How will this module help me?
Discusses 5 steps to implement your new model of behavioral health integration.
Provides answers to frequently asked questions about behavioral health models.
Shares examples of practices that successfully implemented an integrated behavioral health model.
Many medical conditions are greatly affected by patients' mental health and behavioral choices. Physician-led primary care teams often must address many common mental health disorders, such as depression, anxiety, and substance abuse. In addition, behavioral and lifestyle issues, such as smoking, lack of exercise, and poor sleep, impact many aspects of health. By bringing medical and behavioral health services together within primary care, the team is better able to meet both the mental and physical health needs of the patient.
Five STEPS for Integrating a Behavioral Health Model Into Primary Care Practice
Assess Current Needs and Resources.
Design a Team-Based Care Model.
Train Members of the Primary Care Team.
Implement the Team-Based Behavioral Health Model.
Monitor and Improve Processes.
Step 1 Assess Current Needs and Resources.
Quiz Ref IDPhysician-led primary care teams are in a position to effectively screen patients for a range of behavioral health issues and to monitor treatment response. The practice team should review the ways in which behavioral health issues are currently being identified and followed. Defining existing behavioral treatment resources will allow a practice to identify any additional resources that might be needed, such as an embedded behavioral health specialist. Determine the practice needs for behavioral health resources based on your patient population. Caring for a large population of patients with mild or moderate depression or anxiety may warrant the development of a model with a set of resources that is different than that used for patients with chronic disease who need behavior and lifestyle support. Through this exercise, your practice will determine whether, for example, training a nurse to become a behavioral health care manager or hiring a social worker to become the practice's behavioral health specialist will work best based on your patient population's needs.
Step 2 Design a Team-Based Care Model.
In an embedded behavioral health model, team members will often have complementary roles in providing patient-centered care to those with mental health conditions. Frequently, the integrated behavioral health care team will include the patient, the primary care physician, a behavioral health specialist, and a consulting psychiatrist. The behavioral health specialist may be a psychologist, licensed social worker or nurse, or another individual trained in health education or lifestyle counseling. In most models, the psychiatrist is involved on a consultative basis.
The physician-led team works together with shared goals, treatment plans, workflows and, ideally, in a partially co-located space to increase team member communication and collaboration. The primary care physician and/or psychiatrist supervise the hands-on work of the behavioral health specialist and collaborate in frequent patient panel reviews with the team to identify patient needs and opportunities for intervention. In more remote areas or smaller practices, the behavioral health specialist or psychiatrist may consult with the patient using telemedicine technologies; this may be a more cost-effective and feasible approach to offering behavioral health services.
Step 3 Train Members of the Primary Care Team.
Quiz Ref IDIn training the physician-led team to appropriately integrate behavioral health into patient care, there are several critical elements that should be covered.
Know how and when to give mental health assessments.
The team members who will be rooming patients and conducting pre-visit planning should be trained in how to perform mental health screenings using a patient health questionnaire, such as a Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9). On a pre-visit questionnaire, there may be a question or two that is a “trigger” for a more in-depth mental health assessment, such as “Have you felt down, depressed, or hopeless lately?” or, “Have you recently lost interest in doing things you normally enjoy?”
Recognize triggers for involving behavioral health.
Events such as a death in the family, job loss, a recent cancer diagnosis (for the patient, a partner, family member, or friend), domestic abuse, or a history of mental health conditions should trigger a behavioral health assessment and, potentially, a behavioral health referral. For a patient who possesses one or more of these triggers, the practice may decide that they want the behavioral health specialist to be involved in the patient's care.
Understand the Behavioral Health Referral Process.
When a patient requires a behavioral health intervention, make sure the team knows which pathway to follow. Should the patient be assessed that day? Do they need a full consult with a psychiatrist? Create processes and protocols for the entire care team to recognize when the behavioral health specialist should become involved. Also, ensure that the team knows which aspects of patient follow-up are their responsibility and which belong to the behavioral health specialist. This should be determined based on shared practice protocols under the physician's leadership.
Step 4 Implement the Team-Based Behavioral Health Model.
Quiz Ref IDIn a physician-led team-based behavioral health model, the entire team—the primary care physician, behavioral health specialist, nurses, medical assistants, and the consulting psychiatrist—will work together to provide collaborative care to patients.
The medical assistant or nurse assesses the patient for mental health needs by listening for triggers and reviewing any screening questions on the pre-visit questionnaire.
The primary care physician implements screening and monitoring tools for mental health disorders, makes the diagnosis, initiates treatment, and manages medications.
The behavioral health specialist monitors depression symptom severity, treatment adherence, and side effects, and reports these results to the primary care physician. Depending on training, the behavioral health specialist can also provide motivational interviewing, problem-solving therapy, behavioral activation, and grief support. For practices managing patients with addiction, behavioral health specialists can support patients' addiction treatment, dosing, and recovery in consultation with the primary care physician.
A consulting psychiatrist can assist with review of the panel of patients with behavioral health conditions and may answer the primary care physician's questions about diagnosis and medication management in more complex situations or as needed.
Step 5 Monitor and Improve Processes.
Quiz Ref IDAfter the new model has been implemented, the team has the opportunity to continually refine and improve the process. Identifying metrics to track prior to implementation will help the team to stay focused and monitor improvement over time. Include these metrics on the practice dashboard or scorecard, and consider them as part of the practice's most important quality metrics. Examples include the following:
Increased appropriate referrals to the behavioral health specialist.
Increased percentage of patients on antidepressants who are seen by the behavioral health specialist.
Increased use of the following forms:
PHQ-2 and PHQ-9 to screen for depression.
GAD-7 (Generalized Anxiety Disorder 7-item scale) to screen for anxiety.
AUDIT-C to screen for alcohol abuse.
Improved medication adherence.
Decreased depression scores.
Fewer emergency visits.
Fewer hospital readmissions.
Continuous education, reminders, and training opportunities for the team members, including the behavioral health specialist, nurses, and medical assistants, will help them continue to develop their skillsets and more fully integrate their behavioral health knowledge into their daily interactions with patients.
Finally, to keep the focus on improvement, keep the behavioral health team on the agenda at team meetings. This will give the team the opportunity to continuously explore ways to collectively make the process better, increase communication and keep everyone focused on providing the best care to patients.
Embedding behavioral health within primary care practices expands the services a patient can receive. Many medical conditions are affected by patients' behavioral choices and mental health conditions. The reverse is also true; people with chronic medical conditions have a higher risk for depression.1 In fact, people who have depression and another medical illness tend to have more severe symptoms of both illnesses.1 By bringing medical and psychosocial services together within primary care, the team can successfully provide patient-centered care.