SAMHSA provides programs and resources to ensure behavioral health is actively promoted and integrated within health care systems.
Affordable Care Act and Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
With the implementation of the Affordable Care Act and MHPAEA, more than 60 million Americans will have first-time or increased access to mental health and substance abuse prevention and treatment benefits. Along with this increased coverage for behavioral health issues comes increased pressure on the health and behavioral health workforce. SAMHSA is working with the Health Resources and Services Administration (HRSA) within the Department of Health and Human Services (HHS) and other partners to address the workforce shortage and competency issues for communities, coalitions, and prevention specialists; primary care; specialty care (behavioral health and others); emergency care; and rehabilitative care practitioners; as well as for relevant human services and education professionals.
SAMHSA is directing its efforts to define the role of behavioral health in the broader public health and health care systems and improve the service connectivity and financial alignment of health and other social services so people with behavioral health conditions are better able to access services, receive more highly coordinated care, and improve health outcomes at a high value-to-cost ratio. The Section 223 Demonstration Programs to Improve Community Mental Health Services is one approach to testing whether additional funding for specialty behavioral health care infrastructure can help improve the quality of that care.
SAMHSA Grant Programs Focused on Integration of Primary Care and Behavioral Health
The Primary and Behavioral Health Care Integration program (PBHCI) supports the provision of coordinated and integrated services through the co-location of primary and specialty care medical services in community-based mental health settings, with the goal of improving the physical health status of adults with serious mental illnesses who have or are at risk for co-occurring primary care conditions and chronic diseases.
The PBHCI grants aim to help communities integrate primary care services into publicly funded, community-based behavioral health settings. They are designed to support programs to prevent and reduce chronic disease while promoting wellness. Treating behavioral health needs along with other conditions allows PBHCI grantees to:
- Provide, by qualified primary care professionals, onsite primary care services
- Provide, by qualified specialty care professionals or other coordinators of care, medically necessary referrals
- Implement tobacco cessation and nutrition/exercise interventions, in addition to other health promotion programs such as wellness consultation, health education and literacy, and self-help/management programs
- Develop interagency coordination mechanisms and partnerships with other service providers for service delivery, including building provider networks and functional and sustainable linkages among services partners
- Implement needed improvements to collaborative service systems (for example, change standards of practice, data sharing)
- Assist staff or other providers in identifying primary care, mental health and/or substance abuse service issues, including training on coordinating access to, and enrollment in, public and private insurance
- Redesign processes, as needed, to enhance effectiveness, efficiency, and optimal collaboration between primary care and behavioral health provider settings staff
- Use health information technology to link services and assist communication among team members and between the team and the individual’s family caregivers, allowing for feedback
For more information on the PBHCI grantees and tools and resources for bi-directional integration of care, visit the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS).
SAMHSA has proposed the Primary Care and Addiction Services Integration (PCASI) grant program (see SAMHSA Budget Fiscal Year 2015) to help publicly funded community substance use treatment centers provide a full array of both physical health and substance abuse services for clients. To improve health outcomes for people with substance use disorders, PCASI grantees will be expected to increase the availability of primary health care and wellness services for these individuals. The grant program is also designed to promote greater use of integrated health information technology.
To support the PCASI grant program, SAMHSA also seeks to establish the Behavioral Health Information and Privacy Center of Excellence (see SAMHSA Budget Fiscal Year 2015). This center will support the enhancement, adoption, and meaningful use of certified electronic health record technology within behavioral health information technology systems.
In FY 2014, SAMHSA launched the Minority AIDS Initiative Continuum of Care Pilot. The purpose of this program is to integrate care (behavioral health treatment, prevention, and HIV medical care services) for racial/ethnic minority populations at high risk for behavioral health disorders and at high risk for or living with HIV. The grant will fund programs that provide coordinated and integrated services through the co-location of behavioral health treatment and HIV medical care. This program is primarily intended for substance abuse treatment programs and community mental health programs that can co-locate and fully integrate HIV prevention and medical care services within them. An important part of this program includes the use of set-aside funds for viral hepatitis prevention, vaccination, screening and testing, and linkage to clinical care.
SAMHSA is also working closely with its partner agencies to address issues of distinct and specialized care systems and financing structures, which often result in uncoordinated identification, diagnosis, and treatment of behavioral health and physical health conditions.
SAMHSA, with its federal partners and under the auspices of the Behavioral Health Coordinating Council (BHCC), highlighted the role same-day billing can play in integrated health care. SAMHSA and the Centers for Medicare & Medicaid Services (CMS) released a booklet on covered Mental Health Services – 2013 (PDF | 2.4 MB) that affirms the ability of community-based providers to provide same-day billing.
Medical Homes are a model or philosophy of health care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how care should be organized and delivered throughout the health care system. In a medical home, a practitioner or a team of practitioners oversees an enrollee’s entire care, including primary, dental, and behavioral health. That patient’s practitioners all share the same information and coordinate treatment based on that information.
Health homes can be a critical tool in addressing the needs of people with mental and/or substance use disorders. In fact, it is estimated that 70% of people with a significant mental and/or substance use disorder have at least one chronic health condition, 45% have two, and almost 30% have three or more.
The Affordable Care Act health home provision (section 2703) provides the opportunity for states to build a person-centered system of care 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 and social services, care coordination, and recovery supports. SAMHSA and CMS have been collaborating on the implementation of the health home provision and are encouraging states to participate in an innovative way to deliver health care and improve health care quality. To create a health home that serves people with significant behavioral health needs or includes significant behavioral health services, states must consult with SAMHSA on the best path forward for amending their Medicaid plan. SAMHSA urges state coordinators to read the following documents prior to consultation:
- CMS’ State Medicaid Directors Health Homes for Enrollees with Chronic Conditions letter – 2010 (PDF | 135 KB)
- The SAMHSA Consultation Process and Workflow Sample – 2011 (PDF | 128 KB)
- SAMHSA’s Guidance Document and Checklist – 2011 (PDF | 138 KB)
- Joint bulletin on Medication-Assisted Treatment – 2014 (PDF | 155 KB)
Access a State Plan Amendment (SPA) template as well as the online portal for submitting a SPA at the CMS Health Home Information Resource Center. Learn more about developing a health homes program from the following resources:
Health Home Resources
Learn how states have successfully implemented different health home models from the following resources:
- NASHP, Minnesota Health Care Home (HCH) Program – 2010 (PDF | 76 KB)
- NASHP, Rhode Island Health Home Models – 2010 (PDF | 42 KB)
- Oklahoma Health Care Authority, Qualifying Practices as Health Homes – 2009 (PDF | 42 KB)
Discover the lessons learned from behavioral health outcomes and quality measures from the following resources:
- SAMHSA’s National Behavioral Health Quality Framework, Draft – 2013 (PDF | 740 KB)
- Journal of General Internal Medicine, “Defining and Measuring the Patient-Centered Medical Home”
- HealthCare.Gov, Report to Congress: National Strategy for Quality Improvement in Health Care – 2012 (PDF | 403 KB)
Health Information Technology (HIT) Integration
HIT encompasses the comprehensive management and secure exchange of health information electronically among providers, pharmacies, insurers, states, territories, tribes, and consumers. It provides the context from which EHRs evolve and also includes telehealth services used by patients in rural or underserved areas. As such, SAMHSA made a major investment in PBHCI and its CIHS regarding meaningful use and EHR adoption. The CIHS website has more information about health information exchange in behavioral health care and offers significant provider resources.
Behavioral health systems have historically allocated little of their total operating budgets to HIT and EHR spending compared with their primary health care counterparts. SAMHSA’s goal is to connect behavioral health systems to the broader health system and improve access to integrated health care for those being treated for a mental and/or substance use disorder. CIHS provides behavioral health organizations with training and technical assistance to implement EHRs and provides technical assistance and resources to state health information exchanges to work through the barriers of sharing behavioral health data. To learn more about the findings of the CIHS, visit the health information exchange webpage at the SAMHSA-HRSA site.
HIT systems integration is also expected to improve interactions between patients and their providers by minimizing the need for additional paperwork and unnecessary or repetitive tests and procedures.
A common misperception exists that sharing one’s mental health and substance use information with primary care providers is prohibited. However, the Organized Health Care Delivery System – 2011 (PDF | 7 KB) section of the Health Insurance Portability and Accountability Act (HIPAA) states that behavioral health and primary care providers can share personal data to coordinate care. SAMHSA recently held a listening session to solicit feedback on the Confidentiality of Alcohol and Drug Abuse Patient Records Regulations, 42 CFR Part 2. SAMHSA’s goal is to find the appropriate balance between facilitating information exchange and respecting a patient’s legitimate privacy concerns due to discrimination, potential for reduced quality of care, and potential legal consequences.
A SAMHSA priority is promoting the widespread implementation of HIT systems that support quality, integrated behavioral health care while protecting the privacy of consumers. SAMHSA is focusing on three standards regarding the use of HIT and its impact on patient data and privacy:
- Integrity—Collecting accurate information
- Confidentiality—Limiting access to the information to only those who need to use it and with necessary consents
- Availability—Making the information accessible to those who need to use it for treatment and care coordination
The current behavioral health workforce—prevention, treatment, and recovery supports—may not be sufficient in number or have all of the skills necessary to function in an integrated environment. Continued education and training will become increasingly important as integration evolves. All health care disciplines should be adequately trained in the nature of mental health and substance use treatment and how to work in complex team settings. Since physical and behavioral health issues often occur at the same time, health care professionals want to consider all health conditions at the same time. Therefore, more primary care practices have behavioral health professionals on staff or close referral relationships with mental and substance use providers, and more behavioral health organizations are integrating primary care into their service mix.
In addition to its efforts to increase access to integrated health care as part of its strategic plans, SAMHSA will work to promote an integrated, collaborated, competent workforce that strengthens the capabilities of behavioral health providers and promotes the infrastructure of health systems.
Learn more about SAMHSA’s efforts to build the behavioral health workforce.
To improve poor cardiovascular health among people with mental and substance use disorders, SAMHSA broadened its wellness initiative to expand the Department of Health and Human Services’ Million Hearts initiative to peer-run, recovery-oriented community organizations. SAMHSA’s Million Hearts initiative helps these organizations raise awareness and develop strategies for improving the prevention and management of heart disease in people with behavioral health issues.
Community coalitions are increasingly used as a vehicle to foster improvements in community health. A coalition is traditionally defined as “a group of individuals representing diverse organizations, factions, or constituencies who agree to work together to achieve a common goal.” Community coalitions differ from other types of collaborations in that they include professional and grassroots members committed to working together to influence long-term health and welfare practices in areas in which they live and work. Additionally, given their ability to leverage existing local resources and bring diverse groups of people together, community coalitions are considered to be more sustainable than other collaborations.
The federal government has increasingly looked to community coalitions as a way to address emerging health issues at the state and local level. The activities of community coalitions include outreach, education, prevention, service delivery, capacity building, empowerment, community action, and systems change. The presumption is that successful community coalitions are able to identify new resources to continue their activities and sustain their impact in the community over time. Given the large investment in community coalitions, researchers are beginning to systematically explore the factors that affect the long-term sustainability of community coalitions once their initial funding ends.
The White House Office of National Drug Control Policy (ONDCP) and the SAMHSA Center for Substance Abuse Prevention (CSAP) support Drug-Free Communities (DFC) Support Program grants, which were created by the Drug-Free Communities Act of 1997 (Public Law 105-20). The DFC Support Program has two goals:
- Establish and strengthen collaboration among communities, public and private non-profit agencies; as well as federal, state, local, and tribal governments to support the efforts of community coalitions working to prevent and reduce substance use among youth
- Reduce substance use among youth and, over time, reduce substance abuse among adults by addressing the factors in a community that increase the risk of substance abuse and promoting the factors that minimize the risk of substance abuse
Long-term analyses suggest a consistent record of positive accomplishment for substance use outcomes in communities with a DFC grantee from 2002 to 2012. The prevalence of past 30-day use of alcohol, tobacco, and marijuana declined significantly among both middle school and high school students. The prevalence of past 30-day alcohol use dropped the most in absolute percentage point terms, declining by 2.8 percentage points among middle school students and declining by 3.8 percentage points among high school students. The prevalence of past 30-day tobacco use declined by 1.9 percentage points among middle school students, and by 3.2 percentage points among high school students from DFC grantees’ first report to their most recent report. Though significant, the declines in the prevalence of past 30-day marijuana use were less pronounced, declining by 1.3 percentage points among middle school students and by 0.7 percentage points among high school students. Access the 2012 National Evaluation Report (PDF | 645 KB), published in 2013, to learn more about the DFC Support Program.
Learn more about how SAMHSA works to promote prevention of substance abuse and mental illness.