March 20, 2018
In a time when over 80 percent of psychiatric medications are prescribed by primary care providers — due to factors such as stigma associated with psychiatry visits, lack of available psychiatrists and long specialist waitlists — the patient-centered medical home (PCMH) has filled a void.
The PCMH is a model embedding specialty services into primary care, providing general practitioners support through teaming with specialists. The PCMH concept was developed in the 1960s and re-evaluated in the 2000s.
Though initially the PCMH model didn't include behavioral health, over time the medical community realized addressing all patients' needs in primary care couldn't be accomplished without mental and behavioral health care. Further, this approach and its emphasis on care integration and coordination aligns with the Institute for Healthcare Improvement's Triple Aim to improve population health and patient experience, and to lower per person health care costs.
While most patients with behavioral health problems are seen in primary care, another major entry point has been hospital emergency departments (EDs). Some seek ED care due to:
- Psychiatrists' unavailability to see them promptly
- Primary care not being well-equipped to listen to behavioral health issues
- Belief the ED has psychiatric expertise
- Lack of insurance for mental health appointments
- Urgent need when primary care resources aren't available
"Patients with behavioral health problems tend to deteriorate quickly, and the next port of call is the ED," says Akuh Adaji, M.B.B.S., Ph.D., a Mayo Clinic psychiatrist based in primary care at Mayo Clinic Health System in Austin, Minnesota, and Integrated Behavioral Health at Mayo Clinic's campus in Rochester, Minnesota. Dr. Adaji came from Australia to train at Mayo Clinic to be part of a PCMH embedded in primary care.
High ED usage by patients with behavioral health issues has been a concern from a health care utilization standpoint. However, a greater cost-containment concern has been patient hospital admissions resulting from ED visits. Thus, Dr. Adaji and team embarked on an observational study looking at whether PCMH membership affected admissions or return ED visits for patients seeking ED care for behavioral health concerns.
Components and aims of a patient-centered medical home
Conceptual framework for the effectiveness of the patient-centered medical home. Graphic reprinted with permission from Agency for Healthcare Research and Policy, U.S. Department of Health and Human Services.
The study's setting was Mayo Clinic, one of the most highly integrated health care systems worldwide and a PCMH model early adopter. Patients with Mayo Clinic PCMH primary care providers were considered PCMH members, and they became study subjects by visiting the ED at Mayo Clinic Hospital, Saint Marys Campus, in Rochester, Minnesota, for behavioral health concerns.
Investigators looked at all patients presenting to the ED from 2012 to 2013 who underwent psychiatric evaluation and provided research authorization. To determine patient health care utilization, researchers used ED hospital admissions and return ED visits within 72 hours as outcome measures.
Of 3,815 patients studied, 5,398 ED visits occurred, and 2,983 of these led to inpatient admission. Of non-PCMH patients, 57 percent were admitted, while only 53 percent of PCMH patients were admitted. Though PCMH patients were less likely to be hospitalized, investigators didn't discern significant difference in 72-hour ED return rates between the groups.
Study significance and care applications
Per Dr. Adaji, this study's findings, published in the May 9, 2017, Population Health Management issue, imply hospitalization costs for patients with behavioral health problems can be reduced through a PCMH.
One theory investigators postulated for reduced PCMH patient admissions for those seen in the ED for behavioral health problems is ED physicians may be more likely to dismiss patients having PCMH access, feeling more confident in their support. If patients aren't PCMH members, investigators hypothesize ED physicians may be more likely to admit them due to uncertainty regarding safety and support.
Dr. Adaji feels a PCMH model can benefit psychiatrists by providing opportunity to lend expertise to primary care colleagues, lightening these physicians' burdens and making a difference in patients who may never see a psychiatrist.
Integrating with primary care colleagues also can promote referrals, paving the path for psychiatrists with concerns about their patients' nonbehavioral health aspects to reach out to their primary care providers.
Although the PCMH model has more limitations in less integrated medical systems, Dr. Adaji believes it's adaptable to any medical center, provided it's customized (such as with use of virtual consults). "Every organization, in one shape or form, will benefit from the PCMH model. I think it's the future of psychiatry, and clinically, it's showing it's making a difference."
For more information
IHI Triple Aim initiative: Better care for individuals, better health for populations and lower per capita costs. Institute for Healthcare Improvement.
Adaji A, et al. Patient-centered medical home membership is associated with decreased hospital admissions for emergency department behavioral health patients. Population Health Management. May 9, 2017.