The Importance of Integrated Behavioral Health

The US healthcare system is highly specialized. When a patient has an issue with their heart, they go to a cardiac specialist. With their brain, a neurologist. With their reproductive system, an OB/GYN or a urologist. And with their emotions, a psychologist. These specialists are located in different offices, with different administrative systems, and communication between them is not standard practice.

For reasons ranging from physician salaries and prestige to insurance reimbursements, many physicians are increasingly trained in hyper-focused specialties, where they provide narrow methodologies of healing that don’t acknowledge the full interconnectedness of bodily systems, emotions, and the context in which the patient lives. While efficient in some ways, this methodology of care can create blind spots that negatively impact outcomes for the patient, as well as the cost of care and system efficiency.

Integrated behavioral healthcare (IBH) is a fresh approach which pays thought to how a person’s various internal and external systems are connected. IBH steps away from care siloed into specialties and toward a more interdisciplinary cooperative care. It aims to create effective provider relationships across disciplines and practices to provide care that acknowledges the whole patient, the context in which they exist, and the obvious interconnection between the systems in the body.

Because IBH strives to ensure patients are getting the care they need from a team of providers who understand their full story, it’s less likely that patients will get lost in a fragmented system or receive unnecessary or redundant care. IBH is generally believed to be better for the patient, better for the healthcare system, and better for the bottom line.

According to the Agency for Healthcare Research and Quality (AHRQ) Academy (a part of the US Department of Health & Human Services attempting to universalize the language and conception of IBH), the definition of IBH includes a team of primary and mental health clinicians working together with patients and their families. The clinicians provide systematic, patient-centered, and cost-effective care for a defined population. They may address:

• Mental health
• Substance abuse conditions
• Health behaviors
• Life stressors and crises
• Stress-related physical symptoms
• Ineffective patterns of healthcare utilization

IBH is generally recognized as the direction in which healthcare needs to go, as it can decrease costs, increase efficacy, and prepare the US for the struggles associated with aging populations and increasing rates of chronic disease.

Keep reading to learn more about how IBH came to be recognized as a necessary step for healthcare services and systems, as well as the emerging models, frameworks, and resources to help providers, practices, and systems make the transition to an integrated delivery of mental and primary healthcare.

In recognition of the fact that integrated healthcare systems improve quality of care, patient outcomes, and system efficiency, the American medical system has been moving toward integrated healthcare on a systemic level for decades.

In the beginning of the push toward integration, strategies reflected a mechanistic view of healthcare delivery. It featured a horizontal integration* with an emphasis on acute-care, economic arguments, organizational evaluative measures, and the modification of organizational and environmental structures. It was a top-down, command-and-control, centralized power, one-size-fits-all, high-power differential attempt—and it was largely unsuccessful in successfully integrating healthcare.

As institutions and practitioners realized that these integration attempts were failing, the strategies began to evolve into methodologies that were decentralized, put the power into the hands of providers and patients, and incorporated flexibility and adaptability to individualized needs and to change.

Integration became vertical** and the focus of care shifted to the community and social services. Arguments centered around an improved quality of care and creating value, evaluations focused on patient outcomes, and integrations focused on specific populations. Overall, integrations were built on changing work habits, cultural attitudes, and cultural norms.

It was in this fertile soil that the seeds of IBH—which had been planted in small scale by Kaiser in the 1950s—could finally grow into an industry-wide goal. Moving IBH toward the center of care included factors like a seminal paper on the positive impact integrated care on depression in 1995, the military’s adoption of integrated care in the 2000s, the development of the “Triple-Aim,” and the US Department of Health and Human Services creating an official educational organization to shift healthcare toward IBH.

While the struggle in the beginning was to convince providers and policymakers that integration was useful, the current state of the shift toward IBH is to understand exactly what integration means and how best to do it.

*Horizontal integration is the strategy by which one kind of healthcare delivery system attempts to integrate with all of the same kind. In the case of integration in the healthcare services delivery, one example of horizontal integration would be if all the cardiology clinics in one region became a monolithic cardiology group.
**Vertical integration is the strategy by which integration happens in a multi-disciplinary way along the continuum of services. In the case of integration in healthcare, one example would be an acute-care practice integrating with a laboratory services business.

As IBH is relatively new as an industry standard, efforts to streamline understanding, universalize language, and understand best practices are still in flux. In addition, while full integration is often seen as the ultimate goal, the reality of many practices mean that integration may only be possible on partial levels.

Despite no universal understanding of what it means to be an integrated behavioral healthcare service provider, several models, frameworks, and resources have been developed to assist healthcare providers or organizations to achieve integration at the level that makes sense for their clinical reality. The following provides three commonly cited resources that can help healthcare administrators, providers, or practices to begin the journey of moving from separation to integration.

In response to imprecise way in which integration was being discussed over the early years of the push toward integration, The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) developed a standard framework for integrated health solutions. The goal of the framework is to provide precision for communication for the benefit of integration, research, and practice design.

The SAMHSA-HRSA framework classifies the collaboration levels and practice structures for IBH as follows:

Coordinated Care (Practice Structure One)

• Level 1: Minimal Collaboration (Mental health providers and PCPs work in separate facilities. Communication is rare, and generally about specific information.)
• Level 2: Basic Collaboration at a Distance (Separate work spaces and systems. Communication is periodic, although providers see one another as resources. Communication is driven by specific issues.)

Co-Located Care (Practice Structure Two)

• Level 3: Basic Collaboration Onsite (Providers are located in the same facility, with separate systems. Proximity creates greater communication regularity. Patients move between providers through referral. Roles are ambiguous. Providers make individual decisions.)
• Level 4: Close Collaboration with Some System Integration (Providers are in the same facility, and share some systems, i.e. an embedded practice. Practitioners share patients and notes. Referrals are through personal communication.)

Integrated Care (Practice Structure Three)

• Level 5: Close Collaboration Approaching an Integrated Practice (High levels of provider collaboration. Team functioning with frequent personal communication. Team-based problem solving. Still some systemic separation between disciplines. Differentiated roles in the team.)
• Level 6: Full Collaboration in a Transformed/Merged Practice (Single merged practice where patients and providers work toward treating the whole person.)

In 2010, and with an update to the research in 2015, the Milbank Memorial Fund did a massive literature review with the intent to help policymakers and administrators understand move toward integration. In addition to both reports finding that, in general, BHI improves mental health outcomes, the MMF identified and outlined eight models of behavioral health integration (BHI). The eight models of BHI are as follows:

• Improving Collaboration Between Separate Providers: Providers operate in separate facilities using separate systems of administration, finance, and reimbursement. Care managers help to enhance collaboration.
• Medical-Provided Behavioral Healthcare: Behavioral health professionals (BHPs) collaborate with primary care providers (PCPs) in a consultancy role. The delivery of behavioral healthcare is executed by the PCP.
• Colocation of Care: PCPs and BHPs offer services in the same physical location, but systems of administration, finance, and reimbursement are separate.
• Disease Management (Care Management) – Collaborative Care Management (CCM): A relationship-based model, a care manager is responsible for a patient’s follow-up care. The case manager monitors patient response and adherence to treatment, provides education, self-management strategies, and reviews patient progress with a BPH.

In the 2016 update to the research, MMF added:

• Reverse Colocation of Care: In this model, often for patients with serious mental illness or substance use issues, the mental health facility is placed at the center. PCPs provide care at the location where the patient is receiving treatment for mental health. Like in standard colocation, systems are separate.
• Unified Primary and Behavioral Health: Specifically for patients with serious mental illness, this model provides a unified treatment plan for both primary and behavioral health in one location.
• Primary Care Behavioral Health: PCPs serve as the principal providers of care. Behavioral health specialists temporarily comanage patients when referred.
• Collaborative System of Care: Specifically for patients at high risk, a core model of care is identified, with the appropriate social services as a wraparound offering. Care can be fully or partially integrated.

The Integration Academy of the Agency for Health Research And Quality (AHRQ), a program of the US Department of Human and Health Services, was developed in response to a need for actionable information for all parties wishing to do the work of transitioning to IBH.

The Academy provides information from the perspective of helping move integration in a way that achieves the Institute for Healthcare Improvement’s (IHI) “Triple Aim.” IHI’s Triple Aim seeks to optimize healthcare performance through program design that makes healthcare systems and providers accountable to improving patient experience of care, improving population health, and reducing the cost of care per capita.

The AHRQ Academy also seeks to help move systems toward IBH in a way that improves the experience of providing care. AHRQ provides a suite of resources to help with integration.

The Playbook (For Ambulatory Settings)

In addition to research and expert insight, AHRQ has a detailed playbook that provides those looking to integrate within an ambulatory setting a step-by-step guide to moving toward integration. Despite having an ambulatory focus, those looking to integrate mental and behavioral health may find the resource helpful.

Information in the playbook is formatted to help providers and practitioners ask the right reflective questions, perform self-assessments, create a game plan, establish structures, secure finances, collect and use data, educate patient populations, obtain the proper expertise, tailor care teams, track patient progress, and much more. The guide also includes useful information on what to avoid during the transition to IBH.

The Lexicon

In order to foster clean communication and precise understanding of exactly what it means to integrate behavioral and mental healthcare, AHRQ has developed a universalizing lexicon. The lexicon includes concepts, definitions, key elements of an integrated practices, and reasons and rationale for integration.

The Atlas

AHRQ provides the Atlas of Integrated Behavioral Health Care Quality Measures (the IBHC Measures Atlas) to help support health care measurement. The IBHC Atlas helps practices and teams to understand if they are providing high-quality care through a measurement framework centered around user goals.

Literature Collection

For those who wish to do their own review of the literature to assist with integration, AHRQ provides literature on education and the workforce, financing sustainability, HIT and telehealth, healthcare disparities, healthcare policies, key and foundational literature, opioids and substance use, measures, medically unexplained symptoms, and more.

Guidebook of Professional Practices

The AHRQ Guidebook of Professional Practices for Behavioral Health and Primary Care Integration provides real-world case studies of successful IBH in action. The guidebook includes an analysis of IBH at four federally qualified health centers, two hospital systems, one private practice, and one government-operated facility.

Because there are many different approaches to the integration of mental and behavioral healthcare, there are just as many resources that administrators, practices, and providers can turn to if they are looking to begin or improve an integration process.

The following are other resources to help improve understanding of and create movement toward integrated behavioral healthcare.

• AIMS Center – Advancing Integrated Mental Health Solutions
• Institute for Clinical and Economic Review – Integrating Behavioral Health Into Primary Care (Report)
• National Council for Behavioral Health – Center of Excellence for Integrated Health Solutions