Planning for Integration

Define Your Vision

Creating a vision for integrating behavioral health in your ambulatory care setting is an important first step in the planning process. Having a clear vision can help keep your organization motivated and on track to your desired state of integration.

North Star

Aim for a clear, shared vision with incentives, resources, and leadership aligned.

What is the North Star?

The North Star

The North Star reflects ideal practices of an integrated behavioral health and ambulatory care setting. The North Star can act as a goal or guide toward your desired state of integration.

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How Do You Do It?

Identify staff members to serve on the planning and implementation team. Ensure that the team represents all staff roles to better understand how operational changes will affect everyone involved.

Identify a “champion” to lead the team. The champion will be critical to the success of the implementation efforts. You may find that a champion emerges from existing staff.

How Others Are Doing It

Useful Resource(s) for Identifying an Implementation Leader and Planning Team

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It is important for the planning and implementation team to reflect on the desire to achieve changes in the behavioral health aspect of your medical practice. Consider the following questions:

  • What is driving you to work on integrating behavioral health now? What problems are you trying to solve? Do you want to address:
    • Poor access to behavioral health care for your patients?
    • Poor outcomes for common behavioral health or chronic medical conditions?
    • A need for assistance with complex psychiatric medication management?
    • Unmet social service needs among your patients?
  • What resources are available to integrate behavioral health now and in the foreseeable future? Consider personnel, funding, and the capacity of frontline staff to transition to integration.
  • Who is feeling distress with the behavioral health aspect of your practice right now? Consider patients, providers, and other staff.
  • Who has aspirations for the behavioral health aspect of your practice in the future? What are these aspirations?

A stakeholder map may help with this task. To create a stakeholder map, list each stakeholder group and what matters to them. Then ask, how does integrated ambulatory care line up with the priorities of key stakeholder groups?

Useful Resource(s) for Mapping What Matters to Stakeholder Groups

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Implementing integrated care in your practice may require changes to operations, workflows, and staffing. Find out where you, your team, and other staff fall on the continuum:

If:
We don't see a big enough problem with what we're doing now to change much.

Then:
For Inspiration, check out these exemplars.

If:
We see a big enough problem but don't understand it, know what to do about it, or know what changes we are ready to take on.

Then:
The Playbook will guide you through.

If:
We see a problem, have ideas for what to do about it, want to move forward in some way at some time, but aren't sure we're ready to create a real game plan for doing so.

Then:
Defining and communicating a vision for integrated primary care is an important step before working out a game plan. Continue reading to learn how to clarify your vision.

If:
We have all it takes to be ready to develop a game plan for implementation.

If:
We have a game plan and are ready to implement it.

Then:
If you're comfortable with your game plan and have already completed the self-assessment, you're ready to implement the plan.

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Support from leadership, providers, and staff is essential to the success of an integrated ambulatory care program. Communicate how integrating behavioral health into the practice aligns with what matters to each of them.

Depending on the size of your organization, several levels of leadership may impact the success of the program.

  • Senior leadership is important because they can provide direction and broadcast messages about integrated primary care. Resources are often allocated at this level.
  • Midlevel operational leaders play a role in acquiring resources and problem-solving during implementation. They are especially critical in helping with issues that may emerge in larger multi-site organizations.
  • Frontline clinical and operational leaders help staff adjust to changes in workflow and are involved in solving day-to-day implementation problems.

If your leaders are asking “Why integrated care?” you may need to provide them with background information on the potential impact of integration.

Potential benefits of behavioral health integration include:

  • Better access to behavioral health care for ambulatory care patients.
  • Better communication and coordination between medical and behavioral health providers.
  • Assistance for ambulatory care providers and staff with the behavioral and emotional aspects of care, especially for high-risk, complex patients.
  • Better outcomes for patients with common behavioral health conditions and possibly for those with physical health conditions such as chronic illness.

The impact of behavioral health integration on the cost of care is not yet clear. A recent report that Milliman prepared for the American Psychiatric Association suggests substantial potential cost savings based on conservative financial models.

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While thinking about your vision, it is important to understand that there are different integrated care approaches. Approaches for integrating behavioral health in primary or ambulatory care share a common goal, but may use different operating models. Ultimately, how you integrate behavioral health depends on your organization’s behavioral health needs and available resources. The local familiarity or acceptability of different approaches may also influence your decision. What works for one organization may not work for another. Many organizations use a blended approach, integrating aspects of various models to meet their unique needs.

A range of behavioral health issues may be present in your medical setting. Therefore, the scope of desired behavioral health services depends on the types of behavioral health issues you want to address. Do you want to focus on behavior change counseling for improved health (e.g., diet, stress, and physical activity)? Stress-related symptoms? Substance use problems? Comorbid depression and anxiety? Severe mental illness? Behavioral and emotional aspects of chronic illness?

Here are six examples of common approaches for integrating behavioral health into primary care:

  1. Collaborative Care
    Collaborative Care (CC) focuses on tracking identified patient populations in a registry and implementing measurement-based treatment. The care team includes a primary care physician, a mid-level care manager on site, and a consulting psychiatrist. In a review of 79 randomized controlled trials (link is external) comparing CC with routine care or alternative treatments for depression and anxiety, the CC model achieved improved outcomes compared to routine care. Read more about CC at https://aims.uw.edu/collaborative-care (link is external).

  2. Combined Federally Qualified Health Center-Community Mental Health Center
    This approach involves a generalist behavioral health provider who provides rapid access to behavioral interventions. This provider may address a wide range of behavioral health problems. Although this approach is widely used, there is less systematic evidence of its effectiveness compared to CC. Read how Cherokee Health Systems incorporates a behavioral health consultant in primary care at http://www.e-psychologist.org/index.iml?mdl=exam/show_article.mdl&Material_ID=75 (link is external).

  3. Federally Qualified Health Center and Community Mental Health Center Partnerships
    This approach is characterized by close collaboration between behavioral health and primary care, with whole-person care provided in both settings. Patients may move between settings over time depending on acuity and based on a four-quadrant model. Missouri has fostered these partnerships along with Medicaid health homes and has seen significant quality improvement and cost reduction. Read more at http://www.integration.samhsa.gov/about-us/CIHS_Presentation_Slides_062713.pdf (link is external).

  4. Comprehensive Primary Care
    Comprehensive primary care is a team-based approach that includes behavioral health in primary care settings. The SHAPE (Sustaining Healthcare Across Integrated Primary Care Efforts) project in Colorado is testing a global payment method in six primary care practices. Read more at http://sustainingintegratedcare.net (link is external).

  5. Integrated Comprehensive Health Systems
    These systems assume responsibility for all patient care and feature a whole-person approach with inpatient, outpatient, and specialty care. Examples include Intermountain Healthcare in Salt Lake City, UT, and Group Health in Washington. Read about Intermountain Healthcare at https://integrationacademy.ahrq.gov/health-it/case-studies/intermountain-healthcare (link is external).

  6. Massachusetts Child Psychiatry Access Project
    The goal of the Massachusetts Child Psychiatry Access Project is to improve access to child psychiatry services when fully integrated care is not available. Key components include universal behavioral health screening, telephone child psychiatry consultations within a defined period of time, access to face-to-face child psychiatry appointments if needed, and support for primary care providers and families, such as accessing community resources. More information is available at http://www.mcpap.com (link is external).

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If you have not done so already, define your vision for integrated care in your setting. Creating a formal vision statement can help. This vision statement should clearly communicate your purpose and goals. You may need a short sentence or several sentences to capture your goals for integrated care. The following questions can help guide the development of your vision:

  1. What is your desired future state? What things are different in your desired future state compared to now?
  2. Who will be affected by the vision?
    • Outline the expected benefit for the identified patients and how care will be different for them.
    • Outline the expected benefit for the providers/staff and how operations will be different.
  3. What outcomes do you expect? How can you measure these outcomes (e.g., clinical outcomes, patient experience, cost, and utilization)?
    • Are there any measures in place that can evaluate the things you expect to change and the overall success of your behavioral health vision?
  4. How will you measure the reach of behavioral health services and processes (e.g., referrals, productivity, appointment no-shows)?

Here are some examples of vision statements:

Our ambulatory care practice has the capacity to:

  • Address and resolve comorbid behavioral health and medical symptoms with better patient experiences and lower cost than before, including patients with complicated, high-cost conditions.
  • Proactively identify patients who need well-integrated behavioral health and medical care using targeted screening, health system data, or other methods.
  • Deliver targeted behavioral health services for selected, at-risk populations that have been identified.
  • Support medical team recognition, assessment, and treatment of uncomplicated behavioral health issues with a behavioral health provider available for consultation to achieve “treat-to-target” goals.
  • Manage or control total ambulatory care costs through well-integrated services and population health management methods.
  • Expand and diversify behavioral health services and community connections to eventually meet prevalence-based behavioral health needs in the community.

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What Not to Do

  • Don’t bypass creating a vision.
  • Don’t create a vision that providers and staff cannot relate to.
  • Avoid ambiguity in your vision.

Contribute

The Playbook includes many examples of how sites have implemented specific aspects of integration. If you would like to contribute, please send us your example of how your organization created a vision for integrated primary (or integrated ambulatory) care.

Send Us Your Example

Resources

Identify Your Champions

The AIMS Center offers guidance on identifying an implementation leader and planning team for a collaborative care program.

Source: The University of Washington – AIMS Center
Stakeholder Map—What Matters to Whom

You can use this template to map what matters to various stakeholder groups.

Source: Source: Peek, C. (2012)
Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry

A report prepared for the American Psychiatric Association suggests that integration of medical and behavioral health services can potentially result in substantial cost savings based on conservative financial models.

Source: Milliman, Inc.
Leadership for the Project

The North Carolina Foundation for Advanced Health Care Programs provides useful information to consider when identifying leaders and an implementation team for the integrated care program.

Source: North Carolina Foundation for Advanced Health Care Programs
Readiness Assessment & Developing Project Aims

Part 3 (“Assessing Organizational Culture for Change”) offers guidance on building a culture for quality improvement.

Source: U.S. Department Health and Human Services, Health Resources and Services Administration (HRSA)
Collaborative Care

The AIMS Center provides background information on the collaborative care approach, a library of resources, and a free collaborative care implementation guide.

Source: The University of Washington – AIMS Center
Collaborative Care for People with Depression and Anxiety

A review of 79 randomized controlled trials comparing collaborative care with routine care or alternative treatments for depression and anxiety. The authors found that collaborative care was associated with improved depression and anxiety outcomes compared with routine care.

Source: Cochrane
Blending Behavioral Health into Primary Care at Cherokee Health Systems

Dr. Dennis S. Freeman, chief executive officer of Cherokee Health Systems, describes how behavioral health consultants work as core members of the systems’ primary care teams.

Source: National Register of Health Service Psychologists
Medicaid Health Home Implementation in Missouri: A Year Later

Presentation slides on the Missouri Health Homes and lessons learned from implementation.

Source: SAMHSA-HRSA Center for Integrated Health Solutions
SHAPE: Sustaining Integrated Care

This Web site offers information on the SHAPE project in Colorado.

Source: SHAPE
Intermountain Healthcare

Intermountain Healthcare promotes behavioral health integration through its own in-house ambulatory and hospital-based information technology systems.

Source: AHRQ Academy
Massachusetts Child Psychiatry Access Project (MCPAP) Web site

This Web site provides information about MCPAP, related tools, and resources.

Source: Massachusetts Child Psychiatry Access Project (MCPAP)
Integrated Models of Behavioral Health in Primary Care

SAMHSA-HRSA Center for Integrated Health Solutions provides external linkages to information about different approaches to behavioral health integration.

Source: SAMHSA-HRSA Center for Integrated Health Solutions
Mental Health/Primary Care Integration Options Grid

This table provides an overview of the different levels of integration ranging from “minimal collaboration” to “fully integrated/merged.”

Source: SAMHSA-HRSA Center for Integrated Health Solutions
Evolving Models of Behavioral Health Integration in Primary Care

This report provides summaries of different approaches for integrating behavioral health into primary care, guidance on selecting an approach, and recommendations on how to support the implementation of integrated care.

Source: Milbank Memorial Fund
The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes

This brief focuses on the collaborative care approach to implementing integrated care in Medicaid health homes.

Source: Unützer, J., et al.; developed for the Centers for Medicare & Medicaid Services
The DIAMOND Initiative: Implementing Collaborative Care for Depression in 75 Primary Care Clinics

This article presents the results of collaborative care implementation efforts in 70 primary care clinics participating in the DIAMOND Initiative (Depression Improvement Across Minnesota–Offering a New Direction).

Source: Implementation Science, Vol. 8, No. 135 (2013)
Developing and Communicating a Vision

This resource provides guidance on developing, clarifying, and communicating a vision.

Source: The University of Kansas Workgroup for Community Health and Development
Creating a Shared Vision for Collaborative Care

This brief document outlines the steps in creating a vision for collaborative care.

Source: University of Washington – AIMS Center
Leadership in Systems of Care: Creating and Communicating a Shared Vision

This brief describes key steps in creating and communicating a shared vision.

Source: Child Welfare Information Gateway

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