treatment into Primary Care Settings

Medicare and Medicaid Opportunities and Challenges for Integrating Behavioral Health Care in General Medical Settings

The Addiction Recovery Medical Home Model

Panel Reactions and Discussion

Question and Answer Session with Webinar Participants

CLOSING REMARKS

REFERENCES

APPENDIX AWORKSHOP STATEMENT OF TASK

APPENDIX BVIRTUAL WORKSHOP AGENDA

Boxes, Figures, and Tables

BOXES

1Suggestions Made by Individual Participants to Improve Care of People with Mental Health and Substance Use Disorders (MHSUDs) in Primary Care Settings

2The 5Ds: How Children Differ from Adults in Behavioral Health Care

3The 10 Guiding Principles of the Addiction Recovery Medical Home Alternative Payment Model

FIGURES

1Collaborative care, a model for primary care and mental health care integration, based on Wagner’s Chronic Care model

2Principles of collaborative care for effective implementation

3Percentage of depression, anxiety, and behavior disorders, by age

4Core components of the Common Elements Treatment Approach (CETA)

5Mental health care professional shortage areas: Percent of need met

6The treatment gap for mental health and substance use disorders

7Delivery and payment systems must be considered together

TABLES

1Core Tenets of the Collaborative Care Model

2Key Elements of Integrated Care

Acronyms and Abbreviations