Improving Mental Health Care for Medicaid Patients through Primary Care Screenings

November 30, 2022 Posted by Jesse M. Ehrenfeld, MD, MPH

One of the themes Katinka Hooyer, PhD, uncovered in studying the life experiences of patients receiving federal Medicaid assistance is the potential for one person to “change everything” when it comes to the care members of marginalized groups receive. As an assistant professor in the Medical College of Wisconsin’s Family and Community Medicine Department, Hooyer is sharing this insight and others with healthcare providers throughout the state in a unique collaboration with the Wisconsin Collaborative for Healthcare Quality (WCHQ) that is providing training and tools to increase behavioral health treatment for Medicaid patients through targeted primary care screenings.

Addressing a Gap in Care

According to America’s Health Rankings, nearly 20% of adults in Wisconsin reported being diagnosed with a depressive disorder in 2020. WCHQ reports that the depression screening rate for Medicaid recipients in the state is 15% lower than that of Medicare patients (65% versus 80%), according to 2018 clinical data provided by participating health systems. “Medicaid patients are seeking care,” notes WCHQ CEO Gabrielle Rude, PhD, “but when they are seen, they are not being screened for mental health as often as they should.” WCHQ seeks to close this gap with the help of funding from the Advancing a Healthier Wisconsin Endowment and in partnership with Hooyer, who is serving as principal investigator on a project entitled, “Increasing Behavioral Health in Primary Care Settings through Team Training.”

Creating Buy-In for a New Approach

“One day, we hope that all healthcare teams, from primary care to specialty care, provide patients and families with a fully integrated experience as they pursue health and healing.” So reads the mission of the Collaborative Family Healthcare Association (CFHA), whom WCHQ has enlisted to provide training and technical assistance to health systems throughout Wisconsin who have enrolled in the project. Collaborating providers represent systems serving both urban and rural populations and reflect varying degrees of readiness to integrate behavioral health into their primary care practices, notes Rude.

"We rarely have to convince sites of the benefits of integrated care anymore," said Dr. Serrano, himself a primary care psychologist, "but we do have to help sites understand the now well-worn pathways to successful implementation of integrated care models.” Serrano continued, “That's what we have aimed to do in this collaborative, given that the shift from thinking of mental health as a specialty to thinking of it from the standpoint of primary care can be difficult for healthcare administrators."

Since the project kicked off in July 2021, CFHA has provided 12 training sessions and hosted one-on-one consultations with participating health system representatives. CFHA Technical Assistance Project Manager Martha Saucedo, LCSW, has been the lead trainer. Saucedo is a strong advocate in the Latinx Community working towards equality, educating the community, and providing mental health services. She is part of the Latino Health Council and the Latinx Mental Health Coalition.

Training for each participating health system has been tailored to its specific circumstances, as uncovered in a preliminary needs assessment drawing upon a framework established by the Substance Abuse and Mental Health Services Administration (SAMHSA), a leading national organization on mental health housed within the U.S. Department of Health and Human Services. Health systems were asked where they fall within SAMHSA’s six levels of integrated behavioral health, ranging from “coordinated in separate facilities with minimal collaboration” to “integrated in sharing all practice space within same facility with full collaboration in a transformed/merged integrated practice.”

Directed conversations with participants have included creating buy-in from organizational leadership and developing measurable goals, which vary from organization to organization. Creating a business plan that incorporates integrated behavioral health (IBH) requires inter-departmental collaboration as well as resource planning and process development. Program staffing and space requirements need to be considered. Such discussions have been facilitated by Saucedo, Serrano, and WCHQ Interim Director of Practice Transformation Jenifer Koberstein. “Folks at the table,” Koberstein notes, “include psychologists, psychiatrists, quality improvement staff, primary care physicians, and system leadership.”

Integrated Behavioral Health Benefits Patients and Providers Alike

Integrating behavioral health into primary care settings offers the promise of improving health outcomes while lowering costs and increasing provider satisfaction, explains Rude. It also addresses the long-standing and growing shortage of behavioral health providers by training primary care physicians to screen for mental health and substance abuse risk factors.

Hooyer calls mental health assessments done by primary care providers “stealth interventions,” which sidestep the stigma that many people associate with seeking mental health care. By getting more mental health care into primary care settings, notes Koberstein, more issues will be uncovered. And in the integrated behavioral health model, patients with such challenges will be immediately and seamlessly referred to a behavioral health specialist in the same office.

“Once primary healthcare providers buy into IBH and receive training,” relates Rude, “they become very effective in uncovering mental health risk factors and referring patients for specialist care.”

Data available to WCHQ will ultimately show whether the project results in an increase of screening among Medicaid patients in the state. Other methods of evaluating the project’s effectiveness will include assessing health system policy changes; measuring the financial ramifications of IBH adoption; analyzing overall training process outcomes; and studying the impact of project participation among a Medicaid engagement group enlisted to share their lived experiences with health system participants and all WCHQ members and partners.

The People behind the Statistics

Not only is there a stigma to seeking mental health care in some under-resourced communities, Hooyer notes, but Medicaid patients, in particular, may also lack the time or transportation needed to receive such specialty care. All of this makes primary care offices optimum locations for mental health screening and in-office referrals.

To help health system administrators and other mental healthcare stakeholders better understand the unique challenges marginalized patients often face and to better align behavioral health services to the needs of these patients, Hooyer and her colleagues are developing ethnographic portraits of Medicaid recipients. Hooyer describes these as “mini-documentaries” that will be shared with project partners, in addition to direct testimony provided by Medicaid engagement group participants in meetings with health system leaders and providers.

Hooyer explains that the way these patients’ mental health issues have been framed has sometimes been harmful and traumatizing. The ethnography initiative allows them to share their experiences through various media, including alternative forms of storytelling and poetry.

This facet of the IBH project is not only educational for health system participants, but also empowering for the patients who have been enlisted to represent the population that most frequently falls through the cracks of the healthcare system. “WCHQ brings compelling data to the project,” Hooyer observes. “The MCW team, with cinematographer Justin Goodrum, is working on putting a story and a face to the statistics – to show what these patients’ lives look like.”

The result is much needed, deep conversations about mental health that Hooyer and team are confident will save lives.