It has been noted that the biggest problem with behavioral health referrals is that most patients, regardless of insurance coverage, do not make it into specialty care after they are referred.1 Low completion rates may be due to lack of motivation and insight among the patients, long wait lists and poor communication between referring and receiving providers.2 3 Affordability of options provided is also noted by patients as a barrier to treatment connection. This point in the care delivery pathway is particularly vulnerable; innovative strategies to close the referral loop have been emphasized in the literature as essential.4 Finally, benchmarks for referral success have been noted as an important metric to monitor and ensure accountability.1
To address the need for access to behavioral health referrals at Mount Sinai Health System, we interviewed primary care physicians to determine the types of appointments sought, strategies utilized to connect patients with behavioral health appointments, and impediments and challenges encountered in treatment connection. PCPs suggested that the typical approach to making referrals was to provide the patient with a list of resources at the end of a visit with the recommendation for the patient to call and find an available appointment. Insurance coverage and long wait lists were consistently cited as challenges to treatment connection. It was generally acknowledged that patient motivation for follow through was variable and impactful on outcome, particularly when considered with barriers (such as language access, physical accessibility, cost of care for out-of-network providers and availability of modality choice such as telehealth or in-person services). PCPs also acknowledged that consistent preventive screening for common behavioral health conditions, such as depression and anxiety, is dependent on ensuring that providers can connect patients to necessary treatment following positive screening. When queried, PCPs universally welcomed the idea of a systematized approach that provided the PCP with a triage resource who would take over the task of finding a referral appropriate to the level of care required.
We established the behavioral health Referral Access Program, which allows PCPs to refer identified patients to triage staff — a combination of social workers embedded in the primary care practice and a centralized group of care coordinators. Referrals are made through direct email or an order through the EHR. Triage staff are trained on the basics of behavioral health triage, including a review of behavioral health conditions that commonly present in primary care, assessment of mental status, suicide and homicide risk, risk for self-harm and triage based on level of risk. These staff, when they receive the referral, verify patient insurance, confirm patient interest in behavioral health care, gather patient preferences for treatment location, format and modality, and then attempt to find a suitable and acceptable appointment. External partnerships with community-based mental health organizations were established using standardized criteria to create a Trusted Behavioral Health Network. Given that need for behavioral health services frequently outweighs capacity, this additional external network has been essential.
Once the referral pathways were established, we tested our approach with five pilot sites in 2021, gradually scaling the program across Mount Sinai’s primary care network over the course of four years. Data from sites was tracked to gauge volume and type of referrals, success of referral connections and time to appointment. Program volume continued steady upward momentum between 2021 through 2024. In calendar year 2024, the program connected 1,398 referrals with appointments within either the Sinai psychiatric services clinics or through a provider partner from our Trusted Behavioral Health Network. Specifically, out of 2,425 referrals that were attempted within our curated network in CY 2024, 58% were connected with an appointment. Included in this are Certified Community Behavioral Health Center network partners who connected over 61% of Medicaid and Medicare referrals with a timely appointment. Anecdotal feedback from triage staff as well as network partners routinely identifies careful coordination between Mount Sinai program staff and referral recipients as the operant factor for the program’s success. Connection rates did not evidence notable trends based on race or payer. An interactive heatmap was developed to track subthreshold trends in access by race, payer, as well as race and payer. Program data are regularly shared with referring provider groups for ongoing awareness of outcomes, and encouragement for sustained referrals through the program.
As the program pathway has cemented into routine practice across Mount Sinai Health System’s primary care, functional enhancements continue to be applied for continuous improvement. This includes a mechanism to refer to external provider partners using an ambulatory referral placed through the Mount Sinai Health System’s EHR. This approach allows seamless loop closure and end-to-end visibility of referral outcome through the patient’s chart, as well as associated data capture for reporting. The program’s footprint also continues to expand. Current coverage includes all adult and geriatric primary care sites; expansion to pediatric practices is underway.
Author information:
Anitha Iyer, PhD, MPH, is an associate professor of psychiatry at Icahn School of Medicine at Mount Sinai and director of behavioral health population management at Mount Sinai Health Partners.
Nicholas Yip, LMSW, MPH, is senior manager of behavioral health integration at Mount Sinai Health Partners.
Sara Wetzler, MD, MPH, is a resident physician in the obstetrics and gynecology program at Icahn School of Medicine at Mount Sinai.
Arshad Rahim, MD, MBA, FACP, is chief medical officer and senior vice president of population health at Mount Sinai Health System.
- Chung, H., Smali, E., Goldman, M., & Pincus, H. (2019, February). Evaluation of a Continuum-Based Behavioral Health Integration Framework Among Small Primary Care Practices in New York State. United Hospital Fund. https://uhfnyc.org/publications/publication/continuum-based-bh-integration-among-small-primary-care-practices/ ↩︎
- Hacker, K., Goldstein, J., Link, D., Sengupta, N., Bowers, R., Tendulkar, S., & Wissow, L. (2013). Pediatric provider processes for behavioral Health screening, decision making, and referral in sites With Colocated mental health services. Journal of Developmental & Behavioral Pediatrics, 34(9), 680–687. https://doi.org/10.1097/01.dbp.0000437831.04723.6f
↩︎ - Katon, W., Robinson, P., Von Korff, M., Lin, E., Bush, T., Ludman, E., Simon, G., & Walker, E. (1996). A multifaceted intervention to improve treatment of depression in primary care. Archives of general psychiatry, 53(10), 924–932. https://doi.org/10.1001/archpsyc.1996.01830100072009
↩︎ - Patel, M. P., Schettini, P., O’Leary, C. P., Bosworth, H. B., Anderson, J. B., & Shah, K. P. (2018). Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System. Journal of general internal medicine, 33(5), 715–721. https://doi.org/10.1007/s11606-018-4392-z ↩︎
- Chung, H., Smali, E., Goldman, M., & Pincus, H. (2019, February). Evaluation of a Continuum-Based Behavioral Health Integration Framework Among Small Primary Care Practices in New York State. United Hospital Fund. https://uhfnyc.org/publications/publication/continuum-based-bh-integration-among-small-primary-care-practices/ ↩︎
