| 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.