Article Figures & Data
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- Figure 1.
A case study demonstrating how the five organizing constructs intertwine to shape a practice's integration approach.
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Primary Data Type Description of Data Data Collection Process Study Documents Grant applications and reports to TCHF (ACT only), e-mail communications, innovator presentations, and documents from innovators (scheduling templates, educational materials). For ACT, documents were collected throughout the study period and during observation visits. The Program Office and grantees share documents freely. For IWS, we collected relevant care delivery documents during site visits. ACT IWS Online diaries Members from each ACT innovation team (practice) report on implementation experiences via an online journal that is shared with other members of their team and the evaluation team. Evaluation team identified 5 to 7 people in each ACT practice to post diary entries. Each team had a private online diary room. Diary keepers were asked to post every 2 wk. Evaluators interacted with diary keepers to encourage posting. ACT Field observation Two 4-day visits with each practice to observe care delivery During visits, 2 to 5 evaluators observed the care delivery process by shadowing clinicians, clinical support staff, and non-clinical support staff. This included observing huddles and other team meetings. During field observation, researchers took brief notes or jottings and used these to create a detailed set of field notes. ACT IWS Interviews Semi-structured interviews were conducted with practice members We conducted semi-structured interviews with 2 to 17 practice members during field visits, depending on practice size. Practice member with on-the-ground knowledge of practice operations and relevant contextual knowledge were selected for interviews. ACT IWS Survey Completed by each practice to collect information about the organization (e.g., ownership, staffing patterns, turnover, panel characteristics) We distributed surveys to one person at each practice who worked with members of the practice to complete it. Information was returned to us either online or via paper. Survey responses were clarified with practices as needed. ACT IWS REACH Either an exact count or an estimate of the proportion of patients in the practice who received some level of integrated care For ACT we developed and tailored a tracking sheet to collect REACH data. Practices collected these data for one year and shared data with us quarterly. We reviewed data with practice to determine accuracy and made corrections as needed. For IWS practices, the research team used observational to estimate REACH for each practice. ACT ACT, Advancing Care Together; IWS, Integration Workforce Study; TCHF, The Colorado Health Foundation.
Organizing Principles Conceptual Definition Operational Definition Integration REACH Extent to which integrated services are available to practice population Strategy for identifying patient need (systematic, clinical discretion). Access to integrated care (limited, broad) Location of integration workforce Proximity of the professionals on the integrated care team Primary care and behavioral health colocated; Psychiatrist co-located; PCCs and BHCs located in same team workspace Approach to patient transitions Strategies that practice employs when introducing and engaging patients with another professional on the care team Warm-handoffs and referrals Establish care pathways Determining the level and type of care practice can provide, including care requiring referral to outside resources. Establish paths for both. Care paths for patients with more serious illness (emotional and behavioral) are identified (yes/no) Shared mental model Practice members have shared understanding of practice model for integration The majority of practice members talk about and behave in ways that reinforce the same model for integration (yes/no) Practice ID 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Practice characteristics, PC/MH/Both Both Both Both PC PC PC PC PC PC Clinician Hospital system Hospital system Clinician Hospital system, HMO, not for profit Government Hospital system Private, not for profit Private, not for profit Private, not for profit Ownership Private, not for profit Private, not for profit Private Private, not for profit Hospital system Private, not for profit Clinician Private, not for profit Clinician Suburban Rural Suburban Urban Suburban Urban Suburban Rural Suburban Rural Setting Urban Suburban Urban Suburban Urban Suburban Suburban Urban Rural Financial characteristics None None FQHC None None Government FQHC CMHC CMHC CMHC Govt/FQHC/CMHC & FQHC/None FQHC/CMHC FQHC/CMHC Government FQHC None FQHC None FQHC None Practice revenue, % 4 5 57 13.45 27 54 9 10 0.5 3 Medicare 7 10 8 7 15 41 24 4 6 0 40 10 3.97 0.2 0.21 48 25 58 40 Medicaid 35 38 22 30 26 43 10 49 5 91 30 2 63.61 72.8 14.79 8 35 1.2 29 Commercial insurance 39 8.2 24 7 59 1 62 11 69 5 25 31 18.97 0 31 35 30 14 28 Uninsured 19 43.8 46 56 0 14 4 36 20 6 (4.8) 5 (5.0) 5 (3.15) 22 (13.6) 33 (21.9) 71 (70) 9 (9) 6 (6) 1 (0.4)* 3 (2.2) FTE primary care clinicians, n 37 (22.5) 8 (6.5) 56 (48.2) 11 (11) 7 (5.8) 2 (1.2) 14 (10) 12 (9.9) 2 (2) 1 (0.5)* 1 (1.0) 4 (0.9) 5 (1.0)† 1 (0.6) 6 (5.6) 2 (1.4) 2 (2) 26 (22.8) 10 (7.9) FTE behavioral health clinicians, n 8 (7.4) 4 (3.2) 18 (17.4) 2 (2) 2 (1.6) 4 (3.8) 2 (0.5)* 4 (2.9) 1 (0.5)* 15,600 27,000 8,372 47,476 27,748 159,096 17,680 31,200 4,732 7,904 Annual patient visits, n 90,480 10,972 104,520 14,924 10,400 10,693 31,720 102,960 4,680 Yes Yes Yes Yes Yes Yes Yes Yes No No BHC can document in EHR? Yes Yes Yes Yes Yes Yes Yes Yes Yes Characteristics of the integration model Breadth and depth of integration reach Identification of problem Systematic Screening Systematic Screening Systematic Screening Systematic Screening Systematic Screening Systematic Screening Systematic Screening Systematic Screening Systematic Screening Systematic Screening Clinician Discretion Clinician Discretion Clinician Discretion Clinician Discretion Clinician Discretion Systematic Screening Systematic Screening Clinician Discretion Systematic screening Provision of services Limited Broad Broad Broad Broad Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Relevant workforce located in practice Embedded BHC on primary care team No Yes Yes Yes Yes Yes No Yes No Yes No Yes Yes No Yes Yes No No Yes Consulting psychiatrist in practice Yes Yes Yes No Yes Yes No Yes No No No No No In system In system In system In system yes Yes Approach to transitioning patients to BHC Warm hand-off X X X X X X X Referral X X X X X X X X X X X X X X Path identified for other services Specialty MH Referral Referral Referred Referral Referral Referral Referral Referral No Path Referral Referral Referral Referral Referral Referral Referral Referral Referral Referral Substance use Referral Warm-hand off and referral Referral Referral Referral Referral Referral Referral Limited Referral Referral Referral Referral Referral Referral Referral Referral Referral Referral Shared mental model for integration No Yes Yes Yes Yes Yes No No No No Yes No No Yes No No Yes Yes No PC PC PC PC PC Both PC MH MH MH BHC, behavioral health clinician; CMHC, community mental health center; EHR, electronic health record; FTE, full-time equivalent; HMO, health maintenance organization; MH, mental health. PC, primary care.
The designation of government for ownership or financial characteristics indicated a non-FQHC- or CMHC-funded health system where the majority of financing or ownership is from the U.S. government.
↵* Due to ebbs and flows in staffing as a result of turnover and the fact that one BHC sometimes provided services to multiple practices, these are estimated FTEs.
↵† These 5 BHCs were employees of a BHO and not the primary care practice. The practice contracted with the BHO, and different BHCs rotated hours in the primary care practice.
Practice ID Integration Approach 1 FQHC/CMHC within one organization. CMHC employs multiple traditional BHCs including psychiatrists. One BHC serves as a care coordinator/care manager and does the majority of BH intake assessments. BHCs are located on a different floor and isolated from PC teams. In PC, MAs systematically screen for BH needs (PHQ-2/PHQ-9), referring PC patients to BHCs as needed. BHCs provide traditional therapy; psychiatrists handle medication management. Care manager gets involved with primary care when there is a crisis and immediate access to services (same day) is needed. Refer out for SU counseling; care manager handles this referral. 2 FQHC/CMHC within one organization. Practice employs BHCs and has post-doctoral training program in psychology, but trainees do not provide majority of BH care for patients. One BHC is assigned to two PC teams, although BHCs assist other PC teams as needed. Patients systematically screened for BH needs by MA. As needs are identified, BHCs approached for warm hand-off. During hand-offs, BHCs rapidly assess patients' needs, conferring with the patient and PC team about diagnosis and treatment options. BHCs provide brief (30 min) problem-focused therapy to patients, and refer patients with SPMI to CMHC on the third floor. Consulting psychiatrist moves across PC teams and is responsible and available for consultation and assistance with medication management. BHCs conduct several group therapy sessions for patients, including for SU. 3 PC practice in integrated health system that includes a full spectrum of PC and BH services, including specialty services. Practice has hired BHCs to work with the PC teams. Patients are systematically screened for BH needs by MAs and BHCs; BHCs scrub the chart daily to identify patients coming in who might benefit from a brief checkin from the BHC. PCCs engage BHC as needed via warm handoff. BHCs rapidly assess patients' need, determine whether the patient will benefit from brief, problem-focused therapy, and provide that therapy if needed. For patients who require longer-term services, the BHCs refer the patient to the specialty MH services within the organization, including SU, and assist with the transition. The wait for these services can be long, and the BHC might provide a therapy bridge until the patient gets into specialty MH. BHCs do some therapy groups. 4 PC practice with post-doctoral training program in psychology that is the main source of BH care. Staff psychologists supervise students and provide direct care. BHCs are located throughout the building, often in close proximity to the PC teams. Initially, BHCs scrubbed charts to identify patients on the schedule whom they had not yet met, or who had a pre-existing BH need, dropping in to meet, screen, and check in on the wellbeing of these patients. Now MAs systematically screen patients. When a problem is identified, BHCs do a warm handoff, meet with the patient, and offer brief, problem-focused therapy as needed. Patients with SPMI and SU needs are referred out to a local CMHC. BHCs help with this transition. 5 PC practice that is part of a larger health system that focuses on caring for the most complex patients. The practice employs BHCs and 2 consulting psychiatrists. BHCs work closely with PC teams, taking warm hand-offs and scrubbing the chart to identify patients on the schedule who would benefit from a brief BHC visit. BHCs offer brief, problem-focused therapy. Psychiatrists are available for consults and for medication management. Patients with SU problems and SPMI are referred to other programs in the system. BHCs and other team members help with these transitions. 6 PC practice that serves a homeless population. Employs three BHCs. MAs systematically screen for BH needs (PHQ-2/PHQ-9). BHCs have isolated offices and conduct traditional therapy appointments. Onsite psychiatrist and psychiatric NP handle medication management. Warm-handoffs to the BHCs are rare as BHCs are fully scheduled. Patients with SPMI are seen in the clinic. Group therapy sessions are offered and often led by a BHC and PCCs. Practice has a therapy group called Safety Seeking for SU and PTSD. 7 PC practice affiliated with multiple PC practices in the region. BHC is hired to serve patients seen in these practices. BHC is colocated in some practices but not others. Practice does systematic screening to identify BH needs by having front desk give patients a web tablet. PCCs determine when more in-depth psychological assessment is needed. Staff conduct these assessments, the BHC reviews it, meets with the patients to formulate a diagnosis, and works with the PCC and patient to develop treatment plan, which may be carried out by the PCCs or BHC. BHC does traditional therapy. Patients in need of longer MH services and SU services are referred out. 8 PC practice with two BHCs serving multiple PC teams. MAs screen adult patients. BHCs are located in close proximity to PC teams but are backlogged and typically unavailable for warm handoffs. When a warm handoff occurs, patient can wait several weeks for a BHC appointment. This is because demand may exceed what BHCs can provide, and because BHCs are engaging in traditional therapy. 9 Small PC practice working with a local, private, not-for-profit mental health center to embed a BHC. The BHC is part time, working 1 to 2 days a week in the practice. BHC works in close proximity to the PC team. The front desk systematically screens for a range of BH needs. When the screen is positive, the MA flags this for PCCs who then talk to the patient and decide whether the BHC is needed. BHC sees patients in an examination room. BHC schedule is full, making BHC unavailable for warm handoffs or new patients. PCC is aware of this, and may handle some brief counseling him/herself. Practice has limited access and weak relationships with community resources for referral of patients in need of SU or SPMI care. 10 Small PC practice working with local CMHC to embed BHC in the clinic. BHC began part time and expanded to full time. Front desk systematically screens for BH needs. BHC is backlogged and often unavailable for warm handoffs. This may be due to greater need for BH services than BHC can manage and BHC is doing more traditional therapy. BHC handles referrals to the CMHC and other providers for those patients who need longer-term MH services including SU services. This is an effective process for patients with Medicaid. However, CMHC does not have contracts for commercially insured patients, making securing care for these patients challenging. 11 Rural PC practice. Through an arrangement with local CMHC, this practice has one embedded BHC. Clinical discretion used to identify BH needs. BHCs are backlogged and often unavailable to PCCs for warm handoffs, as BHCs are doing traditional therapy and have full schedules. Because BHCs are from a CMHC there is a clear pathway for patients with SPMI and in need of SU counseling. BHCs handle these referrals. 12 PC practice with psychology postdoctoral training program, which is the main source of BHC for practice. PCCs use clinical discretion to identify patients with BH needs. BHC interns are often unavailable to PCCs as they are not located in close proximity to PCC and they have full schedules. Thus, few warm handoffs are made. BHC interns work part time at the practice and see patients based on a referral model for traditionally scheduled therapy appointments. High-needs MH patients are referred out. 13 PC practice with embedded BHCs through an arrangement with a partnering private BH organization. Through a combination of screening during well visits, clinician discretion and BHC outreach to PC teams patients are identified who might benefit from BH services. BHC does warm handoffs and a rapid assessment of patients needs, determining whether patients will benefit from 4 to 6 sessions of brief, problem-focused therapy or if the patient has longer-term needs. BHC provides brief therapy, as needed, or refers (walks) patients in need of long-term therapy to the BH organization, which is located in the same building. Patients with SU needs are referred out to other organizations as are patients with SPMI on Medicaid or Medicare because of reimbursement challenges. 14 PC practice is part of integrated health system that includes a full spectrum of PC and MH services including specialty services. System has hired BHCs to work with PC teams. PCCs use their discretion to identify patients in need of BHC services and refer patients to the BHC using the EHR. Warm-handoffs are rare. BHCs are connected to a PC team but may not be in the same location (separated by halls or floors). BHCs do group therapy sessions, provide brief, problem-focused therapy, and help patients who need specialty MH services make that transition either to internal resources or a local CMHC (Medicaid only). 15 PC practice in integrated health system that includes a full spectrum of PC and BH services, including specialty services. System has hired BHCs to work with PC teams. PCCs use clinical discretion to identify patients who might benefit from BHC services; they will either refer patients to the BHC or arrange for a warm handoff. BHCs are connected to a PC team but may not be in the same location (separated by halls or floors). Distance limits warm handoffs. BHCs do group therapy sessions, provide brief, problem-focused therapy, and help patients who need specialty MH services make that transition. 16 PC practice in integrated health system. PC practice has an embedded BHC to work with the PC teams to do brief, problem-focused therapy. Need for BHCs exceeded FTEs available, and program was expanded to include students who help with access. Onsite SU provider added during intervention. BHCs available for warm handoffs and offer brief, problem-focused therapy to patients. Patients who need longer-term therapy and SU services are referred to another clinic in the system. 17 CMHC hired PA and MA team to serve its patients, and to expand its services to a non-SPMI population. The practice systematically screens its patients to identify physical and behavioral health needs. SPMI patients come to PA by referral from therapist, case managers, or self. Therapists ask patients, including those with SPMI, whether they have a PCC provider. Those without a PCC are offered help in getting them connected with one. The PA, health navigator, or health coach treats patients seeing PC team who are identified with mild to moderate BH needs. Therapists in the clinic treat patients with SPMI and SU needs. PA has > 15 y practicing in the community and has connections with medical specialty care providers. 18 CMHC serving people with SPMI. MH clinicians use their discretion to identify patients who need PCCs and refer these patients to a Care Coordinator. The Care Coordinator assists referred patients with paper work, which must be done prior to the PCC visit. Once completed, Care Coordinator schedules appointment with PCC. PC team is composed of a PA, MA, Care Coordinator, and SU counselor. The PA and MA are on contract with a local FQHC, the SU counselor is on contract with a local SU rehabilitation organization. PC team travels together across 3 CMHC sites. PC team handles the majority of physical health needs as well as likely some mild to moderate BH needs, and refers patients to medical specialists in the community as needed. Because PA works for an FQHC, specialists are easily identified. 19 CMHC hired PCC, MA, and front desk team to serve its patients, and expanded services to a non-SPMI population. Practice systematically screens patients using web tablet distributed at front desk to identify physical and BH needs. In addition to the BHCs providing traditional therapy, 1 BHC is embedded on PC team to provide integrated care. Patients with SPMI and SU needs are seen in this practice through individual and group therapy. PC team handles majority of patients' physical health needs but refers out to specialists in the community as needed. Abbreviations: BH, behavioral health; BHC, behavioral health clinician; CMHC, community mental health center; EHR, electronic health record; FQHC, federally qualified health center; FTE, full-time equivalent; MA, medical assistant; MH, mental health; NP, nurse practitioner; PA, physician assistant; PC, primary care; PCC, primary care clinician; PHQ2/PHQ9, screening tools for depression; SPMI, serious and persistent mental illness; SU, substance use.
- Table 5. Shared mental model for integration and close proximity of BHC and PCCs shapes use of warm handoffs and REACH of integration program among a group of practices with similar characteristics
Practice ID 2 1 4 5 3 Practice Characteristics PC/MH PC/MH PC/MH PC PC PC/MH Ownership Private, not for profit Private, not for profit Private, not for profit Hospital system Private Govt/FQHC/CMHC & FQHC/None FQHC/CMHC FQHC/CMHC FQHC None Government Characteristics of the integration model Breadth and depth of Integration REACH Identification of problem Systematic screening Systematic screening Systematic screening Systematic screening Systematic screening Provision of services Broad Limited Broad Broad Broad Relevant workforce located in practice Embedded BHC on PCC team Yes No Yes Yes Yes Consulting psychiatrist in practice Yes Yes No Yes Yes Approach to transitioning patients to BHC Warm-handoff X X X X Referral X X Path identified for other services Specialty MH Referral Referral Referral Referral Referred Substance Use Warm-handoff and referral Referral Referral Referral Referral Shared Mental Model for Integration Yes No Yes Yes Yes Abbreviations: BHC, behavioral health clinician; CMHC, community mental health center; FQHC, federally qualified health center; FTE, full-time equivalent; MH, mental health; PC, primary care; PCC, primary care clinician.
The designation of Government for ownership or financial characteristics indicated a non-FQHC- or CMHC-funded health system where the majority of financing or ownership is from the U.S. government.
The bold values listed for Practice 1 are to indicate how constructs such as physical distance among professionals and lack of a shared mental model can influence the approach to integrated care, despite practice characteristics that support broader integration approaches in other settings.
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