3 QUESTIONS TO... :

1/ Why did you choose to study the Medicaid Behavioral Health Home (BHH) model developed in the United States over the past ten years?

Individuals living with serious mental illness (SMI) are more often affected by chronic somatic diseases, such as diabetes and cardiovascular disorders. They experience a 15- to 20-year shorter life expectancy, and a risk of all-cause mortality twice that of the general population. While the causes of these comorbidities and excess mortality are multifactorial, these findings suggest an inadequacy of existing care delivery models: most countries are characterized by a fragmentation of physical and mental care, which are often funded and delivered separately. This situation creates barriers to access, particularly in terms of prevention, and hinders coordination between healthcare professionals. A recent international movement has therefore supported the implementation of "reverse" integrated care systems: primary care is delivered within specialized mental health settings, which are often the main point of contact with the healthcare system for people living with SMI, in a holistic, person-centred approach to health. The United States is unique in its adoption of this model over the last ten years and the lessons to be learned are valuable for France.

2/ Could you describe the BHH model and the main results of its evaluations?

The Medicaid BHH model, which was supported by the 2010 Affordable Care Act, provides a follow-up of physical health conditions of individuals living with SMI within community-based specialty mental health services, which serve these individuals in the communities where they reside. This model relies on the presence of a salaried nurse with a role in coordinating care, since these structures work in partnership with a primary care professional - either a physician or the equivalent of an advanced practice nurse - around predefined tasks such as health promotion, comprehensive care management, referrals to specialists… The synthesis of evaluations in real-world settings show encouraging findings: individuals with SMI have a more frequent primary care use and better detection and monitoring of somatic conditions and their risk factors. These are essential first steps toward improving the physical health of this population, which is an encouraging sign given the major difficulties they face in accessing appropriate primary care.
However, to achieve long-term effects, this type of model requires support through sustainable financing models that encourage collaboration between healthcare professionals, an increase in the staffing capacity of community-based specialty mental health services and through investing in data infrastructure for the collection and exchange of health data.

3/ What are the main lessons for France?

The persistent excess mortality of people with SMI should no longer be seen as an unavoidable phenomenon. It is partly explained by the inadequate provision of somatic care, which requires the timely development of new delivery system models. The positive impact of Medicaid BHHs in promoting access to primary care for this population calls for a new national paradigm that reinforces the pivotal role of French outpatient mental healthcare centers (Centres médico-psychologiques, CMPs) at the heart of a comprehensive approach to health for individuals living with SMI.
It is possible to draw on inspiring initiatives emerging within CMPs in France, which should be evaluated in order to guarantee their generalization and sustainability. The challenge is also to prevent the current momentum from relying solely on health professionals in a national context where the health system lacks maturity with regard to an integrated and person-centred approach.