Abstract
Introduction: Integrating behavioral health services into primary care has a strong evidence base, but how primary care training programs incorporate integrated behavioral health (IBH) into care delivery and training has not been well described. The goal of this study was to evaluate factors related to successful IBH implementation in family medicine (FM) residency programs and assess perspectives and attitudes on IBH among program leaders.
Methods: FM residency programs, all which are required to provide IBH training, were recruited from the American Academy of Family Physicians National Research Network. After completing eligibility screening that included the Integrated Practice Assessment Tool (IPAT) questionnaire, 14 training programs were included. Selected practices identified 3 staff in key roles to be interviewed: medical director or similar, behavioral health professional (BHP), and chief medical officer or similar.
Results: Forty-one individuals from 14 FM training programs were interviewed. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration). Screening, outcome tracking, and treatment differed among and within practices. Use of curricula and trainee experience also varied with little standardization. Most participants described similar approaches to communication and collaboration between primary care clinicians and BHPs and believed that IBH should be standard practice. Participants reported space, staff, and billing support as critical for sustainability.
Conclusions: Delivery and training experiences in IBH varied widely despite recognition of the value and benefits to patients and care delivery processes. Standardizing resources and training and simplifying and assuring reimbursement for services may promote sustainable and high quality IBH implementation.
- Family Medicine
- Integrated Behavioral Health
- Integrated Delivery Systems
- Patient Care Team
- Residency
- Practice-Based Research
- Primary Health Care
- Qualitative Research
Introduction
Nearly 70% of primary care visits involve discussion or treatment of at least 1 behavioral health concern,1,2 but there are difficulties in connecting patients to behavioral health services in a timely manner.3 Logistic and insurance coverage challenges4,5 as well as stigma and unfamiliarity limit access to behavioral health services.6 These barriers can be reduced through evidence-based integrated behavioral health (IBH) in primary care, in which medical and behavioral health care are delivered in a single setting.7 IBH increases access to evidence-based care and improves patient outcomes,8 yielding benefits to patients and practices alike.9,10
IBH implementation requires specific skills and specialized training for medical and behavioral health clinicians.11⇓–13 Family medicine residency training programs are required to have behavioral health faculty and provide training in IBH14 and typically serve learners from a variety of professional programs (medical, social work, nursing, psychology, etc.). For trainees in family medicine residencies to effectively meet the demand of addressing patient behavioral health needs, training programs must have a curriculum that includes effective models of IBH delivery.15,16 Apprenticeship is an important element of IBH training, and the formal and informal experience of IBH in family medicine training programs influences and informs future practice of trainees from those programs. However, approaches to IBH delivery and skill development may vary across training programs and have not been well-studied.17 Thus, we examined delivery of IBH and perspectives about facilitators for and challenges to IBH implementation and training in family medicine residency programs.
Methods
Design and Setting
We conducted a qualitative study with in-depth semistructured interviews of clinicians and administrators in family medicine training programs. The American Academy of Family Physicians (AAFP) Institutional Review Board approved this study, and we followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).18
Participant Recruitment
We used purposive sampling to identify family medicine training programs from the Northeast, Midwest, and Pacific Northwest of the US from 2 sources: AAFP National Research Network member practices that were known to have interest in behavioral health studies and practices known to have IBH based on the knowledge of the study team. Designated contacts at the selected practices were sent a survey via Qualtrics (Provo, Utah) to assess for type of IBH training and collect information on the number and types of trainees and behavioral health professionals [BHPs: psychotherapists (psychologists, licensed clinical social workers) and prescribers (psychiatrists, nurse practitioners)]. Of the 20 practices that indicated interest, 6 were determined to be ineligible because they did not have a family medicine residency program.
Data Collection
Designated contacts at each practice were invited to participate and asked to provide the following information about their practice: the IBH model used, for example, Primary Care Behavioral Health Model (PCBH),19 colocated,20,21 blended, and Collaborative Care Model (CoCM)22,23 and the level of behavioral health integration assessed using the Integrated Practice Assessment Tool (IPAT).24 The IPAT is a brief assessment tool based on a decision tree model designed to place practices on the level of collaboration/integration defined by A Standard Framework for Levels of Integrated Health care.25 Eligible practices identified 3 people to participate in interviews: the medical director (or similar role), a BHP (who was part of the residency training faculty), and the chief medical officer or other leader. Each practice that completed the research survey and interviews received a $500 stipend.
The research team, comprised of a psychologist, a psychiatrist, a family physician, and advanced degree primary care researchers, developed the interview guide. Two team members (JW and MF) conducted the interviews virtually in English between March 24, 2021, and July 13, 2021. Interviews were audio-recorded and transcribed verbatim and averaged 50 minutes in length. In addition to the practice stipend, each interviewee received $150 for their time.
Data Analysis
An inductive analytic approach was used to analyze the qualitative text.26,27 The codebook was developed iteratively, and 2 team members (JW and MF) made an initial list of codes. A revised codebook was adopted after 2 iterations based on feedback from MW, CH, and CD. MF and ER coded individual transcripts using Atlas.ti.9. We used ongoing quality assurance where coding was monitored to ensure coders coded similarly. We pilot tested 1, compared results, and discussed discrepancies. Next, we tested 2 more, compared results, then continued coding manuscripts. Then we went back and recoded the original ones we piloted. Thus, we performed calibration exercises to show coders interpreted text in a similar fashion. Once completed, the 2 coders then assessed 25% of manuscripts to ensure that codes and their definitions were applied accurately; discrepancies were resolved by consensus. Four team members (MF, JW, ER, AN) discussed categories. Development of themes surfaced through multiple readings of the data and comparison across transcripts was undertaken to ensure applicability and inclusiveness. This content was finalized by consensus.
Results
We engaged 14 practices and interviewed 41 participants (Table 1). All practices trained resident physicians; 12 had trainees other than residents (ie, medical students and pharmacy students); and 12 had 15 or more primary care physicians (PCPs) and advanced practice medical providers combined. Across the practices, there were 1 to 9 BHPs (mean = 3.50) and 0 to 34 accessible psychiatric prescribers (mean = 13.5). Respondents identified their IBH model as PCBH, colocated, blended, CoCM, multiple models, or none. We found that respondents may have used different classifications for BHPs (ie, including psychiatrists) and/or may have counted clinicians (psychiatrists and others) who were in their network but outside their practice, while others only counted those practicing onsite. In addition, some respondents may have included residents in clinician counts where others did not. IPAT scores ranged from 4 (Close Collaboration Onsite) to 6 (Full Collaboration) (Table 1).
Practice Characteristics
This report focuses on 5 emergent themes arising from the interviews: IBH delivery, benefits and essential elements, training and learner integration, and structural and policy barriers. For exemplary quotes, refer to Table 2.
Exemplary Quotations
Delivery of IBH
Screening
Participants reported screening for depression and/or anxiety at annual wellness visits, behavioral health visits, new patient visits, or other visits based on recent or historic diagnoses or stressors. Other conditions were screened for at some practices including intimate partner violence, alcohol and substance use disorders, and concerns specific to pediatric patients. Positive screens (such as reported psychological distress) triggered a conversation with or referral to a BHP or care manager.
Tracking of Individual and Population Metrics
Participants reported individual-level tracking, population-level tracking, or both. Most participants reported that they tracked quality metrics or screening completion for individual patients, but multiple challenges hampered tracking from being routine, practice-wide, or at the population level: manual entry of data from outside the EHR was time-consuming; inability to search data not captured in the EHR; referrals were not automatic if depression score worsened; and lack of dedicated staff to review the data. A few participants mentioned using registries (eg, for depression or opioid use) to document and track behavioral and mental health services and indicated that this type of monitoring focused on population-level management rather than the individual-level.
Treatment Decision-Making Algorithms
The majority of participants stated either that their practice did not use treatment decision making algorithms to guide behavioral health treatment (9 practices) or that they were not aware of algorithms (2 practices), despite indicating interest in their use. Practices had protocols or EHR recommendations based on screening results, but these were applied with clinician discretion. Algorithms were not used due to both clinical and patient related factors. Clinicians cited perceived disruption to workflow, prior training that emphasized decisions based on clinical interviews, and professional discretion as reasons for not using algorithms. Algorithms were seen as rigid, not allowing for patient buy-in, and/or not recognizing lack of access to suggested treatment.
Communication and Information Sharing
Most stated that BHPs were available to aid in diagnosis, triage, and therapies for specific concerns (eg, eating, developmental disorders). Teams communicated through the EHR, designated internal digital communication platforms, and curbside consults. PCPs had access to social services support via other members of the behavioral health team, such as social workers or care coordinators, either onsite or via telehealth. PCPs also received indirect support from BHPs through informal consults, huddles, case reviews, or warm handoffs.
Providing Therapy in Clinic
All practices provided short-term therapy emphasizing behavior change, self-management, and skill development. Practices often did not have capacity for longer term psychotherapy but occasionally provided it due to lack of referral options.
Perspectives on IBH Benefits and Essential Elements for Successful Delivery
Participants shared that IBH should be standard practice in primary care and that BHP presence is indispensable. They reported that collaboration with members of the behavioral health team made PCPs’ roles easier and improved patient outcomes, and that onsite behavioral health services were convenient for patients and improved follow-up. Participants indicated ideal IBH implementation required adequate BHP staffing, protected time for screening and warm handoffs, and onsite psychiatry services. Dedicated space where team members could gather for warm handoffs or conduct therapy or support groups was also recommended. Support with screening, tracking, and billing was reported as necessary to ensure compensation and improve population health. Participants highlighted the need to offer long-term behavioral health services or better connection to external BHPs and psychiatrists to better meet patients’ needs, as IBH is most appropriate for finite, short-term treatment. Lastly, some participants stressed the importance of better practice-wide education about IBH workflows to clarify roles and service availability to encourage use.
Destigmatizing Behavioral Health and Providing Holistic Care
Participants reported that stigma associated with receiving behavioral health care was decreased by the opportunity to receive care within their practice. Patients were more likely to seek and receive IBH services in the primary care practice because of established rapport with staff and comfort with the environment and processes. Participants noted that patients were more likely to follow through with a BHP or care manager if a warm handoff was facilitated by the trusted PCP.
Participants also reported that integration normalized behavioral health as part of health care, enabling a holistic approach. Interdisciplinary teams identified and treated issues early before they became more serious. In addition, BHPs could assist with a breadth of care needs, including depression, anxiety, and chronic diseases. IBH facilitated care coordination with specialists (psychiatrist, dietician, etc.) and ensured that patients’ needs were met, addressing whole person care through a team approach.
Benefits of Behavioral Health Services to the Practice
Keeps Behavioral Health Services in Clinic
Participants reported that providing behavioral health services in primary care settings improved behavioral health access and outcomes because of better coordination and retention in care. While some BHPs did not have access to psychiatric prescribers or psychiatrists, BHPs specifically were viewed as an added benefit to patient care, contributing to a more holistic and effective approach to care by multidisciplinary teams.
Managing Serious Mental Illness and Crisis
Participants stressed that having a psychiatrist or other psychiatric provider on staff expanded practice capacity for treatment of more complex mental health diagnoses and appreciated even limited psychiatric contributions: performing chart reviews, offering treatment guidance, and in some cases, providing feedback to learners’ case presentations, conducting didactic sessions, or precepting.
Potential Cost Reduction
Some asserted that integration decreased costs of health care due to decreases in emergency department visits and specialty psychiatric care, as well as alleviating time and access barriers. In some cases, psychiatrists were housed in a Department of Psychiatry, so they were available for referrals and not truly integrated, reinforcing fragmentation of behavioral health care. Participants reported that physical and organizational barriers to connecting with psychiatric providers made it difficult to both access and integrate services into practices, likely increasing cost for both patients and the health care system.
Learning to Collaborate and Instilling an IBH Culture
The engagement of learners in IBH occurred in a variety of forms in these residency programs (Table 3). In most models, all learners shadowed behavioral health team members and gained experience working within an IBH model. Hands-on training for residents and other learners occurred in the form of apprenticeship (learning by doing while immersed in an IBH setting). Participants also described didactic IBH curricula but did not provide details. The approach to didactics appeared to vary across programs and was based on clinical context and IBH model.
Training Different Learner Types Together
Participants reported that learners practice IBH from the beginning of their respective training programs by being immersed in all aspects of patient care, including behavioral health. Residents have their own patient panels under attending physician supervision. Participants described different ways that residents interact with other team members, such as initiating warm handoffs, counseling patients, prescribing medication for less complex cases, referring to BHPs for short-term therapy or other resources for long-term therapy or psychiatrists for those requiring complex medication management.
Structural and Policy Barriers to Successful Delivery
According to participants, structural and policy barriers hindered true behavioral health integration in their residency programs (Figure 1). Barriers included lack of organizational buy-in, inadequate funding, heavy workload, limited space, challenges related to copays, and inadequate reimbursement. Participants described having to justify hiring needed staff and often being supported by grants or other programs rather than through reimbursement or organizational core support. They also reported not having adequate space to conduct patient visits or consult with team members. Participants were able to describe workarounds to most of these structural and policy constraints, except for challenges related to patient insurance coverage and cost. On the patient access side of barriers, participants thought insurers should be required to reimburse behavioral and mental health services similarly to preventive health services, as inadequate coverage often leaves gaps in access to behavioral and mental health services for those who need it most.
Structural and policy barriers to IBH in residency programs and potential ways to serve needs. Abbreviations: IBH, integrated behavioral health; FTE, full-time equivalent; QI, quality Improvement; CMS, centers for medicare & medicaid services; ED, emergency department; PCP, primary care physicians.
Discussion
This study describes factors reported as important for successful delivery of IBH in family medicine training programs as well as perspectives regarding IBH training. Though these results are based on our sample of family medicine residency training programs, they are not necessarily unique to training programs. Participants reported the value in IBH models as applied and described strategies they used in care delivery and training. Trainees from multiple disciplines learned from the collaborative processes used to coordinate behavioral health within primary care and their experiences of practicing IBH will influence and inform their future practice. Adequate and appropriate clinic space,28⇓–30 personnel,29,31⇓–33 and referral services (eg, seamless access to psychiatry and long-term psychotherapy) were highlighted as key factors for optimizing IBH. For patients, participants highlighted the benefit of IBH to counter the negative effects of stigma of receiving behavioral health services and to increase access to holistic care. Even though participants discussed structural and policy barriers to behavioral health integration, some stated that certain challenges could be addressed within their organization. The exception was insurance coverage which limited patient access and constrained care teams.
Trainees who are exposed to IBH in residency are likely to be well equipped and prepared to address behavioral health concerns, manage complex care scenarios, and navigate care coordination efforts when entering practice after completing training.34 Furthermore, while some similarities existed among residency programs, there are currently no standardized approaches for teaching IBH, and core competencies that ensure learners have the needed tools to deliver care within IBH practices were not discernible.35,36 Research is needed to identify best practices and inform approaches to standardize IBH training.
Our study provides important insights about IBH implementation and training in family medicine residency programs for the next generation of primary care clinicians. Our findings support prior reports that IBH may improve patient and clinician satisfaction, outcomes, access, and timely treatment for behavioral health concerns.22,37⇓⇓⇓⇓⇓–43 Likewise, the results reinforce documentation of barriers found in prior studies such as inadequate staffing (BHPs and care managers), limited access to psychiatric consultation, organizational and financial barriers, patient insurance challenges, and stigma.30,44⇓⇓⇓–48
Our findings have important implications for gaining organizational buy-in and support, which may require increased preparedness with data to justify upfront expenses (like office space or salary) when seeking to hire a BHP or invest in a psychiatrist. Our findings suggest that showing better patient outcomes37,49 and cost savings50⇓–52 may influence decisions favorably. Increased communication around IBH models may also build or enrich relationships across teams.53 In addition, having an IBH structure is a start, but programs need to infuse an IBH working culture through connections and communications that are truly interdisciplinary.28,54 Clinicians, administrators, and staff may know the intent of IBH, but greater learning and support across organizations may be necessary to accomplish goals.35 Developing protocols and structures that allow organic interactions between team members is an approach that may improve the implementation of IBH.
There are some limitations to our study. This qualitative study with a small sample size within select geographical areas has limits regarding the generalizability of the results. In addition, purposeful sampling is prone to selection bias due to investigator judgment. Challenges of newly established programs may be different from challenges reported here. Next, our findings are based on participants’ perceptions. We did not provide standardized definitions for participants to minimize information bias, which may have skewed survey responses. In addition, key elements for robust IBH implementation depend on the model deployed. In some cases, onsite access to a behavioral health resource, tracking of outcomes, and addressing financial barriers may be important, while in other contexts adapting to differing needs of patients, embedded psychiatric prescribers, and diversification of the behavioral health team (ie, social workers, psychologists, and care managers) may be more important. We did not collect information from learners, which may have enhanced our findings.17 Therefore, future studies incorporating learners’ perspectives on team-based, interdisciplinary training in IBH is important to inform IBH implementation.17,55⇓–57 However, the detailed information gained here from clinical teams on the frontline of care can inform the development of IBH playbooks and curricula to support the design and implementation of effective IBH in clinical practice and training environments.
This study examined perspectives on the implementation of IBH in family medicine training environments with implications for developing, maintaining, standardizing, and strengthening IBH programs. As the need for behavioral and mental health services increases, multipronged approaches and policy changes are needed to support cost-effective implementation and impactful IBH training in primary care. Including behavioral and mental health as part of comprehensive care could increase access for patients and improve insurance coverage and payment. In turn, advocacy efforts could emphasize that high levels of integration drive improved population health, patient experience, clinician well-being, and reduced costs.
Acknowledgments
This study was made possible by the participation of the AAFP National Research Network practices and individual care team members. We thank them for their essential contributions to this work. The authors would also like to thank Elizabeth Staton, MSTC, for her thorough review of the manuscript.
Notes
This article was externally peer reviewed.
Funding: Supported by funding from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP33881 (PI: Doubeni), titled Academic Units for Primary Care Training and Enhancement. This report and the conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. The funder had no role in the decision to submit the manuscript for submission.
Conflict of interest: The authors have no conflicts of interest to disclose.
To see this article online, please go to: http://jabfm.org/content/36/6/1008.full.
- Received for publication February 24, 2023.
- Revision received April 26, 2023.
- Accepted for publication June 21, 2023.
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