The development of a consensus definition of integrated behavioral health care is a useful first step toward identifying and assessing integrated care. The definition is generalizable and portable—meaning it can be applied to a variety of settings and situations. However, a richer framework is needed to take the reader from the brief definition to a more specific set of observable and measurable functions. This section describes an Integration Framework for measuring integrated behavioral health care, including details on how each section of the framework was developed and how applicable measures and resources were identified.
Elements of the Integration Framework
The Integration Framework has two major components, which further specify the components of integrated behavioral health care. These components are functional domains and measurement constructs. The functional domains and measurement constructs are adapted from previous work on the Lexicon.[1] [2]
- Functional Domains divide and organize the Integration Framework into high-level functions or actions. There are 11 functional domains that are organized as follows:
- Domains #1–4 describe the clinical functions necessary for integrated behavioral health care.
- Domains #5–9 describe the enabling functions that support integrated care and allow it to operate successfully on a meaningful scale. These enabling functions are important because integration of behavioral health is not only a matter of clinical processes, but of organizational functions that enable the clinical functions to happen consistently, reliably, and for the entire target population.
- Finally, the potential outcomes of integrated care are described in Domains #10–11. During this first phase of IBHC Measures Atlas development, the scope of outcomes measures was limited to patient experience. Additional outcomes domains, such as provider experience, system experience, clinical outcomes, and financial outcomes, may be considered for inclusion in subsequent releases of the IBHC Measures Atlas.
- Measurement Constructs describe specific characteristics (i.e., structures), actions (i.e., processes), and outcomes that can be observed during integrated behavioral health care. Structure and process constructs can be used to understand if a team is working collaboratively and integration is actually taking place. Often, structures and processes appear in a pattern. Within a functional domain there may be a structural construct, such as a plan describing how an organization will perform a certain aspect of integrated care, and then, there is a process construct to ensure the plan is consistently implemented. Domain #3, Patient Identification, is an example of this pattern. The structure construct states that methods to identify and prioritize individuals for integrated care should be specified in an agreed-upon workflow, and the process construct states that those agreed-upon methods should be used consistently. Outcomes constructs describe the potential results of implementing the structures and processes of integrated behavioral health care.
This framework is presented below. It begins with the overarching definition of integrated behavioral health care. Then, each functional domain and the related measurement constructs are mapped together flowing from left to right. Experienced evaluators may wish to review the attached table displaying both the Integration Framework and the core measures associated with each functional domain.
The Integration Framework
Integrated behavioral health care is the care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.
Functional Domains | Measurement Constructs |
---|---|
1. Care Team ExpertiseThe team is tailored to the needs of particular patients and populations—with a suitable range of expertise and roles. |
Structure:
Process:
|
2. Clinical WorkflowThe team uses shared operations, workflows, and protocols to facilitate collaboration. |
Structure:Clinical protocols and workflows are clearly documented. This implies that the protocols and workflows specify:
Process:
|
3. Patient IdentificationThe team employs systematic methods to identify and prioritize individuals in need of integrated care. |
Structure:Systematic methods to identify and prioritize individuals for integrated behavioral health care are present in the agreed-upon workflow. Process:Screening or other case identification processes are used to identify and prioritize people who need integrated behavioral health care in a timely manner. |
4. Patient and Family EngagementThe team engages patients and family (as appropriate) as active members in the integrated care team and in shared care plans. |
Structure:Protocols or workflows for patient and family engagement are documented for care teams and in care plans. Process:Consistently use agreed-upon workflows for patient and family engagement. |
5. Treatment MonitoringThe team systematically measures patient outcomes over time and adjusts treatment as needed. |
Structure:
Process:
|
6. Leadership AlignmentThe team is supported by leadership and administrative alignment. |
Structure:Explicit, shared values with a visible leadership commitment to establish and maintain collaborative integrated behavioral health care exist. Process:
|
7. Operational ReliabilityThe team is supported by reliable and robust office processes. |
Structure:Office workflows, processes, and quality control processes that support integrated behavioral health care are specified and documented. These structures and office systems may involve clinicians, clinic and office staff, and office processes. Process:
|
8. Business Model SustainabilityThe team is supported by a sustainable business model. |
Structure:A business model that is sustainable for the practice, its providers, and its patients is in place. Sustainability for patients includes copays, time off work required for appointments, driving and transportation costs in time and money—as well as health care premiums. Process:Monitor and modify financial performance of the integrated behavioral health aspect of the practice over time to ensure or improve sustainability, e.g., monitoring revenues, productivity, and outcomes that are rewarded financially in different ways within existing or newly emerging business models in healthcare. |
9. Data Collection and UseThe team is supported by the collection and use of practice-level data to achieve high quality, high value care. |
Structure:Practice-wide systems to collect and use data for data-driven quality improvement are expected and present. Process:
|
10. Desired OutcomesPatient experience (provider and system experience, clinical and financial outcomes to be included in subsequent editions of this IBHC Measures Atlas). |
Outcomes:
|
The following outcomes are beyond the scope of the current IBHC Atlas; however, these domains and constructs are in the long-term plan for IBHC Atlas development.
Other Desired Outcomes | Outcomes include the following |
---|---|
1. Provider Experience |
|
2. Clinical Outcomes |
|
3. Financial Outcomes |
|
4. System Experience |
|
Making Framework Concepts Specific to Integrated Behavioral Health Care
Readers may note that certain principles in the Integration Framework are applicable to health care in general, as well as to integrated behavioral health care specifically. For example, the functional domain of “Care Team Expertise” may be applicable to care teams for a variety of conditions. For this IBHC Measures Atlas, the focus is on care teams for integrated behavioral health care; therefore, concepts like behavioral health expertise, professionals, patient populations, or specific patient needs are highlighted in the measurement constructs for that functional domain.
Interpreting concepts of “good health care” through the lens of integrated behavioral health care provides two advantages. First, it places integrated behavioral health care in the context of good care, in general, and reinforces the fact that integrated behavioral care is a part of broader high-quality health care system. Second, it increases the number and variety of measures available to implementers seeking to assess their integrated behavioral health care programs. Measures and concepts originally pertaining to good health care are included throughout the next section, Overview of Measures. Included in the IBHC Measures Atlas.
Notes
To address issue of having footnotes and the back links to the footnotes not having the same link name, I suggest simply removing the hyperlinks associated with the footnotes number themselves. So there would be links in the text that jump down to the footnotes but not the other way around.
Also, suggest leaving the full URLs spelled out in the references because they are formal citations.
[1] footnote Peek, CJ, and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. Rockville, MD: Agency for Healthcare Research and Quality. April, 2013. AHRQ Publication No. 13-IP001-EF Available at: https://integrationacademy.ahrq.gov/lexicon. Accessed May 2, 2013.
[2] footnote Miller BF, Kessler R, Peek CJ, Kallenberg GA. A National Agenda for Research in Collaborative Care: Papers From the Collaborative Care Research Network Research Development Conference. Rockville, MD: Agency for Healthcare Research and Quality; 2011. AHRQ Publication No. 11-0067. Available at: https://archive.ahrq.gov/research/findings/final-reports/collaborativecare/collabcare.pdf. Accessed Jan. 31, 2013.