Substance Abuse & Mental Health Services Administration

The passage of the Affordable Care Act has ensured many opportunities to improve health care quality. One such opportunity is the integration of primary and behavioral health care. SAMHSA has taken a primary role in the promotion and adoption of primary and behavioral health care integration nationwide through a number of different initiatives, including Section 2703 of the Affordable Care Act, which allows States to establish health homes through their Medicaid program, the establishment and awarding of primary and behavioral health care integration grants nationwide, and the establishment of the SAMHSA - HRSA Center for Integrated Health Solutions. Below is information on each of these initiatives along with tools that can be used when adopting an integrated model.

Health Homes - Section 2703 of the Affordable Care Act

SAMHSA, in collaboration with the Centers for Medicare and Medicaid (CMS), have been working together to encourage States to take advantage of an opportunity, authorized by the Affordable Care Act, (Sec. 2703 & Sec. 19459(e)) for States to build a person-centered health home that results in improved outcomes for beneficiaries and better services and value for State Medicaid and other programs, including mental health and substance abuse agencies.

States interested in adopting the health home model through a Medicaid State Plan Amendment must seek consultation from SAMHSA prior to submission to CMS. The consultation process can be found here and to schedule a consultation please send an e-mail to health.homes@samhsa.hhs.gov.

Based on SAMHSA's initial consultations with States regarding Section 2703, it is clear that States are at different stages of preparing and planning their State Plan Amendments. To that end, SAMHSA developed a Guidance Document for States as they consider taking advantage of the Section 2703 provision for people with behavioral health (i.e., mental health and substance abuse, MH/SA) disorders. The document serves as a checklist of key behavioral health questions organized according to the Health Home Service components involved in Section 2703. By providing States this structured background regarding the core elements of the Section 2703 health home, SAMHSA aims to ensure that key behavioral health topics are considered as States develop health home proposals. This document serves solely as guidance for entities thinking about health homes, and is not meant to be prescriptive or regulatory. The intended audiences for this document are those involved in developing the State Plan Amendment to establish a health home under the Section 2703 provision. Although, SAMHSA believes this document to be useful to health home providers and others interested in health homes.

For more information on the process of implementing health homes, please see the State Medicaid Director letter CMS (PDF | 327k) sent out to States regarding background on the provision and guidance for consultation. Please send questions or comments to health.homes@samhsa.hhs.gov.

Primary and Behavioral Health Integration Grants

Funded primarily by the Affordable Care Act's Prevention and Public Health Fund, SAMHSA has awarded grants to 64 community-based health agencies to build partnerships and infrastructure needed to initiate or expand the integration of primary care services for people in treatment for serious mental illnesses and co-occurring substance use disorders.  The objectives of the grant program are to better coordinate and integrate primary and behavioral health care resulting in:

• Improved access to primary care services;
• Improved prevention, early identification and intervention to reduce the incidence of serious; physical illness, including chronic disease;
• Increased availability of integrated, holistic care for physical and behavioral disorders; and
• Better overall health status of clients.

Services provided at the various sites include:

• Facilitation of screening and referral for primary care prevention and treatment needs;
• Providing and/or ensuring that primary care screening, assessment, treatment and referral be provided in a community-based behavioral health agency;
• Developing and implementing a registry/tracking system to follow primary health care needs and outcomes;
• Offering prevention and wellness support services;
• Establishing referral and follow-up processes for physical health care requiring specialized services beyond the primary care setting.

SAMHSA, along with others nationwide are working to improve the quality of health care through integrated care opportunities. Above, the 64 behavioral health sites are mapped. Explore the different places integration is happening, from Wrangell, Alaska to Miami, Florida.

SAMHSA - HRSA Center for Integrated Health Solutions

The SAMHSA-HRSA Center for Integrated Health Solutions, run by the National Council for Community Behavioral Healthcare under a cooperative agreement from the U.S. Department of Health and Human Services, is funded jointly by SAMHSA and HRSA. The Center promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty behavioral health or primary care provider settings. For more information about the Center for Integrated Health Solutions click here. Additionally, below are a number of tools and documents that can be used when planning and implementing an integrated model.

Screening Tools for Behavioral Health Disorders

SAMHSA recommends the following screening instruments to identify individuals with alcohol abuse or dependence, depression, and/or tobacco use/dependence in primary care or behavioral health care settings:

Alcohol - The Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) is a 3-item alcohol screening instrument that can help identify individuals who engage in unhealthy alcohol use or have active alcohol use disorders (including alcohol abuse or dependence).

Depression - The Patient Health Questionnaire (PHQ-9) is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression.

Tobacco - The “5 A's” Model for Tobacco Use and Dependence is a 5-item screening instrument for tobacco use and dependence that offers medical assistance for appropriate intervention with smoking and tobacco use cessation.

Additionally, below are examples of tools available to screen for behavioral health needs in primary care or behavioral health care settings.

Screening tools for Children

• Center for Epidemiological Studies Depression Scale for Children (20-item questionnaire) is a questionnaire that focuses on how an individual may have felt or acted over the past week. Scores range from 0-60 with a score of 15 or higher being clinically significant of depressive symptoms in children and adolescents.
• Pediatric Symptom Checklist is self-screen used to identify cognitive, emotional, and behavioral problems in children and adolescents.
• Spence Children's Anxiety Scale and Administration and Scoring Instructions is a self-administered tool used to assess anxiety symptoms consistent with the dimensions of anxiety disorder outlined in DSM-IV.

Screening tool for Adolescents

• Global Appraiser of Individual Needs - Short Screener (GAIN-SS) is an evidence-based, brief survey developed by Chestnut Health Systems that identifies needs for further assessment in the areas of mental health, substance abuse and anger management for adolescents.

Screening tool for Adults

• CAGE Questionnaire is a brief assessment instrument for screening for unhealthy alcohol use or people who have active alcohol use disorders. The acronym comes from key words in each of the four yes-no questions. Two or more affirmative responses are indicative of alcohol dependence.

Models

Below are resources that detail State-level experiences with different health home models.

• Milbank Report Evolving Models of Behavioral Health Integration in Primary Care
• NASHP A Tale of Two Systems: A Look at State Efforts to Integrate Primary Care and Behavioral Health in Safety Net Settings
• NASHP Building Medical Homes in State Medicaid and CHIP Programs
• Populations Served and Services Provided: Lessons Learned from Minnesota
• Qualifying Practices as Health Homes: Lessons Learned from Oklahoma
• Managed Care Purchasing Strategies: Lessons Learned from Rhode Island
• Integrating Behavioral Health and Primary Care: The Harris County Community Behavioral Health Program

Outcomes

Below are examples of behavioral health outcome and quality measures to consider when establishing a health home.

• Defining and Measuring the Patient-Centered Medical Home
• Performance Measurement for Integrated Care Programs
• Measurement of Health Status for People with Serious Mental Illnesses
• Monitoring Care and Reporting Quality Measures: Lessons Learned from North Carolina
• National Strategy for Quality Improvement in Health Care

Research

Below are research resources detailing health home demonstration projects, behavioral health and primary care integration, and financing and payment methods.

Health Home Demonstration Projects

• PCMH Report – Patient-Centered Medical Home Building Evidence and Momentum. A compilation of PCMH pilot and demonstration projects
• NASHP – State Involvement in Multi-Payer Medical Home Initiatives
• Buxbaum and Takach - NASHP State Multi-Payer Medical Home Initiatives and Medicare's Advanced Primary Care Demonstration
• A Nationwide Survey of Patient Centered Medical Home Demonstration Projects

Behavioral Health in Primary Care Settings

• A Clarion Call for Nurse-Led SBIRT Across the Continuum of Care
• Integrating Mental Health Treatment Into the Patient Centered Medical Home
• Making Room for Mental Health in the Medical Homes
• Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration
• Specialty Care Medical Homes for People with Severe, Persistent Mental Disorders
• NCCBH - Behavioral Health/Primary Care Integration and the Person-Centered Health care Home

Financing and Payment Methods

• Financial Dimension of Integrating Behavioral Health
• PCPCC – Payment Reform to Support High-Performing Practice: Report of the Payment Reform Task Force

Other Documents

Resources for Providers and Consumers when discussing health homes

• Consumer Tip Sheet: The Importance of Primary and Behavioral Health Care 4/14/11 (PDF 900KB)
• Webinar: Health Care Reform: Implications for Behavioral Health Providers
• Fast Facts on Five Featured Medical Home Initiatives
• Definitions of Serious Mental Illness and Substance Use Disorders (PDF 69KB)

Additional Resources on Section 2703 of the Affordable Care Act

• Health Homes for Medicaid Enrollees with Chronic Conditions: A Conversation with CMS and States Regarding the ACA State Plan Option
• CMS Presentation on Section 2703

Last updated: 07/16/2012