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

doi:10.3122/jabfm.2018.05.170468

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Table 1.

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

Characteristic	N = 30^*	%
Practice characteristics
Organization type
Federally qualified health center	15	50.0
Private practice, multispecialty group	9	30.0
Private practice, primary care only	6	20.0
Number of sites in practice organization
One	7	23.3
2 to 5	6	20.0
6 to 10	8	26.7
11 to 20	4	13.3
Setting
Urban	9	30.0
Suburban	8	26.7
Rural	11	36.7
Multiple	2	6.7
BH specialist staffing characteristics
Any BH specialist present at practice^{^†}	25	83.3
Masters'-level therapists (such as LCSWs)	21	70.0
BH prescribers (psychiatrists or psychiatric NPs)	16	53.3
Psychologists	8	26.7
Substance abuse counselors	3	10.0
Complementary/alternative BH providers (such as art therapists, dance movement therapists)	3	10.0
Affiliation of BH specialist when present (N = 25)^{^‡}
Employed by the practice	14	56.0
Employed by an external organization	8	32.0
Mixed (some BH staff employed by practice, some employed by external organization)	2	8.0
Unknown	1	4.0
BH-related services available
Any BH-related screening^{^†}	22	73.3
Depression (PHQ or others)	22	73.3
Substance use	8	26.7
Anxiety	6	20.0
Any BH-related services^{^†}	27	90.0
Short-term therapeutic approaches	20	66.7
CBT, DBT, and/or ACT	8	26.7
Complementary/alternative BH therapies	5	16.7
Any access to BH prescribers (psychiatrists or psychiatric NPs)^{^†}	18	60.0
Via in-person appointments and consultations	16	53.3
Via telemedicine or phone	3	10.0
Substance use counseling or programs available in the practice	7	23.3

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 Care	Description of Goal	Common Strategies^* for Operationalizing This Goal	Pioneering Strategies^{^†} That May Merit Further Exploration
Provide timely BH care for all patients	Team 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 care	The 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 needs	Team 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 teams	The 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 Patients	Conduct BH Screening	Administer BH Assessments	Connect Patients to BH Services Inside or Outside the Clinic	Collaborate with Other Team Members on BH-Related Treatment Planning	Prescribe Psychiatric Medications	Conduct BH-Related Monitoring and Follow-up	Help Run Programs or Group Visits Related to BH or Chronic Pain
PCP	X			X	X	X		X
BH specialist	X		X	X	X	X^*	X	X
Layperson BH assistant	X		X	X	X
RN	X	X		X	X		X
MA	X	X		X	X
MA care coordinator				X	X		X
Front desk staff				X
Health coach							X	X
OT								X
PT/PT assistant								X
Nutritionist								X

↵* 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.