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Primary care must be the mental health medical home


As a primary care physician, my responsibility to my patients goes beyond just caring for their physical well-being. My obligation-professional and ethical-is to treat the whole person and that means attending to their mental health as well.

Editor’s Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Glen Stream, MD, FAAFP, MBI, a family physician practicing in La Quinta, California, who is also past president of the American Academy of Family Physicians. He serves as the president and board chair of Family Medicine for America’s Health. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


As a primary care physician, my responsibility to my patients goes beyond just caring for their physical well-being. My obligation-professional and ethical-is to treat the whole person and that means attending to their mental health as well.

Glen Stream, MD, FAAFP, MBIMind and body are inseparable. That undeniable truth and its application in medical practice are too often lost. Twenty years ago, the Institute of Medicine issued a report that concluded behavioral healthcare was mostly separated from the country’s primary healthcare system. “Primary care,” it said, “cannot be practiced without addressing mental health concerns, and all attempts to do so result in inferior care.”


More from Dr. Stream: Examining the resurgence of primary care


In the two decades since, we’ve made only slight progress toward full integration of behavioral and primary care. The need to marry the two has never been greater.

According to the National Alliance on Mental Illness, the  statistics are telling:

·      About 1 in 5 adults-nearly 44 million Americans-experience mental illness each year..

·      About 10 million American adults-1 in 25-will experience a serious mental illness in a given year that “substantially interferes with or limits” at least one major life activity such as work.

·      Adults living with serious mental illness face an increased risk of having chronic medical conditions and die on average 25 years earlier than others, “largely due to treatable medical conditions.”

According to a 2014 report by the Commonwealth Fund, a private foundation that promotes improved healthcare quality, “failure to recognize and appropriately treat behavioral health conditions has a significant impact on health outcomes and costs: patients with these diagnoses use more medical resources, are more likely to be hospitalized for medical conditions, and are readmitted to the hospital more frequently.”

Next: Primary care’s role


Primary care’s role

In the face of this evidence, there’s growing recognition of the essential role primary care must play in supporting patients with mental health issues.

To fulfill that role, a number of healthcare systems around the country have implemented programs that integrate mental health into their primary care practices. Under this approach, primary care teams and behavioral health specialists work hand in hand to share patient medical records, treatment plans and manage all aspects-mind and body-of their patients’ healthcare needs.

Health is Primary, a national campaign focused on demonstrating the value of primary care, is highlighting examples of innovation and transformation that are happening across the country. 


More from Dr. Stream: Primary care best equipped to improve patient behaviors


One group taking a holistic approach to mental health integration is Community Health of Central Washington, which provides what it calls a “primary care home” where its 30,000 patients can go for yearly check-ups or when they “feel sick or sad.”

CHCW’s primary care physicians can refer patients to a social worker, a “behavioral health consultant” who is a full-time staff member. During a 15-to-30 minute visit, the consultant would work with a patient on a specific mental health concern and develop a plan to address it.

In Colorado, researchers recently concluded a five-year experiment to see how eight primary care providers and three mental health centers across the state might integrate behavioral health and primary care. The state, working under a grant from the federal Centers for Medicare and Medicaid Innovation, is now aiming to integrate care in 400 Colorado primary care practices and community health centers by 2019.

Despite these all-too-rare advancements, significant roadblocks still stand in the way of full integration of care despite the fact that 43-60% of psychological issues are treated in primary care settings.

One major barrier: fee-for-service payment models that effectively impede the adoption of integration. One solution, experts say, would be to move away from fee-for-service and instead reward providers for controlling costs and improving patient health outcomes. Until then, providers will be forced to pay for integration initiatives themselves or rely on grants from government and other sources.

Next: Change may be slow but it's coming


Integration of behavioral health and primary care is all but inevitable, in part because it’s cost effective,  offers patients “one-stop shopping” for healthcare and helps them avoid the stigma often associated with getting separate treatment for mental health.

Change may be slow but it is coming. The forces encouraging it will speed the march toward full integration of care and in the process improve the delivery of healthcare and the lives and well-being of millions of Americans.


Glen R. Stream is a family physician in La Quinta, CA and president of Family Medicine for America’s Health, which sponsors Health is Primary.



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