From Our Practices to Yours: Key Messages for the Journey to Integrated Behavioral Health

Abstract

Background:The historic, cultural separation of primary care and behavioral health has caused the spread of integrated care to lag behind other practice transformation efforts. The Advancing Care Together study was a 3-year evaluation of how practices implemented integrated care in their local contexts; at its culmination, practice leaders ("innovators") identified lessons learned to pass on to others.Methods: Individual feedback from innovators, key messages created by workgroups of innovators and the study team, and a synthesis of key messages from a facilitated discussion were analyzed for themes via immersion/crystallization.Results: Five key themes were captured: (1) frame integrated care as a necessary paradigm shift to patient-centered, whole-person health care; (2) initialize: define relationships and protocols up-front, understanding they will evolve; (3) build inclusive, empowered teams to provide the foundation for integration; (4) Of adults with a behavioral health (BH) disorder, 67% do not receive adequate treatment.1 Untreated BH conditions result in avoidable suffering and increase the cost of care through lack of medical improvement, decreased adherence to treatment, and inappropriate health care utilization. 2Most patients with BH conditions, including children, are seen in medical settings, most commonly primary care (PC), presenting the need and opportunity to replace separated systems of care that do not adequately meet the needs of patients with integrated, "whole-person" care.Integrated behavioral health (or integrated care) is the care that results from a practice team of PC and BH clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance use conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. The historic, cultural separation of training, payment, and delivery systems for PC and BH have caused the spread of integrated care to lag far behind other practice transformation efforts (eg, the Patient Centered Medical Home [PCMH]). New payment structures and delivery models that support the integration of PC and BH are emerging, facilitating the movement toward integrated care as part of the drive to achieve the This article was externally peer reviewed.

Approaches to Behavioral Health Integration at High Performing Primary Care Practices

“…In fact, many of the pioneering strategies we identified in LEAP practices align with the growing literature on real-world implementation of BH integration. 9,34 -37 For example, practices across the United States are experimenting with open-access scheduling and on-call rotations to facilitate warm handoffs, 38 using registries and other health IT tools to systematically track and follow up on patients' BH-related needs, 11,39 offering in-house counseling or programs for substance use and opioid dependency, 33,40 developing interdisciplinary care plans, 34 and colocating primary care and BH staff to facilitate teamwork and interdisciplinary communication. 41 Other strategies identified in the literature, such as establishing rapid referral pathways for BH services, 37 creating custom EHR templates for BH data, 39 or developing clinic-specific training manuals about BH integration, 42 were ei-ther not present in LEAP practices or not mentioned in our interviews.…”

Colorado’s continuing journey to integrated care: Progress!

“…Program evaluations have provided insights into the costs of integrated care, staffing and scheduling strategies, workspace layouts, workforce development, electronic health record optimization, adaptive leadership, and measurement of integrated care efforts (Green & Cifuentes, 2015). The early adopters shared lessons learned for practices following in their footsteps (Gold, Green, & Peek, 2017), which served as the foundation for a book that we coedited, Integrated Behavioral Health in Primary Care: Your Patients are Waiting (Gold & Green, 2018). These learnings follow a se-quence (Figure 1), starting with conceptualizing the transition to integrated care as a paradigm shift.…”