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Primary Care and Co-Occurring


More than 30 million Americans, including 16 million new Medicaid enrollees, will be covered under health care reform legislation. The Congressional Budget Office projects six to ten million newly enrolled people will present mental illness and/or substance use disorder needs. Newly covered individuals with mental and substance use disorders will account for approximately 32 percent of the entire increase in Medicaid expenditures.

To meet this demand for health and community-based services, SAMHSA is helping to integrate behavioral health and primary care services at the system level. Effective January 2011, states became eligible for SAMHSA funding to coordinate the mental health, substance use, and chronic medical care of persons with co-occurring disorders.

The 2010 Affordable Care Act calls for the delivery of health care to be more coordinated, collaborative, and integrated. This approach supports initiatives for health care homes for people with co-occurring disorders and their complex needs. Health care homes give individuals access to the same treatment team, supporting person-centered self-management goals.

Characteristics of integrated systems may include:

  • Multiple "right doors" for treatment
  • Improved cross-disciplinary knowledge
  • Common treatment plans
  • Person-centered care
  • Shared decision making
  • Shared risk
  • System-level focus on evidence-based practices
  • Collaborative referral networks
  • Integrated health information technology
  • Combined medical records
  • Shared reporting of client outcomes

Severity Reduced — Lives Saved

Serious mental illness can shorten an individual's lifespan by 25 years, in part because of co-existing, untreated chronic conditions. Premature mortality is primarily due to diabetes, infectious, pulmonary, and cardiovascular diseases-conditions frequently seen among those with co-occurring mental and substance use disorders.

With ongoing integrated care, the severity of co-morbid conditions can be reduced and lives saved. Information sharing within an integrated team ensures all physical and behavioral needs of the individual receive attention and coordinated intervention.

Integrated Care Improves Individual Outcomes

Research on behavioral health and primary care integration finds that integrated care improves individual outcomes by:

  • Reducing symptom severity
  • Improving treatment response
  • Reducing remission response

For example:

  • Research from SAMHSA's PRISM-E study found improved engagement patterns among individuals receiving mental health and substance use services within primary care settings.
  • Research on North Carolina Community Care model, which enrolls the most Medicaid participants into integrated, person-centered medical homes using regional, doctor-directed care networks shows that integrated care is improving care and saving costs.

Challenges exist regarding the widespread adoption of integrated approaches. Barriers that can be bridged include:

  • Organizational inability to charge for addressing multiple problems at the same visit
  • Varied language and practice styles of the behavioral health and primary care systems
  • Resistance to system change
  • Absence of common health information technology including different coding and billing frameworks
  • Difficulty of modeling system change costs and impact on health outcomes

Resources and Links

  • This website provides a collection of the latest information on integrated primary care and behavioral health.

  • This website is a national resources for encouraging doctors to pursue primary care careers, for making primary care practice more effective, and for supporting primary care professionals serving in underserved areas.

  • Settings outside the substance abuse and mental health systems, or settings where service missions do not include a primary focus on COD, are the focus of this overview paper. Primary health, public safety and criminal justice, and social service settings, where persons with COD are likely to be seen, are highlighted. These settings should be prepared to identify and effectively respond to persons with COD. The use of specialized techniques appropriate to these settings can increase the likelihood that the person with COD will access needed treatment.

  • This Tool Kit is designed to help primary care clinics and government mental health agencies forge collaborative relationships. It provides practical, operational advice, forms, strategies, and prototypes for integrating mental and physical services. The Tool Kit focuses on California counties, but much of it can be generalized to other locales. It includes sample formal agreements and contracts between primary care and county mental agencies, checklists for MOU and contract content, issues to consider when brokering agreements and mutual role descriptions.