Why integrating mental health with primary care is so critical

It is exciting to see two branches of government and leaders from both political parties giving these issues the attention they deserve and more than 300 stakeholders submitted their views to the Finance Committee, including Oak Street Health. As one of the country’s leading implementers of the behavioral health collaborative care model — which integrates the work of primary care providers and mental health professionals to treat the whole patient — Oak Street is prepared to help providers and policy makers across the country and on both sides of the aisle learn about what works for patients.

According to the Centers for Disease Control and Prevention, 50 percent of the population will receive a mental health diagnosis during their lifetimes. The Commonwealth Fund estimates that ​“about 1 in 4 Medicare beneficiaries have mental illness.” Many Americans experience generalized anxiety disorder, post-traumatic stress disorder, loneliness and grief. A new study published in The Lancet links serious COVID-19 illness to long term adverse symptoms in individuals’ mental health. As a provider of primary care in 20 states, Oak Street is already on the front lines of this very real crisis.

One of the president’s proposals is to integrate mental health and substance abuse treatment into primary care settings. Oak Street is already doing that with great results. By screening almost all of our patients for behavioral health needs, we have found that about 60 percent might benefit from these services, which is about 10 percentage points above the CDC estimate. But by integrating mental health with primary care via the Collaborative Care Model, we have seen individuals respond to treatment within six weeks and demonstrate sustained improvement at six months.

This approach works because the team engages in measurement-based care with timely medical and behavioral health interventions. Our value-based, fully capitated model — in which quality outcomes matter more than the volume of services – allows us to respond successfully to our patients’ needs.

Oak Street Health makes it possible for every patient who needs behavioral health services to get effective quality care quickly. Working with an experienced leadership team, our providers are able to address systemic care gaps and produce high quality outcomes, including beating by 24 percentage points the reduction of depressive symptoms versus traditional behavioral health care models. We achieve this success through five programmatic goals: 

1. Access to qualified Mental Health Professionals: We employ high-caliber behavioral health professionals ranging from licensed clinical social workers to professional counselors to psychiatric nurse practitioners and psychiatrists who extend service access to all our patients across the 20 states in which we operate. If necessary, a patient and primary care provider may receive same-day consultation for a mental health concern. 

2. Screening and Prevention of Depression: All patients receive comprehensive social & emotional screening as part of their Annual Wellness Visit, which is inclusive of depression, anxiety, loneliness and social risk factors such as food insecurity, medication access and transportation needs. By screening almost all of our patients, we are able to remove non-physical obstacles to care because if one of our patients is depressed or lonely, they’re less likely, of course, to take their medication.

3. Proactive Engagement: Traditional care often requires a patient to seek a specialty referral for mental health resulting in less than 10% receiving mental health counseling. Since we universally screen all our patients, we are proactively able to engage those who are either at risk for worsening symptoms or who may benefit from additional support. 

4. Response to treatment: Over time, we repeat evaluations for enrolled patients to monitor progress and ensure not only are patients being seen but that they are getting better. Our results include:

   1. A 5.4% average reduction after six weeks of treatment. In the real world, this means we are significantly reducing a patient’s symptoms within 45 days of treatment. 

   2. At six months, 43% of overall patients have a sustained 50% reduction in symptoms based on the same Patient Health Questionnaire‑9 (PHQ‑9) screening for mental health. 

Oak Street Health’s systematic approach to operational and clinical excellence in the Collaborative Care Model (CoCM) is key to improving our patients’ health potential. Yet, it is not sufficient, however, to concentrate only on treatment. A multidisciplinary workforce integrated in primary care is needed to address a variety of challenges. The CDC uses the measure of healthy days to calculate success. For instance, inadequate social or emotional support and food insecurity can result in fewer healthy days per month. Recent case studies demonstrate patients have more healthy days when interventions occur regularly.

Inside our model, each patient who screens positive for a non-pathological social risk factor, such as food insecurity, loneliness or transportation needs, is partnered with a Wellness Coach. Our Wellness Coaches are extensions of our clinical care teams and are often Community Health Workers (CHWs) and Medical Social Workers (MSWs). These roles serve to accompany and broker community services for patients who may benefit from assistance in navigating complex health and social service institutions. Additionally, each of our centers include a community room for our patients and the community to interact with team members but also one another.

At the end of the day, government can expand access to quality care by focusing on outcomes over volume. The best way to do that is to reward teams incorporating social, mental, and physical health interventions into their care. By implementing the Oak Street approach, we can heal our communities and create a health system responding to the whole person and help begin solving the nation’s mental health crisis. Oak Street is more than proud to help lead the way.

Katherine Suberlak, MSW/LCSW is vice president of clinical services at Oak Street Health where she leads the organization’s behavioral health work.