A Framework for Measuring Integration of Behavioral Health and Primary Care

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 Expertise The team is tailored to the needs of particular patients and populations—with a suitable range of expertise and roles.	Structure: Health care professionals with a range of expertise and roles are available and can be tailored into a team to meet the needs of specific patients and populations. Process: Conduct an individualized needs assessment for a specific patient and family. Develop a unified care plan that builds a team—with necessary members and functions—to care for a given patient. Train the care team to function in collaborative practice and respond as a team to an individual patient’s unique needs. If desired, select a subpopulation of clinic patients with similar needs, such as geriatric care, children with special needs, or chronic illnesses and make available a range of team expertise generally needed to care for the selected subpopulation.
2. Clinical Workflow The 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: the roles, functions, and activities of all team members within the shared workflows; the types of information that need to be shared; and the standard way to manage the addition of team members, transitions (or “handoffs”). Process: Consistently implement specific shared workflows rather than informal processes. Collaborate toward shared goals using shared workflows. Maximize team roles so that team members can do the highest-level tasks permitted by their credentials and licenses. Build workflows that are coordinated, convenient, timely, and efficient from the patient’s perspective.
3. Patient Identification The 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 Engagement The 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 Monitoring The team systematically measures patient outcomes over time and adjusts treatment as needed.	Structure: Clinical information, such as registry, outreach, and other information, is readily available for the purpose of monitoring and adjusting treatment. A followup system (with detail on components) and workflows to use the system are documented. Process: Consistently use followup systems on a regular basis. Adjust treatments if patients do not achieve the desired outcomes.
6. Leadership Alignment The 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: Allocate resources, including money, time, and leader attention, in a manner that is consistent with stated priorities for integrated care. Identify and address practical conflicts with other organizational priorities, incentives, and habits.
7. Operational Reliability The 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: Consistently use specified structures, office workflows, processes, and standards for integrated behavioral health to support highly reliable operations. Employ quality improvement approaches, such as Lean or other process improvement methods, to improve office workflows, processes, and standards.
8. Business Model Sustainability The 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 Use The 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: Collect practice-based data on key processes (e.g., percentage of patients with a shared care plan, percentage of patients with followup monitoring and treatment adjustment or outcomes of care (see outcome measures below). Use the data to inform decisions that improve quality, effectiveness, and value.
10. Desired Outcomes Patient experience (provider and system experience, clinical and financial outcomes to be included in subsequent editions of this IBHC Measures Atlas).	Outcomes: Individual patient experience with integrated behavioral health care. Aggregate patient experience for the panel of patients who receive health care. Aggregate patient experience (for a particular population denominator(s) defined by the practice).

Functional Domains

Measurement Constructs

1. Care Team Expertise

The team is tailored to the needs of particular patients and populations—with a suitable range of expertise and roles.

Structure:

Health care professionals with a range of expertise and roles are available and can be tailored into a team to meet the needs of specific patients and populations.

Process:

Conduct an individualized needs assessment for a specific patient and family.
Develop a unified care plan that builds a team—with necessary members and functions—to care for a given patient.
Train the care team to function in collaborative practice and respond as a team to an individual patient’s unique needs.
If desired, select a subpopulation of clinic patients with similar needs, such as geriatric care, children with special needs, or chronic illnesses and make available a range of team expertise generally needed to care for the selected subpopulation.

2. Clinical Workflow

The 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:

the roles, functions, and activities of all team members within the shared workflows;
the types of information that need to be shared; and
the standard way to manage the addition of team members, transitions (or “handoffs”).

Process:

Consistently implement specific shared workflows rather than informal processes.
Collaborate toward shared goals using shared workflows.
Maximize team roles so that team members can do the highest-level tasks permitted by their credentials and licenses.
Build workflows that are coordinated, convenient, timely, and efficient from the patient’s perspective.

3. Patient Identification

The 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 Engagement

The 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 Monitoring

The team systematically measures patient outcomes over time and adjusts treatment as needed.

Structure:

Clinical information, such as registry, outreach, and other information, is readily available for the purpose of monitoring and adjusting treatment.
A followup system (with detail on components) and workflows to use the system are documented.

Process:

Consistently use followup systems on a regular basis.
Adjust treatments if patients do not achieve the desired outcomes.

6. Leadership Alignment

The 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:

Allocate resources, including money, time, and leader attention, in a manner that is consistent with stated priorities for integrated care.
Identify and address practical conflicts with other organizational priorities, incentives, and habits.

7. Operational Reliability

The 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:

Consistently use specified structures, office workflows, processes, and standards for integrated behavioral health to support highly reliable operations.
Employ quality improvement approaches, such as Lean or other process improvement methods, to improve office workflows, processes, and standards.

8. Business Model Sustainability

The 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 Use

The 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:

Collect practice-based data on key processes (e.g., percentage of patients with a shared care plan, percentage of patients with followup monitoring and treatment adjustment or outcomes of care (see outcome measures below).
Use the data to inform decisions that improve quality, effectiveness, and value.

10. Desired Outcomes

Patient experience (provider and system experience, clinical and financial outcomes to be included in subsequent editions of this IBHC Measures Atlas).

Outcomes:

Individual patient experience with integrated behavioral health care.
Aggregate patient experience for the panel of patients who receive health care.
Aggregate patient experience (for a particular population denominator(s) defined by the practice).

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	Provider experience with integrated behavioral health care.
2. Clinical Outcomes	Individual patient clinical improvements due to integrated behavioral health care (may include self-care). Individual functional improvements due to integrated behavioral health care. Aggregate clinical outcomes for the panel of patients who receive integrated behavioral health care. Aggregate population health (for population denominator(s) defined by the practice).
3. Financial Outcomes	Aggregate total cost of care (or affordability) for the population (for population denominator(s) defined by the practice).
4. System Experience	Health system administrator, leader, or institutional experience with integrated behavioral health care as an aspect of the overall system of care.

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.