Behavioral Health & Substance Use
Behavioral Health & Substance Use
Behavioral Health & Substance Use
Mission, Vision & Objectives
By integrating behavioral health offerings into the primary care setting, Mass General Brigham has been able to establish the universal competence and skill for our interdisciplinary primary care teams. Our primary care teams effectively support patients with behavioral health conditions including depression, anxiety, and substance use disorders using population health management approaches.
The goal of this integrated approach is to engage patients in the primary care setting who present with behavioral health conditions by: (1) seamlessly integrating innovative, evidence-based population health program models, and (2) supporting primary care providers via training and expert consultations.
More broadly, we aim to improve care quality, control costs, enhance the patient experience, and improve provider work life.
The Collaborative Care Team is an integrated care team, anchored by a nonclinical direct service workforce who work alongside clinicians to deliver a suite of behavioral health interventions within the primary care setting. Behavioral health support specialists (BHSS’s), recovery coaches, and resource coordinators, among others, are vital members of our Collaborative Care teams in our primary care practices.
Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) Model is a short-term, evidence-based program offered by a care team to patients in primary care practices in person or via telephone. The IMPACT model offers symptom monitoring, coaching, behavioral activation, psycho-education, support with medication adherence, and psychiatric consultation. It is a treatment-to-target approach.
- Background IMPACT, a team-based approach to behavioral health management in primary care, was introduced at Mass General Brigham in 2014 to improve support for patients presenting with unmet behavioral health needs in the primary care setting.
- Evidence Base Through a multi-site and multi-state study by the University of Washington, researchers have demonstrated the effectiveness of the IMPACT model including reduced depressive symptoms, reduced health-related functional impairment, and improved quality of life. In response to these results, hundreds of organizations in the U.S. and internationally, including Mass General Brigham, have adopted IMPACT.
- Overview of Intervention IMPACT is a core intervention within the Collaborative Care suite of offerings. It utilizes a multidisciplinary team, anchored by a trained behavioral health support specialist (or a licensed social worker) who coaches individual patients and coordinates care with primary care providers, a psychiatric consultant, and licensed social workers.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a one-time intervention that uses screening for substance use, targeted education about substance use and mental health, and referral (as appropriate) to treatment.
- Background SBIRT was initiated in 2017 to facilitate the detection and management of risky alcohol and drug use in primary care. By populating screen results from SBIRT into the Epic electronic medical record, Mass General Brigham now provides primary care teams with a tool for identifying alcohol and opiate misuse, among other substances, within primary care. Furthermore, by training Collaborative Care teams in brief intervention techniques, this program improves the ability of primary care practices to manage risky substance use that is detected by screening.
- Evidence Base SBIRT, a model disseminated by the Substance Abuse Mental Health Services Administration (SAMHSA) was selected for its well-established efficacy in reducing risky alcohol use. It has been used widely used in both health care and in community settings.
- Overview of Intervention In SBIRT, a one-time intervention, support specialists screen all patients referred to Collaborative Care to identify patients with either risky substance use or dependence and in need of services. A decision-support algorithm guides the support specialist’s response to positive screens, which may include targeted education, measures of motivation to change substance use, and referrals. These SBIRT interventions were specifically designed to occur in non-substance abuse treatment settings such as primary care.
Internet-based Cognitive Behavioral Therapy (iCBT) is an online self-directed course in cognitive behavioral therapy (CBT) offered to patients with low to moderate levels of depression and/or anxiety to help them self-manage symptoms of those conditions.
- Background Internet-based cognitive behavioral therapy (iCBT) was introduced at Mass General Brigham in 2016 to address mild to moderate depression, and subsequently also anxiety, in primary care patients via a self-directed learning system. The online learning experience provides an alternative or complement to usual care for patients with barriers to care, such as lack of transportation, or those who simply have interest in trying something new.
- Evidence Base Research by Saint Vincent’s Hospital in Australia, the creator of the Mass General Brigham Care Online curriculum, and McLean Hospital demonstrated the efficacy of Mass General Brigham iCBT learning modules when offered in combination with brief, motivational coaching by support specialists.
- Overview of intervention The iCBT program is a self-directed course based on cognitive behavioral therapy that builds self-help skills for reducing a patient’s own symptoms offered in combination with brief, weekly motivational coaching. New learning modules are being introduced over time to address specific behavioral health conditions.
Resource-Finding is a program to help individual patients find community-based mental health therapists, psychiatrists, or behavioral health treatment programs.
- Background The resource-finding service was introduced at Mass General Brigham in 2014 to help connect adult primary care patients with community-based behavioral health resources, including mental health treatment and substance use disorder programs. In 2018, it expanded to assist the pediatric population.
- Overview of Intervention Resource specialists do the legwork to help patients to find therapists and other providers who accept patients’ insurance and have availability to treat new patients, increasing the likelihood of connection to treatment while reducing time burdens on primary care. Most requests address depression, anxiety, and substance use disorders. Some referrals result directly from screening for substance use disorder carried out in primary care.
Social Work Care Management for Medicaid is individualized outreach and engagement with certain Medicaid patients to foster access to needed community resources for addressing social determinants of health and overall coordination of care.
- Background In 2017, in conjunction with the pilot of Mass General Brigham’s new Medicaid Accountable Care Organization (ACO), Social Work Care Management was offered to certain Medicaid patients. The role is one feature of a multifaceted population health strategy for coordinating and managing care for members of the Medicaid ACO.
- Evidence Base Social Work Care Management is developed from evidence-based models designed for health care settings, many of which are codified for practice by the National Association for Social Work (NASW), that have expanded nationwide for Medicaid and Medicare patients.
- Overview of Intervention For certain members of the Medicaid ACO, Social Work Care Management reaches out to engage patients, including those presenting at emergency departments without connections to their primary care physicians and with unmet behavioral health needs. The care management program includes assessment, problem solving, referrals, advocacy, and long-term connections to primary care for these patients.
- Background Recovery coaching, a peer support model to address substance use disorder, is a complement to the Collaborative Care suite of interventions. It was first introduced at Mass General Brigham in 2014 and expanded to additional Mass General Brigham institutions in 2017.
- Evidence Base Recovery coaching, which has been gaining ground nationally as part of a chronic care management approach to substance use disorders, was pioneered at Partners with evidence of benefits to participating patients.
- Overview of Intervention Recovery Coaching, a non-clinical intervention, is offered in primary care, emergency departments, and specialty substance use disorder clinics for patients with substance use disorders. In this program, peer support specialists with lived experience in recovery mentor patients in earlier stages of recovery. They holistically assist patients on their journey towards health and well-being.
- Background In 2018, Mass General Brigham Behavioral Health Integration piloted an embedded addiction medicine team at one primary care clinic, with the potential for more sites to follow. This model increases access for patients to needed specialty care for addictions, bridges care back to primary care for long-term management, and increases the likelihood of positive outcomes through complementary peer support and care coordination.
- Evidence Base Findings from Massachusetts Health Quality Partners in their 2016 survey of patients’ unmet need for addiction treatment in primary care, among other research, informed planning for the team. As evidence for such integrated substance use disorder teams emerges, the Behavioral Health Integration team will follow the field.
- Overview of intervention In this model, an addiction specialty team, which may include an addiction medicine physician, a nurse practitioner, a recovery coach, and administrative staff, is integrated into primary care clinics or other multi-specialty practices. For targeted patients, the team provides rapid assessment, stabilization, office-based buprenorphine treatment, care coordination, peer support, and initial treatment with the goal of referring stabilized patients back to primary care for management.
Supports for Care Teams
Practice-Based Competency Development is a multifaceted approach to build skills and competence within primary care care teams including tele-mentoring, professional development, peer learning and program-specific tools.
Professional Development includes training, network-wide symposiums, learning collaboratives, mentorships, and peer-to-peer communities of practice for all behavioral health care team members embedded in primary care clinics and their provider colleagues in primary care.
- Orienting New Staff New Behavioral Health staff members participate in a centralized, uniform orientation. Sessions are tailored to new support specialists, recovery coaches, resource specialists, psychiatric consultants, and licensed social workers.
- Training and Education Staff are trained through both in-person workshops and distance learning. These include workshops specific to Collaborative Care’s IMPACT model and a series dedicated to substance use disorders. An annual Behavioral Health Integration Symposium, featuring a full day of guest speakers and thematic discussion groups, is another significant learning event. Each symposium is devoted to a broad topic of key interest to the field. Over the last three years, symposia offered audiences in-depth explorations of Collaborative Care, substance use disorders, and the aging brain. In addition, providers are routinely trained to prescribe buprenorphine for treating substance use disorder and secure the required waiver to prescribe.
- Learning Collaborative Regularly scheduled learning collaboratives are hosted throughout the year for behavioral health service staff such as support specialists, social workers, resource specialists and recovery coaches. These half-day events combine presentations with interactive learning experiences.
- Communities of Practice Local behavioral health team members are convened in “communities of practice” with their peers from other Mass General Brigham institutions. Communities of practice are forums for the exchange of best practices and problem solving.
- Mentorships – Medication for Addiction Treatment Behavioral Health Team organizes mentorship relationships between Mass General Brigham primary care providers who are new to prescribing buprenorphine for patients with substance use disorder and those with more experience.
Extension for Community Healthcare Outcomes (ECHO) is a telementoring program where experts on addiction advise primary care providers seeking help on how to manage their patients using substances. This is a group learning forum.
- Background ECHO: Substance Use Disorder Series is a small group learning forum, first launched at Mass General Brigham in 2017, that takes place via videoconferencing. It was introduced to enable primary care providers to identify and treat more cases of substance use disorders themselves rather than rely entirely on referring patients to specialists.
- Evidence Project ECHO, first developed and studied by the University of New Mexico, has been implemented to address multiple medical conditions. The subject of 39 studies in 17 healthcare fields, ECHO is proven to increase participant knowledge about healthcare treatments such as substance use disorder.
- Overview of intervention The ECHO telementoring program features a panel of subject matter experts on substance use disorders and its treatment, from physicians to resource navigation specialists, holding a videoconference with primary care team providers at satellite sites. Conferences include case presentations by primary care teams, didactic presentations by experts and discussion.
eConsults is an individualized virtual consultation service for primary care providers who need expertise from psychiatrists on how to manage their individual patients’ behavioral health conditions. Providers can submit questions electronically (e.g., via clinical messaging or e-mail), and eConsultants review a patient’s medical record to provide guidance. Background Virtual consultations, in which specialists advise primary care providers on the management of patients based on medical record review and not direct patient contact, were first offered in 2013 at Mass General Brigham. After a few early iterations, these relationships are now organized within an expanded eConsult program as of 2017. Sub-specialty expertise in addictions was added to Collaborative Care for patients with complex substance use disorder starting in 2017. Evidence There is a growing body of evidence for strong outcomes from eConsults within the population health field. Overview Psychiatrists review patient medical records and provide input directly to primary care teams on questions related to medications, diagnostic clarification, appropriate levels of care, care planning, triage, and provider-patient relations.
Program-Specific Enabling Tools are user-friendly resources and learning aids to facilitate program implementation and promote high-quality behavioral health management. These tools include a dashboard on progress towards goals, status reports, and toolkits. Also offered are evidence-based screeners for common behavioral health issues and algorithms for identifying patients for services and making treatment management decisions.
- Reports to the Field Routine status reports, such as program-specific dashboards illustrating progress toward goals at each of Mass General Brigham’s institutions, are provided to behavioral health teams implementing Collaborative Care programs and its related program offering Recovery Coaching. They are used by program administrators for data-driven decision making and quality improvement.
- Screening Tools A collection of evidence-based screening tools for surveying patients’ risks for behavioral health conditions such as substance use disorders and depression is integrated across programs. These screening tools include the Nine-Item Patient Health Questionnaire and the Alcohol Use Disorder Identification Test.
- Algorithms Algorithms are developed and revised to identify patients for targeted behavioral health interventions such as Social Work Care Management for Medicaid patients.
- Registries Registries built within the Epic electronic medical record, such as the depression registry and the buprenorphine registry, help Behavioral Health teams proactively identify patients for outreach, engagement and active management.