Care Integration: An Introduction

Those with mental and substance abuse disorders often have chronic illnesses that go undiagnosed or untreated because of their disorders and the difficulties navigating the healthcare system. Integrating behavioral health and primary care offers the patient a home for coordinated care and easier access to the right care at the right time.
Resource Type: 
  • Guide
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    REFERENCES

     

    The Academy – Integrating Behavioral Health and Primary Care, Agency for Healthcare Research and Quality, integrationacademy.ahrq.gov/.

    “Behavioral Health in Primary Care.” Behavioral Health in Primary Care / SAMHSA-HRSA, www.integration.samhsa.gov/integrated-care-models/behavioral-health-in-primary-care.

    Collins, Chris, et al. “Models of Behavioral Health Integration.” Milbank Memorial Fund, Milbank Memorial Fund, 25 May 2010, www.milbank.org/publications/evolving-models-of-behavioral-health-integration-in-primary-care/.

    Corso, P. B.-D., Hunter, P. A., Dahl, M. F., Kallenbberg, M. G., & Manson, P. L. (2016). Integrating Behavioral Health into the Medical Home: A Rapid Implementation Guide. Phoenix: Greenbranch Publishing

    “In Focus: Integrating Behavioral Health and Primary Care.” In Focus: Integrating Behavioral Health and Primary Care – The Commonwealth Fund, The Commonwealth Fund, www.commonwealthfund.org/publications/newsletters/quality-matters/2014/august-september/in-focus.

    “Integrated Care.” National Institute of Mental Health, U.S. Department of Health and Human Services, www.nimh.nih.gov/health/topics/integrated-care/index.shtml.

    REFERENCES

    Healthcare Integration Defined:

    The Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration Center for Integrated Health Solutions (SAMHSA-HRSA CIHS) defines integrated care as “the systematic coordination of general and behavioral healthcare.” Those with mental and substance abuse disorders often have chronic illnesses that go undiagnosed or untreated because of their disorders and the difficulties navigating the healthcare system. Integrating behavioral health and primary care offers the patient a home for coordinated care and easier access to the right care at the right time.

    In this guide, our focus is on clinical practice integration. Other considerations include financial and structural integration which would inform a more advanced integration model.

    Initial Implementation Steps

    1. Assess the needs of your patient population through risk stratification and any available health status information such as prior screenings, diagnosis, or medications
    2. Assess the readiness of the practice using the Integrated Practice Assessment Tool (IPAT) https://www.integration.samhsa.gov/operations-administration/assessment-tools#IPAT (recommended every 6 months)
    3. Review state laws around integration and information sharing to help define your scope of practice
    4. Select the integration model that best suits your patient needs and practice capacity
    5. Determine what services will be provided by the practice based on the initial assessments:
    • Screening and evaluation/diagnosis
    • Treatment guided by evidence-based guidelines
    • Referral coordination
    • Peer support
    • On-site behavioral health specialist

    Common conditions treated via integrated behavioral health professionals 

    Anxiety Diabetes Insomnia Suicidal Ideation
    Chronic Pain Grief Sexual Dysfunction Tobacco Cessation
    Depression Hypertension Situational Stress Weight Loss

     

    1. For each topic area, identify who will provide the services based on education, training, ability, and state mandates

    Behavioral Health Integration is often talked about as if it is a matter of how integrated the behavioral health services will be with primary care. The truth is, that is just one piece of the puzzle but it is a consideration. Listed below are models of integration to choose from:

    Integrated Behavioral Health Care

    The practice team includes primary care and behavioral health clinicians working with patients and families, using a systematic, seamless and cost-effective approach to provide patient-centered care for a defined population.

    Co-located Specialty Mental Health

    The behavioral health provider works within, or in close proximity to, your facility to allow for warm-introductions and frequent communication. This resource is independent of your organization but will share patients. The BHP in this context is not a member of the care team but a consultant outside the daily activities of providing care thus requiring an increased focus on communication, collaboration, and co-management.

    Collaborative Care Model

    This model is also known as a Care Management, Staff Advisor, or Care Facilitation model. This model includes the primary care provider (PCP), a care manager, and a psychiatric consultant. The psychiatric consultant works primarily with the care manager and sometimes directly with the PCP, often telephonically, to advise and recommend treatment plans based on patient progress and evidence-based guidelines.

    Coordination

    The practice of working across health care settings to exchange the most critical pieces of information about a shared patient and help facilitate their access to care.

    Working with the Patient

    1. Identify methods to determine the behavioral health needs of individual patients:
    • Individual mental health screenings
    • Health Risk Assessment results
    • Prevalence of a specific diagnosis in the population
    • Patients with new diagnosis of chronic condition and/or inability to self-manage
    1. Select screening and patient assessment tool(s) to be used based on the services to be provided and the services to be referred
    2. Work with behavioral health provider(s) to identify evidence-based treatments that will be used in patient care and provide training to staff on selections, some examples:
    • Brief solution focused treatment options such as those listed below – typically limited to 4 to 6 sessions
      • Cognitive Behavioral Therapy
      • Motivational Interviewing
      • Behavioral Activation
    1. Develop workflows to define how patients will be connected to different levels of behavioral health services. Include
    • assessment,
    • referral – both internal and external,
    • management and /or co-management,
    • bi-directional communication of resources,
    • shared care planning, and
    • follow-up with the patient
    1. Provide appropriate tools and instruments and internal trainings to involve staff before implementation and on an ongoing basis, including new staff

    Tracking and Data Use Examples

    1. Identify patients receiving integrated behavioral health services in a discrete searchable field in your EMR for tracking and reporting
    2. Establish regular case conferences for patients being managed; include primary care team and behavioral health provider
    • Define the frequency of these conferences and who will organize and lead the discussion
    1. Establish processes to activate and maintain patient engagement
    • Define who will be responsible for patient activation and ongoing engagement; e.g. behavioral health provider, care manager, nurse, etc.
    • Define frequency of visits, type of visits (in person, telephonic), length of visits, care planning, etc.
    1. Select measure(s) to assess the integration of behavioral health

    Examples:

    • Percentage of patients with a current behavioral health assessment
    • Percentage of patients with a diagnosis of depression who are managed within the practice
    • Percentage of patients with follow up within two weeks of initiating treatment
    1. Select measure(s) to assess the impact of behavioral health services on your patient population

    eCQI Resource Center: https://ecqi.healthit.gov/

    Examples:

    • Patients with depression who show improvement in scores on PHQ 9 over a period of time
    • Percentage of patients with a diagnosis of depression that are actively engaged in behavioral health services

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