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Research ArticleOriginal Research

Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care

Rose Gunn, Melinda M. Davis, Jennifer Hall, John Heintzman, John Muench, Brianna Smeds, Benjamin F. Miller, William L. Miller, Emma Gilchrist, Shandra Brown Levey, Jacqueline Brown, Pam Wise Romero and Deborah J. Cohen
The Journal of the American Board of Family Medicine September 2015, 28 (Supplement 1) S52-S62; DOI: https://doi.org/10.3122/jabfm.2015.S1.150053
Rose Gunn
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
MA
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Melinda M. Davis
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
PhD
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Jennifer Hall
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
MPH
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John Heintzman
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
MD
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John Muench
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
MD, MPH
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Brianna Smeds
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
AIA
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Benjamin F. Miller
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
PsyD
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William L. Miller
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
MD, MA
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Emma Gilchrist
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
MPH
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Shandra Brown Levey
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
PhD
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Jacqueline Brown
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
MSN, APN
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Pam Wise Romero
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
PhD
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Deborah J. Cohen
From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice–Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.)
PhD
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Article Figures & Data

Figures

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    Figure 1.

    Observed type 1 layout: primary care and behavioral health clinicians located in separate work areas.

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    Figure 2.

    Observed type 2 layout: primary care and behavioral health clinicians located in shared work areas.

  • Figure 3.
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    Figure 3.

    Recommended floor plan example, open pod arrangement. BHC, behavioral health clinician; Case Mgr, case manager; MA, medical assistant; PCC, primary care clinician; RN, registered nurse; Sched, Scheduler.

  • Figure 4.
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    Figure 4.

    Recommended floor plan example, closed pod arrangement. BHC, behavioral health clinician; Case Mgr, case manager; EVS, environmental services; MA, medical assistant; PCC, primary care clinician; RN, registered nurse; Sched, Scheduler.

Tables

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    Table 1. Practice Characteristics, Layout of Physical Space, and Observed Patterns of Integrated Care Delivery (N = 19)
    Practice ID14671112131415171825389101619
    Layout typea1111111111122222222
    Practice characteristics
        Primary care/mental healthBothPrimary carePrimary carePrimary CarePrimary carePrimary carePrimary carePrimary careBothMental healthMental healthBothPrimary careBothPrimary CarePrimary carePrimary carePrimary careMental health
        Geographic locationUrbanSuburbanSuburbanSuburbanRuralSuburbanUrbanSuburbanUrbanRuralSuburbanSuburbanUrbanUrbanUrbanRuralSuburbanSuburbanRural
        OwnershipPrivate, not for profitPrivate, not for profitPrivate, not for profitClinicianHospital systemHospital systemClinicianHospital system, HMOGovernmentPrivate, not for profitPrivate, not for profitPrivate, not for profitHospital systemPrivatePrivate, not for profitClinicianClinicianHospital systemPrivate, not for profit
        Funding designationFQHC/CMHCFQHCFQHCNoneNoneFQHCNoneNoneGovernmentCMHCCMHCFQHC/CMHCNoneGovernmentFQHCNoneNoneFQHCCMHC
    Physical layout build/modifications
        New constructionXXX
        Remodeled spaceXXX
        Existing spacebXXXXXXXXXXXXX
    Functional characteristics
        BHC and PCC office locationsSeparate FloorsVariabledSame floorSeparate LocationsSame FloorSame FloorSame FloorVariableVariableSame FloorVariablePodsSame floorSame FloorSame floorSame FloorSame FloorSame FloorSame Floor
        BHC and PCC shared office
        Workflow pathway (BHC in proximity)XXXXXXXXXXX
    Treatment spacec
        Exam roomXXXXXXXX
        Private officeXXXXXXXXXX
        BothXXXXXX
        Accessibility of BHCCrisisSometimesSometimesRareSometimesRareSometimesRareSometimesXXX
    Integrated care typeRareRareAlwaysAlwaysMostSometimesSometimesSometimesSometimesSometimes
        Bidirectional (CMHC-FQHC hybrid)X
        BH in PCXXXXXXXXX
        PC in BHXXXXXX
    Integrated care modelXXX
        Fully integratedXXX
        Partially integratedXXXXX
        ColocatedXXXXX
        Referral onlyXXXXX
    • BH, behavioral health; BHC, behavioral health clinician; CMHC, community mental health center; FQHC, federally qualified health center; HMO, health maintenance organization; PC, primary care; PCC, primary care clinician.

    • ↵a Type 1 nuances: separate floors or same floor, both options (same floor preferred, if not available other floor), another location. Type 2 nuances: all providers/staff in one space; some providers in one space with medical assistants separate; teams organized into pods.

    • ↵b Existing space is defined as clinic existing prior to integration efforts commencing, with only minor changes to accommodate new model of care delivery.

    • ↵c Where the new clinician sees patients.

    • ↵d Variable (primary, same floor; backup, separate locations).

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The Journal of the American Board of Family     Medicine: 28 (Supplement 1)
The Journal of the American Board of Family Medicine
Vol. 28, Issue Supplement 1
September-October 2015
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Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care
Rose Gunn, Melinda M. Davis, Jennifer Hall, John Heintzman, John Muench, Brianna Smeds, Benjamin F. Miller, William L. Miller, Emma Gilchrist, Shandra Brown Levey, Jacqueline Brown, Pam Wise Romero, Deborah J. Cohen
The Journal of the American Board of Family Medicine Sep 2015, 28 (Supplement 1) S52-S62; DOI: 10.3122/jabfm.2015.S1.150053

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Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care
Rose Gunn, Melinda M. Davis, Jennifer Hall, John Heintzman, John Muench, Brianna Smeds, Benjamin F. Miller, William L. Miller, Emma Gilchrist, Shandra Brown Levey, Jacqueline Brown, Pam Wise Romero, Deborah J. Cohen
The Journal of the American Board of Family Medicine Sep 2015, 28 (Supplement 1) S52-S62; DOI: 10.3122/jabfm.2015.S1.150053
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Keywords

  • Behavioral Medicine
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  • Medical Office Buildings
  • Primary Health Care
  • Qualitative Research

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