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

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.

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

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.

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.

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.

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.

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.

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!

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.

Websites

• University of Washington Psychiatry and Behavioral Sciences AIMS Center: Advancing integrated mental health solutions website. Accessed April 16, 2021. https://aims.uw.edu/

• American Medical Association. Behavioral health integration in physician practices. Accessed April 16, 2021. https://www.ama-assn.org/delivering-care/public-health/behavioral-health-integration-physician-practices