Prepare the Infrastructure in Your Setting

Establish Operational Systems to Support Integration

Operational systems are the background systems and workflows that allow staff and providers to work together to address the problems and needs of patients. Having reliable systems is important in all aspects of health care to ensure that all patients receive timely, quality health care. Reliable systems also help prevent confusion among providers and staff about who is supposed to do what. The operational systems for integration should build on your existing platform and serve as the foundation for translating your behavioral health integration game plan into your daily work.

These tips can help you transition from referring your patients to a behavioral health provider to integrating the behavioral health provider in the patient care workflow.

North Star

The setting has operational systems in place to support the daily functions of integrated ambulatory care.

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.

How Do You Do It?

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Operational systems include workflows and protocols to identify patients’ needs and subsequently manage, treat, and monitor them in a way that is clear to providers and reduces errors and oversights. Every practice setting has workflows to manage its patient panel. Workflows related to integration should specify how to:

  1. Identify patients who might benefit from integration.
  2. Engage patients in integrated care.
  3. Communicate about shared patients.
  4. Monitor patients, including adjustments to treatment.

The workflow should indicate not just what needs to be done, but also who is responsible for doing what and how the team will work together. Keep in mind that one narrowly defined workflow will not be ideal for all patients all of the time. Build workflows that have core features but can be tailored for particular patients and populations. For example, use similar communication and documentation processes but involve different team configurations or different clinical interventions. Flexible implementation is essential.

To get started:

  1. Define the target population (refer back to your Game Plan).
  2. Define the roles of providers and staff who will manage, treat, and monitor the identified patients.

How Others Are Doing It

Barre Family Health Center (BFHC), a part of UMass Memorial Health Care, has instituted an initiative to build behavioral health into the clinical workflow of their patient-centered medical home. As part of this initiative, BFHC routinely screens patients for unidentified or untreated behavioral health needs. Profile: Incorporating Routine Behavioral Health Screenings Into the Patient-Centered Medical Home (University of Massachusetts Medical School) (PDF - 2740 KB)

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When designing and organizing your operational systems for integrated behavioral health in your ambulatory care setting, identify metrics you want to capture. Think about which metrics will be most useful for your setting (e.g., metrics to assess how well your system is working and metrics of clinical progress) and consider how to incorporate the metrics into routine operational systems rather than having “add-ons” that are hard to maintain.

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To bill for services, the behavioral health provider must be credentialed with the health plans that serve your patient population. Credentialing must be done separately for each plan. This process can take from a few weeks to months. Some plans allow retroactive billing once credentialing is complete. Check with each plan about this.

Health systems and other large health care organizations might enter into a joint dialogue with payers about how they can support integrated care programs and provide the reimbursement necessary to provide behavioral health care for their members. This dialogue will help them understand that the behavioral health provider is part of the care team, not a specialist operating in a referral mode from a distant site. Emphasize that integrated workflows can help improve outcomes for complex patients, and work with payers to determine billing procedures.

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Designate workspace that maximizes ease of contact between behavioral health providers and medical clinicians and that supports both exchange of information and convenient dialogue with patients. Locating the behavioral health provider physically in the middle of the clinical area seems to be an important factor in the success of an integrated program. This facilitates informal conversations about patients and helps bring the behavioral health provider into the care team for patients who could benefit from behavioral health services.

When not seeing patients, the behavioral health provider can be available to medical staff. This is particularly helpful when they recognize a patient needing behavioral health services and want to make a “warm hand-off.”  Configure the behavioral health provider’s schedule so it includes unscheduled time for communication and warm hand-offs. Aim to find the right balance of access, productivity, and flexibility that the integrated program can sustain.

One of the advantages of integrated care is the ability to provide patients with quick and convenient access to behavioral health services. Long waiting lists for behavioral health care interfere with access. Monitoring access to the behavioral health provider is important during program startup and should be done regularly as the program matures. Learn more about collecting and using data in Collect and Use Data for Quality Improvement.

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Integration is supported by documentation in a common medical record. Documentation by the behavioral health provider should be brief and focused on the information needed by the medical provider, such as:

  • What is the diagnosis, and is it different from what the medical provider thought?
  • What type of treatment will be provided?
  • Is the patient engaged in treatment? If not, what are the obstacles and what should the care team watch out for?
  • Is treatment helping? If not, what adjustments might be needed?
  • What, if any, treatment or coordination of care is needed from the medical provider?

Understanding privacy and confidentiality regulations related to behavioral health treatment in medical settings is an essential aspect of documentation. Behavioral health care involves specific restrictions on how patient information is handled. In general, however, if the patient understands and agrees to the sharing of information, it is okay to do so. Here are some tips on how to approach privacy and confidentiality in your integrated setting:

  • Revise general patient consent and authorization forms to incorporate information about the sharing of behavioral health information among providers and other members of the care team. This will make it clear that communication and information-sharing among members of the care team, including the behavioral health provider, are routine in the practice.
  • Psychotherapy process notes are a specific type of documentation that requires additional protection. These records rarely need to be shared with the rest of the team. File these notes separately, with special processes in place for team members to gain access.
  • Information about substance abuse treatment also has special protection, but only when generated by substance abuse treatment facilities and programs that receive Federal assistance. Substance abuse treatment information in primary care or other medical settings can be shared like other types of personal health information in the medical record.

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When adopting a new operational system, it is important to start small. Have one or two providers try the new system with a few patients, expand it to more providers and more patients as “bugs” are worked out and confidence is gained. Pay attention to what works and what doesn’t as you expand the operational system. Give providers and staff an opportunity to provide suggestions on how to enhance the new system. This will allow you to identify workflows that maximize patient and provider outcomes before proceeding to wider implementation.

Make sure to train all staff in the new integration processes and associated billing procedures. Recognize that adjustments will be needed during the transition to a new integrated environment. 

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Measurement is an important part of implementation. As new workflows are implemented, you should measure key process steps and components to ensure that you are doing what you intended. The workflow you are redesigning will determine the process measures you will use.

Workflows are generally connected to desired patient outcomes. In most situations, these include clinical, functional, satisfaction, quality of life, and economic outcomes. Workflows that are not leading to desired outcomes in these targeted areas should be modified. Try to measure something about the intended impact—some desired outcome of your system—to see if what you are doing is having the impact you expected. The metrics incorporated into the operational system can be used to determine if the transition has succeeded and to identify areas for improvement.

How Others Are Doing It

MaineHealth is an integrated healthcare system of leading, high-quality providers and other healthcare organizations working together across Central and Southern Maine. The Behavioral Health Integration program, a program of MaineHealth and Maine Behavioral Healthcare (a member of MaineHealth), consists of approximately thirty clinicians working in close to forty different practices within seven hospital system members of MaineHealth.  MaineHealth’s integration efforts started with grant funded pilot work in twenty practices around the state. There was great flexibility in trying a variety of models during this pilot work, which allowed the leadership of the integration program at MaineHealth to explore various levels of integration and decide what would work best for their needs. It was deemed that the most effective and efficient method for integration was for providers to be able to work directly in the electronic medical record (EMR) and for those notes to be simultaneously used as a shared form of communication between providers. MaineHealth has since adopted a system that promotes shared medical decision making by allowing providers to easily store and transmit patient information.

Integrative Electronic Medical Records

At MaineHealth all primary care providers operate directly in the EMR with record keeping occurring in relatively real time. The behavioral health specialist also works directly in the EMR and has the ability to view the patient’s entire medical record. The EMR systems at MaineHealth feature a flag alert communication tool in which behavioral health and primary care providers can send messages to each other that are not part of the patient progress notes, but instead serve as internal instant message logs.  Primary care physicians receive complete feedback from the behavioral health provider both in person as well as by simply accessing the EMR when behavioral health providers route their notes directly to the primary care provider.

The EMRs at MaineHealth incorporate a series of tools and patient engagement features used by both behavioral health providers and primary care physicians. The system incorporates PHQ9 screening for depression into the EMR as a standard behavioral health assessment.  MaineHealth also incorporates PHQ9 into their registries for some chronic health conditions.  The registry includes how many patients have been screened using PHQ9 and information regarding PHQ9 follow ups. Although MaineHealth does not possess registries of specific psychiatric conditions, a behavioral health clinician looking for patient information regarding a psychiatric or behavioral health condition is able to do so through the integrated physician’s notes and any documents that come from other agencies around their mental health care.  All supplemental documents are scanned and electronically entered into the patient record.  Documentation of present behavioral health conditions is stored in the EMR during the patient visit.

The EMR systems at MaineHealth also support the everyday needs of the office.  For example, the EMR includes a referral system that supports scheduling patients.  To promote integrated care MaineHealth encourages warm handoffs in which the provider directly introduces the patient to the behavioral health provider.  These warm handoffs can increase a patient’s trust level in the behavioral health provider and help to ensure the patient will follow up on their behavioral health needs.  While the warm handoffs occur in person, the EMR is used to log the order for a referral for behavioral health service so that front office staff can create and schedule the appointment electronically with the patient at check out.

Addressing Confidentiality

MaineHealth recognizes the need to maintain confidentiality of records while employing health information technology for purposes of behavioral health integration.  A key priority is to always acknowledge that behavioral health records are sensitive and, as such, MaineHealth has enacted specific procedures for managing behavioral health records.  For example, the behavioral health portion of a patient medical record has limited access.  Since behavioral health information is protected by extra levels of sensitivity, there is specific access designated for doctors, nurses, and care managers to be able to access documentation coming from the behavioral health clinician.  MaineHealth recognizes the need to balance the ability to coordinate care with the need for privacy by ensuring that behavioral health information gets to the right people without allowing the information to flow unnecessarily to others.  Any information that does go outside of a particular hospital system within MaineHealth would need a release of information signed by the patient.

When a patient is referred to a behavioral health clinician at MaineHealth, the patient is informed that information will be shared across their providers both electronically and in person.  If a patient is not comfortable with that sharing of information, the patient can be referred elsewhere.  The vast majority of patients, however, appreciate the sharing of information between their mental health providers and primary care clinicians.   Appreciation of these integrative efforts is part of why patients come to MaineHealth.

Promoting Interoperability

At present there are four different electronic medical record (EMR) systems used by integrated behavioral health clinicians working in the MaineHealth hospital-owned primary care practices, although there are plans to continue to reduce the number of vendors.  In the meantime, MaineHealth has enacted efforts to promote interoperability and standardization across systems.

Much progress has been made thus far in standardizing the typical documentation of the behavioral health clinician. The largest challenge in implementing health information technology systems for behavioral health integration has been the need to have someone in the IT systems available to build templates for behavioral health documentation and to create processes for storing behavioral health information.  None of the EMR systems in use at MaineHealth came with behavioral health templates that met their needs, so MaineHealth opted to develop their own templates that would be standardized across all of their HIT systems.  MaineHealth continues to work toward building templates that span all of behavioral health that can be incorporated into all of the electronic systems.  To assist in everyday needs, IT staff are connected to the hospital systems and are available to support primary care providers and behavioral health clinicians in all MaineHealth locations.

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What Not to Do

  • Don't approach integration as a “project.” Projects end. Instead, approach integration as a change in the way that care will be provided in your setting.
  • Don’t get stuck in the planning stages. Some things can only be figured out by trying something and adjusting as needed.
  • Don’t expect a single “one-size-fits-all” workflow to work for all patients. Different population segments are likely to need different workflows.
  • Avoid a workflow that relies only on provider memory during a busy office visit.

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 established operational systems to support integrated behavioral health in your ambulatory care setting.

Send Us Your Example

Resources

Integrating Behavioral and Physical Health Care in the Real World: Early Lessons from Advancing Care Together

This article presents implementation challenges and lessons learned from a study of 11 practices participating in the Advancing Care Together (ACT) program.

Source: Journal of the American Board of Family Medicine, Vol. 28, No. 5 (2013)
Profile: Incorporating Routine Behavioral Health Screenings Into the Patient-Centered Medical Home

This case study illustrates how Barre Family Health Center incorporated behavioral health into the clinical workflow of their patient-centered medical home by routinely screening patients for unidentified or untreated behavioral health needs.

Source: University of Massachusetts Medical School
Billing Tools: Paying for Primary Care and Behavioral Health Services Provided in Integrated Care Settings

Billing and financial worksheets for each State can be downloaded.

Source: SAMHSA-HRSA Center for Integrated Health Solutions
Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care

Gunn et al. observed spatial layout design of 19 integrated care practices and suggest two promising layouts based on their findings.

Source: Journal of The American Board of Family Medicine, Vol. 28 Supplement (2015)
Redesigning Your Work Space to Support Team-Based Care

McGough et al. offer four design elements to improve your team-based care.

Source: Family Practice Management, Vol. 20, No. 2 (2013)
Clinician Staffing, Scheduling, and Engagement Strategies Among Primary Care Practices Delivering Integrated Care

In this article, Davis et al. report their observations of staffing, scheduling, and workflows to bring behavioral health providers into patients’ care teams.

Source: Journal of The American Board of Family Medicine, Vol. 28 Supplement (2015)
Behavioral Health Integration Toolkit

This toolkit, originally developed for the Massachusetts Patient-Centered Medical Home Initiative, provides strategies for integrating behavioral health in primary care settings.

Source: University of Massachusetts Medical School
Medicare Annual Wellness Visit – Health Risk Assessment

An example form to document a patient health risk assessment in an electronic health record system.

Source: MaineHealth
Privacy and Sharing

This resource includes links to The Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA) and the Privacy Rule.

Source: HHS
Confidentiality

Information and resources to help providers navigate information exchange for effective care coordination.

Source: SAMHSA-HRSA Center for Integrated Health Solutions
Integrating Physical and Behavioral Health: Strategies for Overcoming Legal Barriers to Health Information Exchange

This brief reviews strategies to overcome barriers to information exchange between behavioral and medical health providers.

Source: Manatt Health Solutions
Privacy and Integrated Behavioral Health – Special Considerations Under HIPAA and Part 2

This Webinar addresses common misconceptions about regulations for sharing behavioral health information.

Source: Mental Health America of Greater Houston
How Does Integrated Behavioral Health Care Work?

This resource includes examples of process measures to evaluate how well your integrated care program is working, in addition to other assessment resources.

Source: California Mental Health Services Authority, Integrated Behavioral Health Project
Workflow Assessment for Health IT Toolkit

A toolkit to help analyze workflows as they relate to the implementation of health information technology.

Source: AHRQ National Resource Center

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