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Behavioral Health Integration Into Primary CareExpand Patient Access to Behavioral and Mental Health Services and Improve Patient Care

Learning Objectives
1. Describe different integrated behavioral health models
2. Select and implement the ideal model for your practice
0.5 Credit CME
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Learning Objectives

  1. Describe different integrated behavioral health models

  2. Select and implement the ideal model for your practice

Introduction

Primary care clinicians are in a unique position to effectively screen, diagnose, and treat a range of behavioral health issues. Physician-led primary care teams frequently address common mental health disorders, such as depression, anxiety, and substance abuse, as well as behavioral and lifestyle issues, such as smoking, lack of exercise, and poor sleep. Furthermore, patients who are not adequately treated for depression or anxiety are less likely to take their medications for other chronic medical conditions such as diabetes and high blood pressure, and, as a result, outcome goals are more difficult to achieve.

Therefore, a team-based approach to bringing medical and behavioral health services together within primary care is essential.

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Q&A

  • What is behavioral health?

    The Substance Abuse and Mental Health Services Administration (SAMHSA) defines behavioral health as1:

    • The promotion of mental health, resilience, and well-being

    • The treatment of mental and substance use disorders

    • The support of those who experience and/or are in recovery from these conditions, along with their families and communities

    Clinicians often think of the term “behavioral health” as “healthy lifestyle choices,” encompassing healthy diet, regular exercise, not smoking, and other behaviors to prevent chronic disease. On the other hand, clinicians use the term “mental health” to encompass psychiatric illness and substance use disorders. For the purposes of this toolkit, “behavioral health” will refer to the broader definition as used by the SAMHSA, but at your practice, you can define what the scope of your behavioral health interventions can and should include.

  • What is behavioral health integration?

    Behavioral health integration (BHI) is a systematic approach to deliver behavioral health services where primary care (or subspecialty) physicians and a behavioral health team work together with patients and families to provide patient-centered care.

  • Why is behavioral health integration important?

    Behavioral health integration addresses the current mismatch between the prevalence of behavioral health conditions and the proportion of individuals who receive effective treatment. This mismatch is due to stigma, system fragmentation, and shortages in clinical resources and qualified mental health professionals. BHI provides effective solutions for closing this gap.3

    For more information on the background of behavioral health integration and the resources available for clinicians, see The Behavioral Health Integration Compendium, developed by the BHI Collaborative—a partnership between the AMA and 7 of the nation's leading physician organizations—and published in January 2021.2

Five STEPS for Integrating Behavioral Health Care Into Your Primary Care Practice

  1. Assess Your Current Needs and Resources

  2. Choose a Team-Based Behavioral Health Model

  3. Train Members of the Primary Care Team

  4. Implement the Model

  5. Evaluate and Improve

STEP 1 Assess Your Current Needs and Resources

Quiz Ref IDBehavioral health integration (BHI) is not a “one-size-fits-all” approach. Your practice team should first evaluate how individuals with behavioral health issues are currently identified, treated, and followed, and who performs each of these tasks in your practice. Defining existing behavioral treatment processes and resource utilization will allow your team to identify any additional resources your team/practice might need.Figure 1 depicts some resource needs to consider.

Figure 1. Processes and Resource Utilization to Consider Before Integrating Behavioral Health4

Some behavioral health clinicians your practice may consider engaging include:

  • A diabetes educator, covered by Centers for Medicare and Medicaid Services (CMS) for Medicare beneficiaries

  • An embedded behavioral health specialist/manager

  • An embedded pharmacist

  • A psychiatrist

  • A psychologist

  • A smoking cessation counselor

  • A social worker (eg, a licensed clinical social worker [LCSW])

The Practice Scenarios illustrate how integrated behavioral health can detect serve to detect early warning signs of worsening mental health status so primary care physicians can work with their patients to revise their treatment plans. You may see patients like those in the example in your practice, and this can help you determine the types of resources you will need to create your own program.

Practice Scenarios. Examples of Patients Who Received Care From an Integrated Behavioral Health Team

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Practice Scenarios. Examples of Patients Who Received Care From an Integrated Behavioral Health Team

Patient 1: Anna is a 50-year-old female business executive who has a history of depression and who has been stable for many years with the help of a daily antidepressant. The medical assistant administers a Patient Health Questionnaire-9 (PHQ-9) during Anna's yearly physical that detects worsening mood symptoms, so the medical assistant alerts the physician. The patient confides in her physician that she and her husband have recently separated. Over several months, Anna's primary care physician increases her antidepressant dose and ultimately adds another medicine for augmentation, but no improvement is seen and Anna reports experiencing unwanted side effects. She is referred to the practice's behavioral health care manager for brief psychotherapy over the next 6 weeks. Anna's case is reviewed with the embedded psychiatrist during a routine panel management meeting and the care team agrees on a transition to a different antidepressant. Anna's primary care physician implements this plan with the support of the behavioral health specialist. Anna is reevaluated in 6 weeks and her symptoms have improved dramatically.

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Patient 2: Rhoda is a 40-year-old female teacher who has had stable depression for 5 years on an antidepressant. She is enrolled in a depression population registry through her primary care physician's office. The practice's behavioral health specialist calls her every 3 months to administer a PHQ-9 screen over the phone. Until the most recent call, Rhoda had consistently scored lower than 4 (favorable), but during the most recent call, Rhoda scores 17 (indicative of residual depressive symptoms). The behavioral health specialist learns of the recent unexpected death of Rhoda's child. An urgent appointment is scheduled with Rhoda's primary care physician and Rhoda is diagnosed with recurrent depression. Rhoda's medications are adjusted accordingly. The case manager offers grief counseling, and also refers Rhoda to a grief support group. Over time, Rhoda reaches her treatment goals.

Patient 2: Rhoda is a 40-year-old female teacher who has had stable depression for 5 years on an antidepressant. She is enrolled in a depression population registry through her primary care physician's office. The practice's behavioral health specialist calls her every 3 months to administer a PHQ-9 screen over the phone. Until the most recent call, Rhoda had consistently scored lower than 4 (favorable), but during the most recent call, Rhoda scores 17 (indicative of residual depressive symptoms). The behavioral health specialist learns of the recent unexpected death of Rhoda's child. An urgent appointment is scheduled with Rhoda's primary care physician and Rhoda is diagnosed with recurrent depression. Rhoda's medications are adjusted accordingly. The case manager offers grief counseling, and also refers Rhoda to a grief support group. Over time, Rhoda reaches her treatment goals.

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Q&A

  • Which patients would benefit most from the behavioral health integration model?

    Behavioral health integration (BHI) is most beneficial to patients with:

    • Mild to moderate mood disorders, such as depression or anxiety5

    • A lifestyle-altering condition, such as obesity, diabetes, hypertension, or chronic pain (with or without substance use disorder)

    The BHI model is not meant to meet the needs of patients who have active suicidal ideation or unstable psychosis. These patients should be referred to the direct care of a psychiatrist.

  • How many patients with behavioral health needs warrants embedding a behavioral health specialist?

    The ideal staffing composition and ratio for your practice depend on the characteristics of your patient population, your patients' behavioral health needs, and your current care model.

    The University of Washington Advancing Integrated Mental Health Solutions (AIMS) Center created a matrix of staffing ratios (Figure 2) for diverse clinic settings that offers recommendations for full-time equivalent (FTE) care managers and psychiatric consultants based on the size, complexity, and other characteristics of your patient population.6 The matrix also includes the suggested caseload for each care manager within the model. Tools like this matrix can help your practice determine the resources you'll need to support your patients.

    Figure 2. Caseload Size Matrix for a Full Time (1.0 FTE) Behavioral Health Care Manager6
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    Q&A

  • How can the behavioral health specialist support multiple teams in a practice?

    A behavioral health specialist that is on-site could support multiple clinicians within a practice and, with a warm handoff, could potentially facilitate support at multiple clinics.

    For the behavioral health specialist to support multiple teams, the practice needs to first identify patients who will require assistance. Working with the scheduler, the team can then request that the behavioral health specialist and the patients who need additional support are in the clinic on the same days. This will ensure that warm handoffs are seamless, thereby decreasing wait time for the patients, primary care physicians, and the behavioral health specialist.

  • How does behavioral health integration work if not all team members are co-located or on-site?

    The behavioral health specialist or psychiatrist may use telemedicine technologies to consult with patients; this could be a more cost-effective and feasible approach to offering behavioral health services than attempting to coordinate schedules and space for multiple team members. However, a partially co-located space is beneficial for increasing team member communication and collaboration, and is thus preferable to a model where the behavioral health specialist or psychiatrist is always off-site.

STEP 2 Choose a Team-Based Behavioral Health Model

Quiz Ref IDTeam-based behavioral health models vary depending on a practice's existing resources and capabilities along with the needs of the practice's patient population. While there are a number of models to choose from, some have been more rigorously evaluated than others. Models include the Collaborative Care Model (CoCM) and the Primary Care Behavioral Health (PCBH) Model. Many practices, however, take a hybrid approach that incorporates elements from available models that best support their patients. Learn more about each model below so you can choose the model, or aspects of models, that will work best for your practice.

Collaborative Care Model

Quiz Ref IDThe cornerstone of the Collaborative Care Model (CoCM) is the implementation of a care team, including:

  1. A behavioral health (BH) care manager

  2. A consulting psychiatrist

  3. The primary care clinician

The behavioral health care manager is typically someone with a master's level of education (eg, Master of Social Work [MSW] or Licensed Clinical Social Worker [LCSW]) or specialized training in behavioral health.

In this model, the consulting psychiatrist delivers weekly consultation to the primary care practice on a panel of patients, typically those patients who are not improving. The consulting psychiatrist discusses these patients with the care manager and makes treatment recommendations.

Treatment can include focused talk-therapies delivered by the licensed behavioral health care manager and, when indicated, medication prescribed by the primary care clinician and overseen by the consulting psychiatrist. Screening tools, such as the Patient Health Questionnaire-9 (PHQ-9) and a registry, can be used to monitor patient progress routinely.

Primary Care Behavioral Health Model

Quiz Ref IDThe Primary Care Behavioral Health (PCBH) Model, otherwise known as the Behavioral Health Consultant Model, is an alternative to consider if your practice has a sizable patient population that would make implementing the Collaborative Care Model difficult.

In the Primary Care Behavioral Health Model, the behavioral health consultant may be a PsyD, PhD, master's-level clinician, LCSW, or CRNP certified or trained in behavioral health. The behavioral health consultant typically sees an individual patient for a limited time and a limited number of visits. Scheduled visits with individual patients are balanced with enough flexibility in their appointment schedule to be available for same-day warm patient handoffs or other referrals from the primary care physician and other team members.

Hybrid Models

Quiz Ref IDSome practices may expand on or blend components of different models, such as the Collaborative Care Model and Primary Care Behavioral Health Model to offer a broader array of behavioral health services. One such expanded model might include health educators trained in lifestyle counseling for weight loss, exercise, and smoking cessation. A health educator functions as an advanced health coach; such a position could be filled by a high performer who already works in the practice and has an interest in supplemental training.

Another example of the expanded practice model could involve a nurse or social worker who gives lifestyle counseling and addresses anxiety, depression, sleep disturbances, and social service needs.

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Q&A

  • How might a team-based behavioral health model address the needs of pediatric patients?

    Many states are developing child psychiatry access programs as part of the National Network of Child Psychiatry Access Programs; there are also unaffiliated programs at individual organizations.6 These programs provide child psychiatry consultation services to pediatric primary care providers. This consultation model has also been applied to address maternal depression and other related behavioral disorders.2

  • How are behavioral health services billed in these models?

    Many insurers are encouraging behavioral health integration (BHI) models. Check with the plans you accept about how to bill related services before launching your new model to help patients avoid receiving multiple requests for copays. For a patient who is anxious about finances, receiving one bill for the primary care visit and another, higher bill for the specialist care may exacerbate their mental health challenges.

    Billing and coding for behavioral health services can be unfamiliar and often complex for patients and health care providers alike. There are often significant variations in reimbursement, and practices should be aware of these implications.

    The AMA offers additional resources about billing and coding for behavioral health services.

STEP 3 Train Members of the Primary Care Team

No matter which model you select, there are several critical elements to cover when training the primary care team to integrate behavioral health into patient care appropriately.

Know how and when to give mental health assessments

Train all the team members who will be rooming patients and conducting pre-visit planning how to perform mental health screenings on every patient using a patient health questionnaire, such as the Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-9 (PHQ-9), Alcohol Use Disorders Identification Test-Concise (AUDIT-C), or Generalized Anxiety Disorder-7 (GAD-7). A diagnosis of depression or anxiety, or noting current psychiatric medication such as selective serotonin reuptake inhibitors (SSRIs), can trigger a PHQ-9 upon check-in or any time during pre-visit planning. Mental health screening helps the team know how patients are doing and if they are responding to therapy—similar to a blood pressure reading for blood pressure management. Let patients receiving treatment for depression or anxiety know that they will be asked to fill out these forms before each visit and that the clinician will review prior scores with them to celebrate improvement. Feeling better (or worse) can be subtle for many patients, and regular screening can help identify these incremental changes.

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, current or recent pregnancy, or a history of mental health conditions should trigger a mental health assessment and, potentially, a behavioral health referral. The practice may decide that they want the behavioral health specialist to be involved in caring for a patient who has experienced one or more of these triggers.

Understand the behavioral health referral process

Make sure the team knows which pathway to follow when a patient requires a behavioral health intervention.

For example, what criteria should the patient meet to require assessment that day? And what factors would precipitate a full consultation 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 are the responsibility of the behavioral health specialist. This determination should be based on shared practice protocols under the physician's leadership. The referral process will vary depending on the model used in the practice.

Learn how to transition care with a warm handoff

One commonality between the 3 models is the warm handoff. A warm handoff is when a primary care physician, medical assistant, or nurse invites the behavioral health specialist into the room with the patient present to facilitate an in-person introduction between the patient and the behavioral health specialist before stepping out to allow further conversation between the two. This type of transition increases the patient's trust and the specialist's credibility. Furthermore, the patient does not need to make a separate follow-up appointment in order to receive specialist care.

Further information about warm handoffs, including downloadable scripts for physicians and behavioral health specialists to use, is provided here by Integrated Behavioral Health Partners.

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Q&A

STEP 4 Implement the Model

In a physician-led, team-based behavioral health model, the entire team—the primary care physician, behavioral health specialist, nurses, medical assistants, and, depending on your model, the consulting psychiatrist—will work together to provide collaborative care to patients.

The first step in implementing your model is to develop a workflow.

For example, in a Collaborative Care Model:

  1. The medical assistant or nurse reviews responses on the pre-visit questionnaire

  2. The primary care physician:

    • Evaluates the screening results and monitoring tools for mental health disorders

    • Obtains additional information from the patient and other sources

    • Makes the diagnosis

    • Initiates treatment and behavioral health referral

    • Manages medications

  3. The behavioral health specialist:

    • Monitors symptom severity and response to treatment

    • Checks for treatment adherence and side effects

  4. If permitted in their practice jurisdiction and consistent with their training, certification, and licensure, a behavioral health specialist may also provide:

    • Motivational interviewing

    • Problem-solving therapy

    • Behavioral activation

    • Grief support

  5. A consulting psychiatrist can assist with more complex situations by reviewing the panel of patients with behavioral health conditions and may answer the primary care physician's questions about diagnoses and medication management

Think about whether you want to pilot the model with a few physicians before expanding to the entire practice.

STEP 5 Evaluate and Improve

Your team should take every opportunity to refine and improve your chosen behavioral health integration model on an ongoing basis. It is helpful to identify metrics to track prior to implementation; doing so will help your team stay focused and monitor improvement over time. Include the members of the team who will be doing the work to decide on relevant and meaningful metrics that they would like to track. You can share previously-identified metrics c on the practice dashboard or scorecard as part of the practice's most important quality metrics. Be sure to make the goals achievable in a short time. Celebrate and highlight achieved goals.

Examples of metrics include:

  • Increases in the number of referrals to the behavioral health specialist over time (based on criteria developed by your practice, eg, PHQ-9 score > 10 prompting immediate referral)

  • Increased use of screening forms during pre-visit planning tracked in the electronic health record (EHR)

  • Increases in the use of standing orders for patients with specific diagnoses, such as referrals to a diabetes educator or a tobacco cessation program

  • Improvement in pain management through more referrals to physical therapy and decreasing the number of patients on opioids for noncancer pain

  • Improved medication adherence

  • Changes in assessment and treatment of anxiety and depression for patients on opioids for noncancer pain

  • Improvements in depression scores on screening tools

  • Fewer emergency room visits and fewer hospital admissions for acute depression or anxiety, such as suicidal ideation or panic attacks

Ongoing education, reminders, and training opportunities for team members will help them continue to develop their skillsets and fully integrate their behavioral health knowledge into their daily interactions with patients. Keeping the behavioral health team on the agenda at team meetings will allow the team to explore ways to improve the process, increase communication, and keep everyone focused on providing the best care to patients collectively.

Share stories of specific patients who benefitted from behavioral health integration and celebrate these successes with the team!

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Q&A

  • What about patient outcomes?

    From a patient perspective, success will correlate with decreased symptoms and will be evident in improved scores on symptom-based scales or improved functioning. Population health data will show decreased symptoms, improved functional status, and enhanced well-being and quality of life for patients. The program's success will also be reflected in the health care team members' satisfaction as they provide their patients with quality care in a timely, integrated fashion.

Conclusion

Integrating behavioral health into primary care practices expands the services a patient can receive from one team. 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.8 In fact, people who have depression and another medical illness tend to have more severe symptoms of both illnesses.8 By bringing medical and psychosocial services together within primary care, the team can successfully provide high-quality, longitudinal, patient-centered care for this important group of patients.

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AMA Pearls

AMA Pearls

  • Physicians alone cannot address behavioral health for their patients; a team-based approach with practice-integrated services is essential

  • Behavioral health integration improves both physician and patient well-being

Further Reading

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Disclaimer: AMA STEPS Forward™ content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward™ content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward™ content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward™ content.

About the AMA Professional Satisfaction and Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity, and reduce health care costs.

Acknowledgements:

We thank the following for reviewing this toolkit:

  • Meghan Kwiatkowski, MAIO, CPHQ, LSSGB, Senior Practice Analyst, American Medical Association

  • Chris Botts, Care Delivery and Payment Manager, American Medical Association

  • Kathleen Blake, MD, MPH, Vice President of Healthcare Quality, American Medical Association

References
1.
Substance Abuse and Mental Health Services Administration.  SAMSA-Behavioral Health Integration. US Department of Health and Human Services. Accessed December 14, 2020. https://www.samhsa.gov/sites/default/files/samhsa-behavioral-health-integration.pdf
2.
BHI Collaborative.  Behavioral Health Integration Compendium.  Published 2020. Accessed December 14, 2020. https://www.ama-assn.org/system/files/2020-12/bhi-compendium.pdf
3.
Center of Excellence in Integrated Health Solutions.  The value of integrated behavioral health.  September 7 , 2018. Accessed December 14, 2020. https://www.thenationalcouncil.org/integrated-health-coe/resources/
4.
Malâtre-Lansac  A, Engel  CC, Xenakis  L,  et al.  Factors influencing physician practices' adoption of behavioral health integration in the United States: a qualitative study.  Ann Intern Med. 2020;173(2):92–99. doi:10.7326/M20-0132Google ScholarCrossref
5.
Archer  J, Bower  P, Gilbody  S,  et al.  Collaborative care for people with depression and anxiety.  Cochrane Database Syst Rev. 2012;10:CD006525. doi:10.1002/14651858.CD006525.pub2Google Scholar
6.
AIMS Center.  Caseload size guidance for behavioral health care managers. University of Washington Psychiatry & Behavioral Sciences. Published 2020. Accessed January 22, 2021. https://aims.uw.edu/sites/default/files/Behavioral%20Health%20Care%20Manager%20Caseload%20Guidelines_072120%20Final.pdf
7.
National Network of Child Psychiatry Access Programs (NNCPAP). Johns Hopkins Bloomberg School of Public Health Center for Mental Health Services in Pediatric Primary Care. Accessed January 16, 2021. http://web.jhu.edu/pedmentalhealth/nncpap_members.html
8.
National Institute of Mental Health.  Chronic illness & mental health.  Accessed January 14, 2021. https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health/index.shtml

Disclaimer: AMA STEPS Forward™ content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward™ content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward™ content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward™ content.

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