One common mistake organizations make as they embark on integration is to simply read a book or a few articles in a journal about how behavioral integration works—including all its features—and believe that these materials alone will adequately equip the organization to forge a successful integrated primary care program. We have never seen this happen in our collective experience.
Integrated behavioral health programs require a fundamentally different approach to the delivery of services to people with mental health and health behaviors. These changes include different coding and billing practices, different clinical skill sets, and medical record documentation, as well as different team-based approaches to managing patient healthcare.
There is also a gap in the mental health field—in training and experience in the philosophy underlying integrated care, population health concepts, the medical home model, and the Triple Aim, which lie at the heart of our reasons for integrating. This is particularly true for anyone who completed graduate school before the turn of this century. Notwithstanding this, integrated care concepts are a fairly new paradigm for many seasoned mental healthcare professionals. Despite 30 years of research on these topics, many behavioral health professionals are just learning about them. Consequently, most mental health providers available for hire will need explicit respecialization training—some more than others.
Choosing a model of integrated mental health is important. Sure, various studies have tested specific services, models, or components of models. But to make this ship sail, you will need maps, instructional guides, and other tools to integrate all of these programmatic elements in an efficient way. No one wants to pioneer a program that is implemented in an ineffective way. Consider focusing more on how the models function (i.e., what the professional actually does with and for the patient and the healthcare team) and less on how they are branded or what they are named.
Although there is nothing inherently wrong with simply hiring a behavioral health provider and then following certain processes for transforming your practice into an integrated one, we believe it’s important to give you specific and calibrated tools. These tools come in the form of formal models that have been discussed in the research conceptually, and, in some cases, studied empirically. We believe your pace of integrating and likelihood of developing a successful integrated behavioral health service rests in your ability to implement well-defined models of integration. This also helps you understand the risks and benefits of these models in advance versus having to clumsily learn them along the way.
Although there has been some discussion in the field about what constitutes a unique model and who decides that one model is unique from another, we have boiled it down to the models that operate uniquely and in clearly defined ways. We have selected models with the most research or with clear, uniform training standards. Adopting such a model will increase your likelihood of finding the right behavioral health providers (BHPs) for the program you launch.
Service Delivery Models
There are five formal models you might consider launching.
Primary care behavioral health model (PCBH): A biopsychosocial approach to population-based clinical healthcare that is simultaneously collocated, collaborative, and integrated within primary care. The goal of PCBH is to improve and promote overall health and mental health (this may include substance abuse) within the primary care population. The hallmark of this model is that the BHP serves as a consultant to the PCPs and helps patients self-manage their symptoms. This does not provide a level of services equal to outpatient mental health (e.g., psychotherapy), and, therefore, is not a substitute for those services if they are clinically warranted. The BHP’s schedule and practice style mirrors that of the PCPs, where each appointment is 15 to 30 minutes and up to 16 patients may be seen daily by a BHP. These BHPs also may provide curbside consults, educational classes for patients, or shared medical appointments.
Critically, the BHP’s recommendations are intended to initiate, enhance, or assist with the PCPs’ and patients’ treatment plans and healthcare goals.Collocated specialty mental health: In collocated specialty mental health, the BHP works at the same site as the PCPs, which could be somewhere in the same building, floor, or even wing as the PCPs. This model lacks many elements of integration, including shared treatment planning, documentation, and provider goals; population focus; focus on general health conditions; and published quality metrics. Providers in this model will have the same limited access, small caseloads, and long wait times observed in non-integrated specialty mental health clinics. Finally, it places the burden of collaboration on BHPs who may not have adequate training, skills, and buy-in to accomplish this. Yet, this remains an easy way to begin integration, and many of the tools developed by the Substance Abuse and Mental Health Services Administration are geared toward this model.
Medical family therapy (MedFT): MedFT uniquely incorporates a stronger emphasis on patients’ individual and social relational context in reference to their physical and mental health. Like PCBH, it is also collocated, collaborative, and integrated within primary care. MedFT typically refers to marriage and family therapists who have received additional training in adapting their clinical skills to integrated behavioral health settings. They apply biopsychosocial systems theory to conducting psychotherapy with patients and their families, trauma, or disability. These professionals also may provide more abbreviated care when time does not permit the specialty level of care it embodies. When time for specialty-based care is not available, these BHPs deliver a brief service more like the PCBH, with the additions of the social relational perspective mentioned above.
Collaborative care model: The collaborative care model (also known as the care management, staff advisor, or care facilitation model) targets specific diseases for which patients are being prescribed psychotropic medication in order to drive down disease prevalence, contain cost, increase treatment effectiveness and adherence, and access psychiatry consultation services. These services usually are conducted telephonically, making them fairly easy to integrate, because they don’t require exam room space. Psychiatry services in primary care may be most helpful if delivered in the context of this model. These are billable. Note that for simplicity, we use the term care management model to differentiate this model from the others and to avoid confusing this with care which happens to be collaborative or managed. Most of the primary literature refers to this as the collaborative care model.
Bidirectional or reverse integration: Bidirectional integration often is supported by mental health and substance abuse administrations within states in an attempt to meet quality improvement through integrated care for specific seriously and persistently mentally ill or other identified populations. This model typically is limited in scope, breadth, and depth of integration. Its hallmark is hiring a PCP to work inside a specialty mental health clinic. There is benefit to this model, particularly for patients having severe mental illness, who tend to die younger and often do not receive primary care services routinely.
All of these models can use standard (and free) clinical outcome instruments to gauge the clinical progress of patients. These measures are short and appropriate for primary care.
Excerpted from Integrating Behavioral Health into the Medical Home: A Rapid Implementation Guide.