Practical Approaches for Achieving Integrated Behavioral Health Care in Primary Care Settings.

Behavioral health problems are common, yet most patients do not receive effective treatment in primary care settings. Despite availability of effective models for integrating behavioral health care in primary care settings, uptake has been slow. The Behavioral Health Integration Implementation Guide provides practical guidance for adapting and implementing effective integrated behavioral health care into patient-centered medical homes. The authors gathered input from stakeholders involved in behavioral health integration efforts: safety net providers, subject matter experts in primary care and behavioral health, a behavioral health patient and peer specialist, and state and national policy makers. Stakeholder input informed development of the Behavioral Health Integration Implementation Guide and the GROW Pathway Planning Worksheet. The Behavioral Health Integration Implementation Guide is model neutral and allows organizations to take meaningful steps toward providing integrated care that achieves access and accountability.

Behavioral health problems are common and significantly affect patients’ health and quality of life. Although most treatment for common mental disorders is provided in primary care, there are significant opportunities for improvement in both processes and outcomes.[1,2] For example, as few as 20% of patients treated in “usual” primary care show substantial clinical improvement.[3] Unfortunately, simply referring patients to a mental health specialist also is not effective for achieving better outcomes or improving access.[4]

Delivering behavioral health services within the primary care setting enhances access to care, produces better patient outcomes,[5] reduces health care costs,[6] and may improve the patient’s experience of care.[3] High-risk populations, in particular, such as those served by safety net clinics, may benefit from programs able to address both physical health and behavioral health needs.

In 2014, the Working Party Group on Integrated Behavioral Healthcare revisited the Joint Principles for the Patient-Centered Medical Home (PCMH)[7] and proposed a complementary set of principles that emphasized the centrality of behavioral health for patient-centered care.[8,9] PCMH recognition and certification programs, including the National Committee for Quality Assurance 2014 PCMH Recognition Program,[10] have increasingly emphasized the importance of behavioral health integration. Furthermore, the American Academy of Family Physicians Mental Health Care Services Position Paper “supports the development of new treatment strategies to improve the percentages of patients receiving adequate treatment and follow-up through both primary and mental health specialty care providers.”[11]

There are a variety of models for integrating mental health treatment into primary care.[12] Yet despite a strong evidence base and enabling policies to promote integration, limited practical guidance for organizations with widely variable resources and circumstances has been a barrier to model selection and implementation.

Practices participating in the Safety Net Medical Home Initiative,[13] a national effort to support PCMH transformation in the safety net, identified the lack of practical guidance as a key gap in tools to support transformation. This article describes the development of resources to assist primary care practices in selecting and implementing approaches to behavioral health integration.

Methods

The Project Team (which included representatives from the AIMS Center, Qualis Health, the MacColl Center for Health Care Innovation, and The Commonwealth Fund) used a 3-tiered approach to gather input from stakeholders who are instrumental in behavioral health integration efforts: safety net and community providers, subject matter experts in primary care and behavioral health, a behavioral health patient and peer specialist, and state and national policy makers. This included (1) seeking recommendations on existing resources, (2) feedback on an early draft, and (3) experience from early adopters.

Technical Advisor Panel

The Project Team convened 13 primary care and behavioral health experts to serve as technical advisors and to suggest existing resources that should be reviewed by the authors and considered for citation. A total of 145 resources and tools were recommended by technical advisors and members of the Project Team. These included survey results, book chapters, Web sites, reports, peer-reviewed articles, newsletters, reports, slide decks, toolkits, and white papers dating from 1987 to 2013. Suggested resources were reviewed by at least 2 members of the Project Team and themed by content area.

Expert Review Group

Sixteen individuals were identified to form the Expert Review Group and were tasked with providing feedback on draft materials. This included 4 members from the original Technical Advisor Panel and an additional 12 individuals from the same stakeholder categories. The authors requested feedback in writing; and for the purpose of building consensus from diverse viewpoints, the authors held a 2-day face-to-face review session in March 2014.

A systematic review process led to 15 recommended modifications to the draft, and all were addressed in the revision. However, major changes in the revision focused on the 4 recommendations that were most strongly endorsed by the Expert Review Group: Enhance content on financial sustainability; Build a decision tree or pathway to help practices identify where to begin, illustrated by case examples of the variety of options; Enhance measurement section; Add content on health information technology (HIT).

Case Examples

In order to identify meaningful lessons about behavioral health integration into real-world practices, the authors conducted interviews with 11 primary care safety net sites. Sites were selected so there would be diversity across the cohort in terms of implementation status, geography, practice size, and patient demographics. Full case examples were developed based on the results of 5 of these interviews; quotes from the remaining interviews were used throughout the guide to showcase specific lessons and offer testimonials from key members of the practice team.

Results

Behavioral Health Integration Implementation Guide

The resulting behavioral health integration implementation guide[14] is divided into 6 sections, which provide an overview of behavioral health care, practical guidance for integrating care as a part of the overall PCMH implementation process, and guidance on sustainability (what is it and how it works, implementing behavioral health care, monitoring progress, building integrated care teams, leveraging success, and HIT considerations). Practical tips and tables to summarize information are featured throughout the guide. Tools were included to support behavioral health integration, including a tool to assess a practice’s current level of behavioral health integration (PCMH-A), information on how to make the case for integration and overcoming resistance, strategies to address common team challenges, additional resources to support behavioral health integration, and 4 case examples from early adopters to illustrate common approaches to integration.

GROW Pathway Planning Tool

One clear priority from the Expert Review Group was the need for a tool a primary care practice could use to identify and actualize a path toward integration that was not limited to one particular model or that required substantial resources. In order to meet this need, the GROW Pathway Planning Worksheet was developed (Figure 1). This tool leads an organization through 4 phases of assessment for behavioral health integration: goals, resources, options, and workflow. First, the organization sets behavioral health integration goals to establish a clear target population. Next, the organization considers available resources to identify the most realistic approach for behavioral health integration. As part of this planning phase, the organization must consider the options it has to improve both access to behavioral health care, and accountability associated with assessing, monitoring, and improving health outcomes. Last, the organization must take the behavioral health integration vision and develop a new workflow to implement these changes.

Figure 1.

GROW pathway worksheet.

This worksheet can be used by organizations to assess current practice and move toward behavioral health integration. A modifiable version of this GROW Worksheet and a completed example are also available at http://www.safetynetmedicalhome.org/change-concepts/organized-evidence-based-care/behavioral-health.

HIT, health information technology.

Although the majority of patients will address behavioral health problems with self-management and/or with support in a primary care setting,[15] the ability to deliver more intensive behavioral health services through emerging models,[12,16] such as Behavioral Health Consultation and Collaborative Care, will enhance access to care—a core component of the PCMH. Organizations also may work to improve their capacity to manage care transitions when patients require higher levels of care, such as care from a community mental health center or inpatient setting, as part of their commitment to continuous quality improvement.

Regardless of where an organization starts, the commitment to continuous improvement and enhancement of services needs to be a core component of the integration process. This tool was designed so that organizations may repeat the GROW cycle several times to fully realize their vision and progressively enhance their capacity to provide care.

Conclusions

The Behavioral Health Integration Implementation Guide and the GROW Pathway Planning Tool help organizations move toward evidence-based behavioral health integration strategies. They are intended to assist practices in building a vision, specific to the needs of their respective patient populations, and identify achievable first steps. Importantly, these tools provide a platform for encouraging practices to continuously enhance their capacity to provide treatment in the primary care setting, thereby enhancing the spectrum of care available to patients (Figure 2).

Figure 2.

Spectrum of behavioral health care.

The Behavioral Health Integration Implementation Guide focuses on developing enhanced capacity for behavioral health care in the primary care setting. This figure shows the full spectrum of behavioral health care, from self-management approaches to inpatient hospitalization for mental health disorders. The implementation guide focuses on developing capacity to provide more support for behavioral health problems in the primary care setting through approaches such as collaborative care and the delivery of brief behavioral interventions.

Safety net practices were the targeted audience for these tools; however, the multitiered approach used to gather input from diverse stakeholders resulted in practical concepts and resources that are flexible. As such, the authors believe they can be applied in a wide variety of both developing and established PCMH settings, and will prove to be useful tools in accelerating the adoption of integrated care nationwide.