Integrating behavioral health directly into primary health has shown to improve access to treatment. Healthcare Innovation recently spoke with Kristin MacGregor, Ph.D., a licensed clinical health psychologist who serves as the National Clinical Director for Integrated Behavioral Health (IBH) at LifeStance, which has more than 8,000 clinicians across 33 states, including psychiatrists, psychiatric nurse practitioners, psychologists and master's level therapists. She leads efforts to advance whole-person care by partnering with health systems to build out their IBH programs.

Even with referral partnerships, the rate at which patients attend their initial behavioral health appointment after being referred remains suboptimal, LifeStance noted.

To address this issue, LifeStance partnered with a large primary care medical group to close this gap and improve access to behavioral healthcare by implementing two parallel programs: a coordinated behavioral health referral pathway and an integrated behavioral health (IBH) program using the Collaborative Care Model (CoCM).

Healthcare Innovation: Could you talk about your role in fostering an integrated behavioral health approach?

MacGregor: I’ve worked in integrated settings for my whole career. I joined LifeStance about five years ago to direct the large integrated behavioral health footprint we have in Massachusetts. I came in to direct that service line, which was a slightly different model of integrated care. Over the last four years, I've taken on this national role to help partner with large health systems — identifying folks who would benefit from assistance in that area. Because of my clinical background, I also help design the clinical model, and then help to recruit, train, and manage the clinicians that are operating in that model.

HCI: You mentioned the experience in Massachusetts but you said it was a slightly different model. Can you talk about what was different about it?

MacGregor: LifeStance was born out of a lot of acquisitions across the country. We had different groups that had partnered with primary care in various ways over the course of time. We all know that primary care is the de facto mental health system, right? So as a behavioral health organization, it makes a lot of sense to partner with these groups in the community. In Massachusetts, we utilized more of a primary care behavioral health model. That means dedicating psychologists to primary care, fielding referrals directly from those providers, and engaging in brief evidence-based care, which is very similar to the Collaborative Care Model, without the psychiatric consultation. What's challenging about doing that from a partner standpoint and working for separate agencies is that you're still billing psychotherapy codes out under our contracts. Even though we're in network with many, many payers, you can never really be payer-agnostic doing it that way, because there's always a behavioral health carve-out. There's always a weird plan that has restrictions around who can bill it. And secondly, because we were billing out of our LifeStance contracts, we’re documenting in our own system. We know that electronic health records do not work well with one another, so if you can't engage in effective health information exchange, it's very difficult to have that true integrated feel with the team-based care.

HCI: I was going to ask you about that. Have you overcome that data-sharing issue in other instances?

MacGregor: Yes. The Collaborative Care Model, which is what we're utilizing now, does solve for those issues — first, because the codes that you bill to the insurance plan go out under the primary care provider. When you're billing under the primary care provider, you are in network with all of the payers in the primary care providers’ network, so it solves for the payer-agnostic problem. Because of that, our clinician’s schedule actually sits in the electronic health record of the primary care provider. Patients are able to be scheduled directly at checkout, and our documentation goes in the health record of the primary care provider. So even though we're working for two separate systems, the intention is for the patient to not know that — for us to just be a natural extension of the care team, which reduces a lot of the friction getting into care, which is how this white paper came about, that we get a lot more patients in care this way, just reducing that friction.

HCI: Tell me a little bit more about this partnership. Although this primary care group you partnered with didn’t want their name used, can you describe them and go into what you worked on there and what you found?

MacGregor: Yes. It's a large primary care network of clinics. They were interested in building out their integrated behavioral health program. And instead of building it in-house, they elected to seek out a vendor to do this. We identified 10 participating physicians who were eager to sign on to ensure that we got some good traction to test this out. Their advanced practice providers also participated. This is just a small footprint of the larger health network. In order to be able to help meet the behavioral health needs of the rest of the system, we rolled out a coordinated referral pathway, which is kind of an easy button for referrals. For the rest of the system, they built an order in their EHR to be able to just send all outpatient referrals to us while we tested this out.

HCI: Does this require training of that primary care team and some early work to make this go smoothly?

MacGregor: There's all the technical implementation that needs to happen, including building out a schedule, creating a provider profile in the electronic health record, teaching the billing team how to drop these codes, and ensuring that there is payer coverage. 

On the clinical side, we went to the clinic and met with the physicians to explain who's a great fit for this program, who maybe wouldn't be a good fit, and how to place a referral and how to get in touch with us. The PCPs don’t need to learn to do a complex triage around this; they really just needed to learn how to refer, how to get in touch with the clinician, or if there's a psychiatric consultant on the team, how to get in touch with her, and then just turn on the referrals and see what happens.

HCI: Is a big part of the problem you're addressing is that people don't show up for appointments after being referred? 

MacGregor: Yes. The asynchronous setup of the majority of referrals, even outside of behavioral health, is an issue. The patients have to call and make the appointment, or even just answer the phone — people don't answer the phone anymore. I don't have any empirical data to back this up, but to me, that is the biggest barrier, especially when you're talking about people who are anxious or depressed. They’re either not motivated, because their depression is making it so, or they're freaked out about answering the phone. So you just lose so so many people in that process. We find that we have to put a schedule in your system, and the first appointment has to be booked by the front desk, so that there's so much less time for the patient to talk themselves out of it. Then the onus is on the therapist to keep them in care once they show up to that first appointment.

HCI: What were some other goals or targets of this project with these primary care providers that they wanted to see and you wanted to see, and did you hit those?

MacGregor: Access was the primary thing. We know that PCPs are doing this work anyway. They are prescribing antidepressants. They are trying their best to give people resources. I think another goal was to resource these PCPs in a way where they don't feel by themselves, because even with a strong referral partner, I think the place that the patient goes back to if they didn't get connected, or they didn't answer the phone, or they didn't say yes to that referral, is back on the PCP’s schedule. So we want to give the primary care providers a safety net, and collaborative care has lots of safety nets. The therapist is right there. The schedule is open for patients to book into. We strive to make it so that there's an available appointment within two weeks of referral anytime. 

People need to be moved through the system efficiently in order to make sure that we're able to adhere to that. Part of collaborative care is tracking patients in a registry platform, so that you always know at any given time which patients are enrolled in the program. It helps the therapist to say ‘I haven't seen John in a while. I'm going to reach back out and make sure he gets back into care.’ There are more checks and balances for that natural attrition that sometimes happens when people get enrolled in care. 

The psychiatric consultation is a game changer for these primary care doctors, because many of them do feel comfortable with a first- and second-line antidepressant treatment, and then would feel comfortable prescribing something else, but just don't know what to prescribe. So the psychiatrist might say ‘Try this. Augment with this. Take them off this. It doesn't seem to be working quickly.’ 

As a result, people get better so much faster than even on the outpatient side. Even when people get into care efficiently on the outpatient side, it still takes a while to get that first appointment. You spend a lot of time digging deep into what people are coming into care for, and then a referral to a psychiatrist. There are just more steps that happen when it's not all one team working together.

HCI: Is the the primary care network often looking for ways to take some of the burden off of their clinicians because they're feeling overwhelmed, and they don't have a partner in the community, or a lot of the behavioral health providers have long wait times for people to come in?

MacGregor: Yes, 100%. If you don't have a reliable referral partner or an integrated care program, you just have names on a piece of paper and there's no one calling those people to find out if they are full or not in network with this insurance anymore. So it's often not up-to-date information. 

Another complaint we hear a lot from our partners is that they don't know what happens to those people after they send them. Behavioral health, historically, has not been very good at communicating. We keep everything so secret and private. On the one hand, it makes sense why that happens. The things you talk about in therapy are private, and at the same time, I think it has perpetuated the stigma of behavioral health as well. People think that nobody should know that you're depressed, nobody should know you had this trauma, when in actuality, your whole treatment team should know, because it impacts all of these health indices, and it puts into context why someone might not be adherent to their treatment plan. So with integrated care, it's just a thing that the patient seeking care is socialized to. I write in your record that I will talk to your primary care provider right after we're done. A PCP should know more than just what psychiatric medications a patient is taking, in my opinion. And the data shows that when we communicate, more people get better.

HCI: Have you had enough time with the 10 physicians for the primary care network to make a decision about whether they want to expand this model more broadly? 

MacGregor: We are in those discussions currently. Like with most things in healthcare, we are doing the financial analysis around the return on investment. I think we all feel very hopeful that we will be able to expand relatively shortly. What’s tricky is that you have to look at: are we not losing money on this program, just from a purely financial standpoint? And then what becomes more challenging is: are we saving money by treating these folks and getting their mental health under control so that their other health indices follow? That has always been the challenge. There's newer data that does demonstrate total cost of care reduction for people who are enrolled in in collaborative care, but it takes a long time to demonstrate cost savings.

But everybody feels hopeful, because the primary care providers love this. The patients are getting better. The clinician is really happy in her role. They really like having her on site, even though it's very hard to make the case with a lot of health systems to make space for these therapists to sit there on site, but the benefit is definitely there with everybody being in the same setting.