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Research ArticleOriginal Research

Approaches to Behavioral Health Integration at High Performing Primary Care Practices

Paula R. Blasi, DeAnn Cromp, Sarah McDonald, Clarissa Hsu, Katie Coleman, Margaret Flinter and Edward H. Wagner
The Journal of the American Board of Family Medicine September 2018, 31 (5) 691-701; DOI: https://doi.org/10.3122/jabfm.2018.05.170468
Paula R. Blasi
Kaiser Permanente Washington Health Research Institute, Seattle, WA (PRB, DC, SM, CH, EHW, KC); Community Health Center, Inc., Middletown, CT (MF).
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DeAnn Cromp
Kaiser Permanente Washington Health Research Institute, Seattle, WA (PRB, DC, SM, CH, EHW, KC); Community Health Center, Inc., Middletown, CT (MF).
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Sarah McDonald
Kaiser Permanente Washington Health Research Institute, Seattle, WA (PRB, DC, SM, CH, EHW, KC); Community Health Center, Inc., Middletown, CT (MF).
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Clarissa Hsu
Kaiser Permanente Washington Health Research Institute, Seattle, WA (PRB, DC, SM, CH, EHW, KC); Community Health Center, Inc., Middletown, CT (MF).
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Katie Coleman
Kaiser Permanente Washington Health Research Institute, Seattle, WA (PRB, DC, SM, CH, EHW, KC); Community Health Center, Inc., Middletown, CT (MF).
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Margaret Flinter
Kaiser Permanente Washington Health Research Institute, Seattle, WA (PRB, DC, SM, CH, EHW, KC); Community Health Center, Inc., Middletown, CT (MF).
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Edward H. Wagner
Kaiser Permanente Washington Health Research Institute, Seattle, WA (PRB, DC, SM, CH, EHW, KC); Community Health Center, Inc., Middletown, CT (MF).
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Article Figures & Data

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    Table 1.

    Characteristics of Learning from Effective Ambulatory Practices and Behavioral Health Integration, 2013

    CharacteristicN = 30*%
    Practice characteristics
    Organization type
        Federally qualified health center1550.0
        Private practice, multispecialty group930.0
        Private practice, primary care only620.0
    Number of sites in practice organization
        One723.3
        2 to 5620.0
        6 to 10826.7
        11 to 20413.3
    Setting
        Urban930.0
        Suburban826.7
        Rural1136.7
        Multiple26.7
    BH specialist staffing characteristics
    Any BH specialist present at practice†2583.3
        Masters'-level therapists (such as LCSWs)2170.0
        BH prescribers (psychiatrists or psychiatric NPs)1653.3
        Psychologists826.7
        Substance abuse counselors310.0
        Complementary/alternative BH providers (such as art therapists, dance movement therapists)310.0
    Affiliation of BH specialist when present (N = 25)‡
        Employed by the practice1456.0
        Employed by an external organization832.0
        Mixed (some BH staff employed by practice, some employed by external organization)28.0
        Unknown14.0
    BH-related services available
    Any BH-related screening†2273.3
        Depression (PHQ or others)2273.3
        Substance use826.7
        Anxiety620.0
    Any BH-related services†2790.0
        Short-term therapeutic approaches2066.7
        CBT, DBT, and/or ACT826.7
        Complementary/alternative BH therapies516.7
    Any access to BH prescribers (psychiatrists or psychiatric NPs)†1860.0
        Via in-person appointments and consultations1653.3
        Via telemedicine or phone310.0
    Substance use counseling or programs available in the practice723.3
    • BH, behavioral health; CBT, cognitive behavioral therapy; DBT, dialectical behavioral therapy; ACT, acceptance and commitment therapy; PCP, primary care provider; PHQ, Patient Health Questionnaire; LCSW, licensed clinical social workers; NP, nurse practitioner.

    • ↵* Except where otherwise noted.

    • ↵† Multiple options could apply to each site.

    • ↵‡ 25 of 30 LEAP practices had at least one BH specialist available to provide BH services at the practice.

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    Table 2.

    Key Goals Related to Behavioral Health Integration and Strategies to Operationalize These Goals as Observed at Learning from Effective Ambulatory Practices, 2013

    Key Goals of BH Integration in Primary CareDescription of GoalCommon Strategies* for Operationalizing This GoalPioneering Strategies† That May Merit Further Exploration
    Provide timely BH care for all patientsTeam members understand that primary care practices play a key role in proactively identifying BH issues, connecting patients to BH services in a timely manner, and providing immediate assistance to patients in crisis.Screening all patients or all new patients for BH-related issues (universal screening).
    Providing short-term therapy in the practice followed by referrals to mental health specialty care for patients needing longer-term, more intensive services (stepped care).
    Maximizing BH specialists' availability by instituting open-access scheduling or on-call rotations.
    Using registries and other health IT tools to systematically track and follow up on patients' BH-related needs.
    Share the work of providing BH-related careThe practice recognizes that BH integration can ease the burden on individual clinicians by involving multiple team members in identifying, addressing, and following up on patients' BH needs.Providing onsite access to BH specialists.
    Delegating BH-related screening to MAs or RNs.
    Using care coordinators, community resource specialists, or front desk staff to connect patients to external BH resources.
    Colocating BH and primary care working areas to facilitate regular interdisciplinary communication.
    Delegating BH-related assessments and follow-up to RNs, care coordinators, health coaches, or layperson BH assistants.
    Meet the full spectrum of patient needsTeam members understand how physical, mental, behavioral, and social needs can affect a patient's wellness, and they share a philosophy that primary care practices must attend to the full range of factors that influence a patient's health.Offering a wide array of services in the practice, including BH therapy, psychiatric medication management, and chronic pain management services.
    Offering BH services to support patients in managing chronic conditions.
    Offering in-house substance use counseling or programs.
    Ensuring each patient has an interdisciplinary care plan tailored to his or her specific needs.
    Improve the capacity and functioning of care teamsThe practice recognizes that BH integration can improve team functioning and reduce staff burnout by expanding the skills of team members, promoting positive team dynamics, and improving communication.Training primary care staff on BH-related competencies, such as suicide prevention or working with patients who have substance use issues.Involving BH specialists in improving teambuilding, problem-solving, and interpersonal relationships.
    Involving BH specialists in facilitating regular team huddles or meetings
    • BH, behavioral health; LEAP, Learning from Effective Ambulatory Practices; IT, information technology; MA, medical assistant; RN, registered nurse.

    • ↵* Strategies were classified as “common” if they were identified in 10 or more LEAP practices.

    • ↵† Strategies were classified as “pioneering” if (1) they were identified in fewer than 10 LEAP practices and (2) the site visit data suggested they were key for operationalizing the practice's goals for BH integration.

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    Table 3.

    Common Behavioral Health Services Performed by Primary Care Team Members at Learning from Effective Ambulatory Practices, 2013†

    Elicit BH Concerns during Interactions with PatientsConduct BH ScreeningAdminister BH AssessmentsConnect Patients to BH Services Inside or Outside the ClinicCollaborate with Other Team Members on BH-Related Treatment PlanningPrescribe Psychiatric MedicationsConduct BH-Related Monitoring and Follow-upHelp Run Programs or Group Visits Related to BH or Chronic Pain
    PCPXXXXX
    BH specialistXXXXX*XX
    Layperson BH assistantXXXX
    RNXXXXX
    MAXXXX
    MA care coordinatorXXX
    Front desk staffX
    Health coachXX
    OTX
    PT/PT assistantX
    NutritionistX
    • ↵* BH prescribers (e.g., psychiatrists, psychiatric nurse practitioners) prescribed psychiatric medications but other BH specialists (e.g., psychologists, masters-level therapists) did not.

    • BH, behavioral health; PCP, primary care provider; RN, registered nurse; MA, medical assistant; OT, occupational therapist; PT, physical therapist; PCP, primary care provider.

    • ↵† “X” denotes that the identified team members performed the identified services at multiple LEAP practices.

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The Journal of the American Board of Family     Medicine: 31 (5)
The Journal of the American Board of Family Medicine
Vol. 31, Issue 5
September-October 2018
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Approaches to Behavioral Health Integration at High Performing Primary Care Practices
Paula R. Blasi, DeAnn Cromp, Sarah McDonald, Clarissa Hsu, Katie Coleman, Margaret Flinter, Edward H. Wagner
The Journal of the American Board of Family Medicine Sep 2018, 31 (5) 691-701; DOI: 10.3122/jabfm.2018.05.170468

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Approaches to Behavioral Health Integration at High Performing Primary Care Practices
Paula R. Blasi, DeAnn Cromp, Sarah McDonald, Clarissa Hsu, Katie Coleman, Margaret Flinter, Edward H. Wagner
The Journal of the American Board of Family Medicine Sep 2018, 31 (5) 691-701; DOI: 10.3122/jabfm.2018.05.170468
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