Introducing behavioral health services into small primary care settings enhances patient-centered care and provides higher-quality care and greater treatment options for patients with behavioral health conditions such as depression and anxiety. For small practices already facing the burden of narrow operating margins and heavy patient caseloads, the ability to achieve the Triple Aim of improved quality, improved patient satisfaction, and lower costs requires the adoption of a practical and sustainable behavioral health integration model. A Montefiore project team led by Dr. Henry Chung developed a customizable process for integrating behavioral health into primary care using a continuum-based Framework. The Framework lays out key domains of integrated care found across evidence based integration models, grouped, in the original version, into eight broad domains: (1) Case finding, screening, and referral to care; (2) Use of a multidisciplinary professional team—including patients—to provide care; (3) Ongoing care management; (4) Systematic quality improvement; (5) Decision support for measurement-based, stepped care; (6) Culturally adapted self-management support; (7) Information tracking and exchange among providers; (8) Linkages with community/social services.
The Framework provides a roadmap to help practices make investments in time, training, workforce, and other resources necessary to implement behavioral health integration and improve patient care. It contains a series of steps—identifying preliminary, intermediate, and advanced stages for each of the eight key domains of practice integration—that allow practices with different resources to assess, track, and make incremental and sustainable progress. The Framework was designed to help practices organize their integration efforts by assessing and building on existing strengths and priorities. It also recognizes that achieving the most advanced state of each domain and its components might not necessarily be the ultimate target for every practice.
With the support from United Hospital Fund and New York State Health Foundation, the continuum-based Framework was evaluated during a 12-month pilot of 11 small primary care practices in NYC (6) and across NYS (5). The Framework was used to identify practices at their baseline and help them set and assess 6- and 12-month goals for advancing integration within their chosen target domains. Regardless of reported readiness for integration at the start of the pilot, all the practices acknowledged the utility of such a framework for both strategic planning and implementation efforts. By the 12-month goal assessment, practices made substantial progress toward higher levels of integration.
The project team also conducted site visits at 10 of 11 small practices and conducted an extensive qualitative analysis using key informant interviews of primary care and behavioral health providers, leadership team members, and practice staff. These discussions provided detailed information on the approaches the sites took to implement the behavioral health integration goals identified in the Framework, the barriers they encountered, and the ways that behavioral health integration affected practice workflows, staff dynamics, and patient outcomes. This work resulted in the collection of lessons learned for practitioners and policy leaders and the release of a revised Framework to improve clarity of the tool and the inclusion of a new domain on Sustainability. The practices stressed the need for a sustainability domain to help sites focus on how to capture revenue and ensure that investments in behavioral health integration can be maintained long-term.
The key lessons gleaned from our work were published to inform efforts by providers, clinic leadership, policymakers, payers, and other stakeholders as they plan for and support future implementation of behavioral health integration. For primary care practices in integrated care settings we identified the following lessons:
- Practice champions, early staff involvement, and engagement of executive leadership help promote and advance behavioral health integration; engagement of staff at every level is critical.
- Primary care providers benefit from ongoing training to expand the scope of behavioral health care they can provide.
- Behavioral health providers face unique challenges in the integrated setting, such as the lack of coordination with primary care providers, insufficient use of behavioral health service billing codes, and the need to work as part of an overall team that shares information and to perform multiple tasks ranging from therapy to care management.
- Collaborative agreements strengthen treatment referrals, communication with external behavioral health specialty care providers, and care coordination between those external providers and primary care providers.
- Clinical behavioral health tracking tools are most effective when integrated into the electronic health record.
- Condensed behavioral health treatment planning notes facilitate information sharing in the electronic health record.
- Integrated visits with primary care providers and behavioral health providers together can help engage patients with complex care needs.
- Self-management supports help patients stay engaged in behavioral health care.
- Quality improvement efforts are difficult to implement and require additional support to increase uptake.
- Participation in policy or quality improvement initiatives helps motivate behavioral health integration practice advancement.
- Financial sustainability is critical; multiple evolving opportunities for revenue capture require monitoring and adoption.
Policy-related obstacles to progress in behavioral health integration include financial, licensing, and resource issues, among them the difficulty of sustaining services financed primarily by time-limited grants or policy initiatives such as Delivery System Reform Incentive Payment (DSRIP) program, the uncertainty of billing for behavioral health integration in primary care, and inadequate behavioral health networks of many health plans. To overcome these hurdles, we have outlined the following recommendations for policymakers and regulators:
- Continue to modernize policies and regulations that improve implementation and sustainability of behavioral health integration, especially in telehealth.
- Providers seeking NYS patient-centered medical home status should use the Framework to assist with meeting the required behavioral health elements.
- Promote use of National Committee for Quality Assessment measures relevant to behavioral health integration to improve measurement/evaluation.
- Support community behavioral health transformation that improves connections to primary care.
- Clarify and support behavioral health integration payment policies for practices.
- Expand NYS Project TEACH, which currently provides remote BH consults and advice to pediatricians and maternal health providers, to all primary care providers.
- Promote uptake of new technology, such as access to telehealth services and supports.
During our work, many stakeholders and behavioral health partners recommended that we develop a similar framework to advance physical health integration into behavioral health settings. Such an effort was promoted under the DSRIP program, but appears to have had very limited uptake (with some notable exceptions) by behavioral health specialty providers across NY State, primarily because the model promoted was co-location of primary care providers in behavioral health settings. Both cost and regulatory barriers make this type of advanced model difficult to achieve. We believe, however, that a new, tailored Framework could help behavioral health practices incorporate a whole-health orientation, up to and including making primary care services available, by introducing the same sort of continuum-based approach to transformation as we developed for primary care. Therefore, our project team, with the support of the NY Community Trust has begun working on a new continuum-based framework for physical health integration into behavioral health settings.
To date, the current project has developed a draft physical health integration framework that clearly and systematically outlines the component parts of integration within a continuum model, founded in evidence and supporting literature, with stakeholder recommended components for adoption, tailored for setting characteristics. In addition, we convened a stakeholder meeting with leadership representation from NYS behavioral health providers, payers and policymakers working on advancing integration efforts. During this roundtable meeting we discussed the regulatory and policy landscape for integration, reviewed the draft framework and affirmed its potential utility for community behavioral health programs. To highlight this early work, we expect to release the physical health integration continuum-based framework and stakeholder feedback in an upcoming issue brief to be distributed in early 2020. This report will also discuss current trends for physical health integration and discuss the challenges faced by behavioral health centers seeking to expand physical care to the Medicaid and homeless population that faces an array of chronic medical conditions and have highly-complex preventative health needs.
Learn more about the Continuum Based Framework for Behavioral Health Integration in Small Primary Care Settings on the United Hospital Fund website: https://uhfnyc.org/publications/publication/continuum-based-bh-integration-among-small-primary-care-practices/.
To contact our team about the Framework, please reach out to Dr. Henry Chung at hchung@montefiore.org.
