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A Brief History of the Integration of Behavioral Health in Primary Care

Posted By Alexander Blount, Friday, April 10, 2015


(This blog post is a reprint of a piece by Dr. Blount. Click here for the original post. Reprinted with permission)

A colleague said he needed a slide on the history of integrated of behavioral health and could I give him a few high points.  This is what I wrote.

The first integrated behavioral health program that I know about that was a large implementation and not just a couple of practitioners working together was the Gouverneur Health Program in New York in the 70’s.  There is a chapter in my book about it, Integrated Primary Care: The Future of Medical and Mental Health Collaboration, Norton, 1998.  There was a fully integrated program at the first HMO which was in New Haven that is described by Coleman, et al.  In 1994 I published a paper in which the term "integrated primary care” was used for the first time.  

1995 was a big year for integrated care.  It was the publication of Katon, et al’s big JAMA article with the evidence for integrated care for depression and it was the first meeting of the Collaborative Family Healthcare Association, the first organization made up of physicians and behavioral health folks focused on collaborative care  After that it was sort of a steady development for a while.  The work in Seattle kept on, supported by RWJ and MacArthur, building to the IMPACT model and beyond.  The Behavioral Health Consultant model also build out of the Northwest, from Kirk Strosahl and Patty Robinson’s work.  You can see it almost formulated in Kirk’s chapter in my book. 

Various pieces fell in place.  The military picked up integration as did HRSA in the early 2000’s.  Centers of excellence were built at Health Partners in Minneapolis by CJ Peek and at Sharp Health in San Diego.  Lots of different reports fell into place. The next monumental moment was the passage of the ACA.  That kicked integrated care into actuality all over the country.  That was the start of the AHRQ Academy for the Integration of Behavioral Health and Primary Care.  The BPHCI grant program of HRSA and SAMHSA juiced the mental health guild organization called NCCBH into creating the Center for Integrated Health Solutions which is trying to be sure that integration doesn’t marginalize the mental health centers by being a great source of information for the entire field.

Now we are at the point where the leaders are seeing the impetus behindthe movement begin to push it out in front of them. We find ourselves having to define what counts as integration so that the term doesn’t get applied to whatever people are doing that they want to be sure is in on the action. We see people placing mental health clinicians from mental health centers into primary care who don’t realize that what they have been trained in is specialty mental health care and what is needed is primary care behavioral health.  That is why we started our training program to make sure folks can get the rigorous orientation they need to succeed.  We have to keep reminding each other not to ask does integration work?, does the PCMH work?, can integration save money? We have to ask what form of integration works in what context?  How are they doing the PCMH in what regulatory and payment environment so that it works?  What sort of integration or camre management program targeted at which patients, accounted by looking at what parts of the system works financially?

Our current success and rapid development great, but it is a movement that is much bigger than all of the pioneers now.  We have to keep reminding ourselves that integrated primary care, or integrated behavioral health, or whatever else we call it, is not important.  Better care for patients is important.  If we keep our eyes always on that, integration will evolve and be durable for a long time.

Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA. At UMass he has developed training programs in Primary Care Behavioral Health and Integrated Care Management that have already trained 2000 people for the workforce needs of the transformation of healthcare. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’. He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.

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