Mental health, substance abuse, and health behavior services in patient-centered medical homes

Purpose: The purpose of this study was to understand mental health, substance use, and health behavior activities within primary care practices recognized by the National Committee for Quality Assurance as patient-centered medical homes (PCMHs).

Methods: We identified 447 practices with all levels of National Committee for Quality Assurance PCMH recognition as of March 1, 2010. We selected the largest practice from multisite groups, and 238 practices were contacted. We received 123 responses, for a 52% response rate. A 40-item web-based survey was collected.

Results: Of PCMH practices, 42% have a behavioral health clinician on site; social workers were the most frequent category of provider delivering behavioral services. There are also were care managers-distinct from behavioral health clinician-at 62% of practices. Surveyed practices were less likely to have procedures for referrals, communication, and patient scheduling for responding to mental health and substance use services than for other medical subspecialties (50% compared with 73% for cardiology and 69% for endocrinology). More than half of practices (62%) reported using electronic, standardized depression screening and monitoring; practices were less likely to screen for substance use than mental health. Among the practices, 54% used evidence-based health behavior protocols for mental health and substance use conditions. Practices reported that lack of reimbursement, time, and sufficient knowledge were obstacles. Practices serving a higher proportion of low-income patients performed more mental health organizational and clinical activities.

Conclusions: In PCMHs, practice organization and response to behavioral issues seem to be less well developed than other types of medical care. These results support further efforts to develop whole-person care in the PCMH, with greater emphasis on access to and coordination of mental health, substance abuse, and health behavior services. Focusing primary care practices on this aspect of whole-person care will benefit from program sponsors' support and rewarding better integration with behavioral health.