This page represents a brief overview of the role of behavioral health integration in reducing disparities in health and healthcare, and shares practical strategies and resources for ensuring integrated practices are advancing health equity.
This page covers the following topics:
- Background - Foundational Information on Disparities in Health and healthcare
- What We Know - The Role of Behavioral Health Integration in Reducing Disparities
- Ensuring the Advancement of Health Equity within Integrated Care Settings-What Works
Underlying social, economic, and environmental inequities in relation to housing, education, food access, employment, and safety are central factors in creating disparities in health and healthcare. These disparities are reflected in differences in health outcomes such as life expectancy, quality of life, and morbidity and mortality rates based on gender, race, socioeconomic status, sexual orientation and gender identity, physical ability, age, weight, geographic region, housing status, and immigration status.1,2
Disparities in health and healthcare disproportionately impact people who are racial and ethnic minorities; have disabilities; reside in rural communities; are lesbian, gay, bisexual, transgender, and queer (LGBTQ); are women; experience homelessness; have behavioral health conditions; are immigrants; and have lower incomes.1,2 People that fall within multiple social, economic, or other classifications commonly cope with intersecting inequities and compounding disparities in health and healthcare - referred to as intersectionality.3
- Health equity means that “everyone has a fair and just opportunity to be as healthy as possible”.4,5,6
- Health disparities are preventable differences in the burden of disease, injury, violence, disability, or mortality experienced in one population group relative to another.7
- Healthcare disparities are preventable differences in the access to care, quality of care, and healthcare coverage experienced in one population group relative to another.7
- Patient-centered care engages, informs, and empowers patients and caregivers to participate in their care; addresses barriers to care; and meets patient needs for physical health, mental health, and substance use disorder treatment.8
- Groups and communities that have been marginalized experience discrimination and social, political, and economic exclusion because of unequal power relationships across economic, political, social, and cultural dimensions.9
What We Know-The Role of Behavioral Health Integration in Reducing Disparities
Mental health, substance use, and physical health have mutually influencing interactions, and all correlate with histories of trauma and with lower income.10,11 People with mental health and substance use disorders have a higher prevalence of other chronic conditions, such as cardiovascular disease, stroke, high blood pressure, diabetes, cancer, HIV and hepatitis, and vice versa.10,11,12,13,14,15
Fragmented and uncoordinated healthcare and social service systems compound underlying social, economic, and environmental inequities and make it difficult to fully address the entire array of biological, psychological, and social problems and illnesses that people bring into the healthcare system. People with multiple chronic conditions have poorer health outcomes, use more health services, and spend more on healthcare.16,17Integrating behavioral health into primary care can provide the collaborative, patient-centered, and whole-person care needed to address biopsychosocial factors that affect health, well-being, and quality of life and reduce disparities in health and healthcare.17,18,19
Addressing Fragmentation and Lack of Coordination
Integrating behavioral health into primary care addresses fragmentation and lack of coordination. Integrated teams of medical and behavioral health providers deliver care for medical conditions, including problematic health behaviors, crises in life, mental health disorders, and substance use in primary and ambulatory care settings. Patients are active participants and partners in making decisions about their healthcare. Practices create workflows, protocols, and procedures for screening, brief intervention, and referral to treatment (SBIRT) for patients with mental health and substance use disorders. Practices build partnerships and establish referral processes with mental health, substance use, and other specialty providers in the community (e.g., addiction medicine providers, residential addiction treatment centers, health departments, and recovery supports).
Stigma is another key barrier to behavioral healthcare access.20,21,22 Patients in some communities, including minority, low-income, and rural communities, prefer - largely due to perceived stigma - to receive behavioral consultations within a primary care setting compared to a mental healthcare setting.23,24,25 A considerable amount of specialty mental healthcare is already taking place within primary care settings.26,27 Integrating behavioral health into primary care reduces the stigma associated with accessing behavioral healthcare and decreases no-show rates for behavioral health-related visits.28,29,30,31,32,33,34
Reducing Healthcare Utilization and Costs
The more chronic health conditions people have, the more healthcare services they use and the higher the healthcare costs.15,16,35,36 High out-of-pocket cost is another key barrier to behavioral healthcare access, especially for people with multiple chronic conditions, including diabetes, hypertension, depression, anxiety, and substance use.15,16,21,22,36,37,38Integrating behavioral health in primary care reduces healthcare utilization, including visits, admissions, and length of stay, and reduces healthcare costs for patients, practices, health systems, and payers.30,34,39,40,41,42,43,44,45 These cost -savings can even offset some or all of the costs needed to finance integrated behavioral health.46,47
Improving Quality of Care
Fragmented and uncoordinated care cannot adequately meet the needs of people with multiple chronic conditions and other complex care needs.17 Integrating behavioral health into primary care improves several quality-of-care measures related to screening, diagnosis, management, treatment, and follow-up for chronic conditions, such as screening rates, wait times for behavioral health services, and provision of guideline-concordant care.39,48,49,50Integrating behavioral health into primary care also improves patient satisfaction with care.48,49,51,52,53,54
Improving Health Outcomes
The more chronic health conditions people have, the more likely they are to report poor health.16,55Integrating behavioral health into primary care improves health outcomes, including adherence to treatment, adherence to relapse prevention plans, response to treatment, remission of symptoms, recovery from symptoms, and mental health-related quality of life, especially for people with depression, anxiety, diabetes, high cholesterol, and high blood pressure.39,44,48,49,51,52,53,54,56,57,58,59,60,61,62,63
Ensuring the Advancement of Health Equity within Integrated Care Settings-What Works
Integrating behavioral health into primary care provides the collaborative, patient-centered, and whole-person clinical care needed to address biopsychosocial factors that affect health, well-being, and quality of life and to reduce disparities in health and healthcare.17,18,64To ensure the advancement of health equity, integrated care practices and health systems must also take steps to address mid- and upstream factors like social determinants of health and community conditions that impact their patients.65,66
1. Update Organizational Mission and Goals to Include Health Equity
Integrated care practices and health systems need to build health equity into all aspects and levels of the organization. Updating an organization’s mission and goals requires a clear, shared vision with aligned incentives, resources, and buy-in.
- Assemble a planning and implementation team for this initiative and provide appropriate training, such as this toolkit for addressing health equity and racial justice within integrated care settings or this health equity curricular toolkit
- Assess the organization’s readiness to make changes - you can use a tool such as this health equity self-assessment (PDF - 1,033 KB) or a diversity, equity, and inclusion organizational assessment (PDF - 907 KB)
- Begin data-informed planning (PDF - 917 KB) of desired changes and how those may impact organizational structures, policies, and procedures - this toolkit outlines key drivers of racial health equity for review (PDF - 3.1 MB)
- Determine and implement strategies to get buy-in and funding from leadership, providers, staff, and patients
- Implement changes - you can use an implementation tool such as this framework for belonging, dignity, and justice or this framework for addressing social determinants of health in primary care (PDF - 952 KB)
2. Create a Workplace Culture of Belonging, Dignity, and Justice
Representation, compensation, and/or provider experience for several healthcare professions are disproportionately lower or poorer for providers who are racial and ethnic minorities, are women, are LGBTQ, and have disabilities.67,68,69,70,71,72,73,74,75 Promoting belonging, dignity, and justice within integrated care settings is key to creating a culture and climate in which all care team members, staff, and stakeholders feel welcome, valued, and safe.
- Assess current workplace culture - you can develop a new assessment tool or use an existing assessment tool.
- Develop and implement strategies, activities, and tactics to recruit, support, affirm, and recognize staff and stakeholders from groups that are underrepresented, such as these strategies for retaining staff from racial and ethnic minorities groups, these strategies for affirming LGBTQ+ staff, and these steps for recruiting a diverse board.
3. Implement Policies and Training to Eliminate Bias, Discrimination, and Racism
Patients commonly report experiencing stigma and discrimination based on race/ethnicity, educational level, income level, sexual orientation, and weight when interacting with the healthcare system.76,77,78,79,80,81 Stigma, discrimination, and racism create negative healthcare experiences for patients, and also prevent providers from providing equitable quality of care (e.g., failing to offer routine services or not adhering to practice standards for communicating with patients, referring patients for screening/diagnostic testing, and making treatment decisions).1,66,82,83,84,85,86,87,88,89
- Assess current policies and training - this assessment worksheet provides a health equity lens (PDF - 621 KB).
- Make updates to include policies and trainings that promote, facilitate, and build capacity for:
- Acknowledging lived experience (PDF - 1,422 KB)
- Addressing implicit bias (PDF - 52.3 KB)
- Advancing behavioral health equity
- Advancing health equity
- Affirming patient personhood and dignity
- Avoiding stigmatizing, depersonalizing, and derogatory language and behavior
- Communicating internally and externally about equity in health and healthcare
- Creating welcoming and safe health spaces (PDF - 166 KB)
- Cultural humility and respect
- Recognizing and dismantling discrimination and racism
4. Screen for Social Determinants of Health
Poverty, transportation barriers, food and housing insecurity, lack of social support, and other social determinants of health are driving factors of disparities in health and healthcare, and are accountable for up to 30% of a person’s long-term health outcomes.90,91
- Select a screening tool for social determinants of health - this guide has steps for developing a customized screening program (PDF - 711 KB)
- Implement screening for social determinants of health - this guide has strategies for engaging patients about their social risks and needs
- Establish partnerships and referral processes with social services providers and other community resources (e.g., emergency food providers, income support programs, housing support services, family planning, employment assistance, and transportation assistance services) to ensure that patients can access the services and support, if needed - this playbook has strategies for fostering community partnerships to address social needs (PDF - 16.8 MB)
5. Screen for Trauma
Traumatic experiences, such as neglect, abuse, violence and household dysfunction during childhood (referred to as adverse childhood experiences or ACEs) are strongly related to the development of chronic conditions in adulthood, including mental health and substance use disorders.92,93,94 Children in groups or communities that have been marginalized have a disproportionately higher prevalence of ACEs, increasing the risk of negative health behavior and poor health outcomes throughout life.95
- Select an ACEs screening tool - this guide has steps for selecting a screening a tool (PDF - 268 KB)
- Implement screening for ACEs and other trauma - this guide has steps for implementing an ACEs screening program
- Establish partnerships and referral processes with community resources (e.g., crisis and distress hotlines, domestic and intimate partner violence shelters, sexual assault and other violence intervention and recovery programs, and trauma support networks) to ensure that patients can access the services and supports, if needed - this guide has strategies for developing a cross-sector trauma-informed network of care for preventing and addressing the impact of ACEs (PDF - 4.8 MB)
ACEs screening can lead to a better understanding of patients’ backgrounds, increased empathy, and enhanced provider-patient relationships.96 Care must be taken not to use ACEs scores as a diagnostic tool or in a way that may stigmatize or lead to discrimination of patients based upon an ACE score.97
6. Improve Access to Telehealth Technologies
Since the onset of the pandemic, outpatient telehealth visits have increased from 7% to 16%.98Telehealth can expand access to integrated behavioral health care, but disparities in access to and use of telehealth technologies, internet, broadband, and cellular network access must be addressed.99
- Institute outreach and screening to determine the digital access, skills, and preferences of patients - you can use existing tools such as this guide of equitable considerations (PDF - 163 KB), these screening scripts and intake forms, or this equity assessment questionnaire (PDF - 2.3 MB)
- Determine how to help patients get connected to telehealth technologies and adapt patient care to meet needs and align with preferences - you can use a guide such as this digital equity playbook (PDF - 5.1 MB) or this list of methods for improving access to telehealth
7. Monitor and Evaluate Health Equity on a Regular Basis
Once you have taken steps to ensure that your integrated practice or health system is advancing health equity, it is essential to regularly monitor and evaluate your progress.
- Review current data collection efforts - this guide has ideas and questions for addressing health equity in evaluation efforts (PDF - 600 KB)
- Expand data collection, as needed, to include health equity, diversity, and inclusion measures; workplace culture measures; race, ethnicity, language, and other demographic data measures; and measures of social conditions, health, community, and well-being.
- Create or update monitoring and reporting tools that make data easily accessible and actionable - this toolkit has templates, tools, and samples for collecting, managing, and evaluation health equity data (PDF - 1,340 KB)
Data on Disparities in Health and Healthcare
- 2021 National Healthcare Quality and Disparities Report - Agency for Healthcare Research and Quality
- National Healthcare Quality and Disparities Report Chartbooks for Priority Areas and Populations - Agency for Healthcare Research and Quality
- Disparities in Health and Health Care: 5 Key Questions and Answers - Kaiser Family Foundation
- Achieving Racial and Ethnic Equity in U.S. Health Care: Scorecard - The Commonwealth Fund
- The Economic Burden of Mental Health Inequities in the United States Report (PDF - 10.2 MB) - Satcher Health Leadership Institute at Morehouse School of Medicine
- Behavioral Health Care in the United States: How It Works and Where It Falls Short - The Commonwealth Fund
1. Agency for Healthcare Research and Quality. 2021 national healthcare quality and disparities report. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Pub. No. 21(22)-0054-EF. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr21/index.html. Accessed September 23, 2022.
2. Office of Disease Prevention and Health Promotion. Social Determinants of Health Literature Summaries: Discrimination. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/discrimination. Accessed September 23, 2022.
3. Lopez N, Gadsden VL. Health inequities, social determinants, and intersectionality. NAM Perspectives. 2015, Dec:1-15. https://doi.org/10.31478/201612a. Accessed September 23, 2022.
4. Braveman P, Arkin E, Orleans T, Proctor D, Plough A. What is health equity and what difference does a definition make? Princeton, NJ: Robert Wood Johnson Foundation; 2017. https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html. Accessed September 23, 2022.
5. Centers for Disease Control and Prevention. What is health equity? https://www.cdc.gov/healthequity/whatis/index.html. Accessed September 23, 2022.
6. American Medical Association. What is health equity? https://www.ama-assn.org/delivering-care/health-equity/what-health-equity. Accessed September 23, 2022.
7. Ndugga N, Artiga S. Disparities in health and health care: 5 key questions and answers. Washington, DC: Kaiser Family Foundation; 2021 May. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/. Accessed September 23, 2022.
8. Blount A. Patient-Centered primary care: getting from good to great. Switzerland: Springer; 2019. Chapter 4, Getting from “delivering care to patients” to “partnership with patients.” Accessed September 23, 2022.
9, National Collaborating Centre for Determinants of Health. Glossary of essential health equity terms. https://nccdh.ca/glossary/entry/marginalized-populations. Accessed September 23, 2022.
10. National Institute on Drug Abuse. Part 2: Co-occurring substance use disorder and physical comorbidities. https://nida.nih.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-2-co-occurring-substance-use-disorder-physical-comorbidities. Accessed September 23, 2022.
11. National Institute of Mental Health. Chronic illness and mental health: Recognizing and treating depression. https://www.nimh.nih.gov/health/publications/chronic-illness-mental-health. Accessed September 23, 2022.
12. Substance Abuse and Mental Health Services Administration. Co-Occurring disorders and other health conditions. https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/co-occurring-disorders. Accessed September 23, 2022.
13. Alegria M, Jackson JS, Kessler RC, Takeuchi D. National comorbidity survey replication (NCS-R), 2001-2003. Ann Arbor, MI: Interuniversity Consortium for Political and Social Research; 2003. Accessed September 23, 2022.
14. Wu LT, Zhu H, Ghitza UE. Multicomorbidity of chronic diseases and substance use disorders and their association with hospitalization: Results from electronic health records data. Drug Alcohol Depend. 2018 Nov 1;192:316-323. https://doi.org/10.1016%2Fj.drugalcdep.2018.08.013. Accessed September 23, 2022.
15. Thorpe K, Jain S, Joski P. Prevalence and spending associated with patients who have a behavioral health disorder and other conditions. Health Affairs. 2017 Jan 1;36(1):124-32. https://doi.org/10.1377/hlthaff.2016.0875. Accessed September 23, 2022.
16. Buttorff C, Ruder T, Bauman M. Multiple chronic conditions in the United States. Santa Monica, CA: RAND Corporation; 2017. https://www.rand.org/pubs/tools/TL221.html. Accessed September 23, 2022.
17. Agency for Healthcare Research and Quality. Advancing patient-centered care for people living with multiple chronic conditions. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/multichronic/mcc.html. Accessed September 23, 2022.
18. County Health Rankings & Roadmaps. Behavioral health primary care integration. https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/strategies/behavioral-health-primary-care-integration. Accessed September 23, 2022.
19. Bombard Y, Baker GR, Orlando E, Fancott C, Bhatia P, Casalino S, Onate K, Denis JL, Pomey MP. Engaging patients to improve quality of care: A systematic review. Implement Sci. 2018 Jul 26;13(1):98. https://doi.org/10.1186%2Fs13012-018-0784-z. Accessed September 23, 2022.
20. Coombs NC, Meriwether WE, Caringi J, Newcomer SR. Barriers to healthcare access among US adults with mental health challenges: A population-based study. SSM-Population Health. 2021 Sep 1;15:100847. https://doi.org/10.1016/j.ssmph.2021.100847. Accessed September 23, 2022.
21. United States Government Accountability Office. Behavioral health: Research on health care costs of untreated conditions is limited. Washington, DC: United States Government Accountability Office; 2019 Feb. Report GAO-19-274. https://www.gao.gov/products/gao-19-274. Accessed September 23, 2022.
22. United States Government Accountability Office. Mental health care: Access challenges for covered consumers and relevant federal efforts. Washington, DC: United States Government Accountability Office; 2022 Mar. Report GAO-22-104597. https://www.gao.gov/products/gao-22-104597. Accessed September 23, 2022.
23. Dunn JA, Chokron Garneau H, Filipowicz H, Mahoney M, Seay-Morrison T, Dent K, McGovern M. What are patient preferences for integrated behavioral health in primary care? J Prim Care Community Health. 2021 Jan-Dec;12:21501327211049053. https://doi.org/10.1177%2F21501327211049053. Accessed September 23, 2022.
24. Ogbeide SA, Landoll RR, Nielsen MK, Kanzler KE. To go or not go: Patient preference in seeking specialty mental health versus behavioral consultation within the primary care behavioral health consultation model. Families, Systems, & Health. 2018;36(4):513-517. https://doi.org/10.1037/fsh0000374. Accessed September 23, 2022.
25. Manoleas P. Integrated primary care and behavioral health services for Latinos: A blueprint and research agenda. Social work in health care. 2008 Oct 22;47(4):438-54. https://doi.org/10.1080/00981380802344480. Accessed September 23, 2022.
26. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system: Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50(2):85-94. https://doi.org/10.1001/archpsyc.1993.01820140007001. Accessed September 23, 2022.
27. Morning Consult, Bipartisan Policy Center. Mental health and substance use treatment services utilization. Washington, DC: Bipartisan Policy Center; 2021 May. https://bipartisanpolicy.org/download/?file=/wp-content/uploads/2021/03/BPC-MC-FINAL-Slide-deck-on-Mental-Health-Analysis-Poll.pdf (PDF - 665 KB). Accessed September 23, 2022.
28. Gallo JJ, Zubritsky C, Maxwell J, Nazar M, Bogner HR, Quijano LM, Syropoulos HJ, Cheal KL, Chen H, Sanchez H, Dodson J. Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: Results from a multisite effectiveness trial (PRISM-e). The Annals of Family Medicine. 2004 Jul 1;2(4):305-9. https://www.annfammed.org/content/annalsfm/2/4/305.full.pdf (PDF - 71.8 KB). Accessed September 23, 2022.
29. Miller-Matero LR, Khan S, Thiem R, DeHondt T, Dubaybo H, Moore D. Integrated primary care: Patient perceptions and the role of mental health stigma. Primary Health Care Research & Development. Cambridge University Press; 2019;20:e48. https://doi.org/10.1017/S1463423618000403. Accessed September 23, 2022.
30. American Hospital Association. Integrating behavioral health across the continuum of care. Chicago, IL: Health Research & Educational Trust; 2014 Feb). www.hpoe.org/integratingbehavioralhealth. Accessed September 23, 2022.
31. Integrating behavioral health services into patient-centered medical home primary care practices. Washington, DC: American Hospital Association; 2019 May. https://www.aha.org/system/files/media/file/2019/05/aha-cs-gbmc-0519.pdf (PDF - 325 KB). Accessed September 23, 2022.
32. Pomerantz A, Cole BH, Watts BV, Weeks WB. Improving efficiency and access to mental health care: Combining integrated care and advanced access. General hospital psychiatry. 2008 Nov 1;30(6):546-51. https://doi.org/10.1016/j.genhosppsych.2008.09.004. Accessed September 23, 2022.
33. Possemato K, Johnson EM, Beehler GP, Shepardson RL, King P, Vair CL, Funderburk JS, Maisto SA, Wray LO. Patient outcomes associated with primary care behavioral health services: A systematic review. General Hospital Psychiatry. 2018 Jul 1;53:1-1. https://doi.org/10.1016/j.genhosppsych.2018.04.002. Accessed September 23, 2022.
34. O'Loughlin K, Donovan EK, Radcliff Z, Ryan M, Rybarczyk B. Using integrated behavioral healthcare to address behavioral health disparities in underserved populations. Translational Issues in Psychological Science. 2019 Dec;5(4):374. https://doi.org/10.1037/tps0000213. Accessed September 23, 2022.
35. Walker ER, Druss BG. Cumulative burden of comorbid mental disorders, substance use disorders, chronic medical conditions, and poverty on health among adults in the U.S.A. Psychol Health Med. 2017 Jul;22(6):727-735. https://doi.org/10.1080%2F13548506.2016.1227855. Accessed September 23, 2022.
36. Davenport S, Gray TJ, Melek SP. How do individuals with behavioral health conditions contribute to physical and total healthcare spending? Seattle, WA: Milliman; 2020 Aug. Accessed September 23, 2022.
37. Crapanzano KA, Hammarlund R, Ahmad B, Hunsinger N, Kullar R. The association between perceived stigma and substance use disorder treatment outcomes: a review. Subst Abuse Rehabil. 2018 Dec 27;10:1-12. https://doi.org/10.2147%2FSAR.S183252. Accessed September 23, 2022.
38. Coombs NC, Meriwether WE, Caringi J, Newcomer SR. Barriers to healthcare access among US adults with mental health challenges: A population-based study. SSM-Population Health. 2021 Sep 1;15:100847. https://doi.org/10.1016/j.ssmph.2021.100847. Accessed September 23, 2022.
39. Reiss-Brennan B, Brunisholz KD, Dredge C, Briot P, Grazier K, Wilcox A, Savitz L, James B. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016 Aug 23;316(8):826-34. https://doi.org/10.1001/jama.2016.11232. Accessed September 23, 2022.
40. Thapa BB, Laws MB, Galárraga O. Evaluating the impact of integrated behavioral health intervention: Evidence from Rhode Island. Medicine. 2021 Aug 8;100(34). https://doi.org/10.1097/MD.0000000000027066. Accessed September 23, 2022.
41. Ross KM, Klein B, Ferro K, McQueeney DA, Gernon R, Miller BF. The cost effectiveness of embedding a behavioral health clinician into an existing primary care practice to facilitate the integration of care: A prospective, case-control program evaluation. Journal of Clinical Psychology in Medical Settings. 2019 Mar;26(1):59-67. https://doi.org/10.1007/s10880-018-9564-9. Accessed September 23, 2022.
42. Behavioral health integration: Treating the whole person. Washington, DC: American Hospital Association; 2019. https://www.aha.org/center/emerging-issues/market-insights/behavioral-health-integration/behavioral-health-integration-treating-whole-person. Accessed September 23, 2022.
43. Integrated behavioral health is high-value care. Washington, DC: American Hospital Association; 2019 Dec. https://www.aha.org/issue-brief/2019-12-11-integrated-behavioral-health-high-value-care. Accessed September 23, 2022.
44. Katon W, UNutzer J, Fan MY, Williams Jr JW, Schoenbaum M, Lin EH, Hunkeler EM. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care. 2006 Feb 1;29(2):265-70. https://doi.org/10.2337/diacare.29.02.06.dc05-1572. Accessed September 23, 2022.
45. Beil H, Feinberg RK, Patel SV, Romaire MA. Behavioral health integration with primary care: Implementation experience and impacts from the State Innovation Model round 1 states. The Milbank Quarterly. 2019 Jun;97(2):543-82. Accessed September 23, 2022.
46. Jacob V, Chattopadhyay SK, Sipe TA, Thota AB, Byard GJ, Chapman DP, Community Preventive Services Task Force. Economics of collaborative care for management of depressive disorders: A community guide systematic review. American Journal of Preventive Medicine. 2012 May 1;42(5):539-49. https://doi.org/10.1016/j.amepre.2012.01.011. Accessed September 23, 2022.
47. Melek SP, Norris DT, Paulus J, Matthews K, Weaver A, Davenport S. Potential economic impact of integrated medical-behavioral healthcare: Updated projections for 2017. Seattle, WA: Milliman; 2018 Jan. Accessed September 23, 2022.
48. Davis MM, Gunn R, Gowen LK, Miller BF, Green LA, Cohen DJ. A qualitative study of patient experiences of care in integrated behavioral health and primary care settings: More similar than different. Translational Behavioral Medicine. 2018 Oct;8(5):649-59. https://doi.org/10.1093/tbm/ibx001. Accessed September 23, 2022.
49. Thota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, McKnight-Eily LR, Chapman DP, Abraido-Lanza AF, Pearson JL, Anderson CW, Gelenberg AJ, Hennessy KD, Duffy FF, Vernon-Smiley ME, Nease DE Jr, Williams SP; Community Preventive Services Task Force. Collaborative care to improve the management of depressive disorders: A community guide systematic review and meta-analysis. Am J Prev Med. 2012 May;42(5):525-38. https://doi.org/10.1016/j.amepre.2012.01.019. Accessed September 23, 2022.
50. Druss BG, von Esenwein SA, Glick GE, Deubler E, Lally C, Ward MC, Rask KJ. Randomized trial of an integrated behavioral health home: The health outcomes management and evaluation (HOME) study. American Journal of Psychiatry. 2017 Mar 1;174(3):246-55. https://doi.org/10.1176/appi.ajp.2016.16050507. Accessed September 23, 2022.
51. Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews. 2012(10). https://doi.org/10.1002/14651858.CD006525.pub2. Accessed September 23, 2022.
52. Robinson P, Von Korff M, Bush T, Lin EH, Ludman EJ. The impact of primary care behavioral health services on patient behaviors: A randomized controlled trial. Families, Systems, & Health. 2020 Mar;38(1):6-15. https://doi.org/10.1037/fsh0000474. Accessed September 23, 2022.
53. Balasubramanian BA, Cohen DJ, Jetelina KK, Dickinson LM, Davis M, Gunn R, Gowen K, DeGruy FV, Miller BF, Green LA. Outcomes of integrated behavioral health with primary care. The Journal of the American Board of Family Medicine. 2017 Mar 1;30(2):130-9. https://www.jabfm.org/content/jabfp/30/2/130.full.pdf (PDF - 135 KB). Accessed September 23, 2022.
54. Kolko DJ, Campo J, Kilbourne AM, Hart J, Sakolsky D, Wisniewski S. Collaborative care outcomes for pediatric behavioral health problems: A cluster randomized trial. Pediatrics. 2014 Apr;133(4):e981-92. https://doi.org/10.1542%2Fpeds.2013-2516. Accessed September 23, 2022.
55. Walker ER, Druss BG. Cumulative burden of comorbid mental disorders, substance use disorders, chronic medical conditions, and poverty on health among adults in the U.S.A. Psychol Health Med. 2017 Jul;22(6):727-735. https://doi.org/10.1080%2F13548506.2016.1227855. Accessed September 23, 2022.
56. Slomski A. Primary care treatment of substance use disorder reaches more patients. JAMA. 2017 Nov 28;318(20): https://doi.org/10.1001/jama.2017.17949. Accessed September 23, 2022.
57. Katon W, Russo J, Sherbourne C, Stein MB, Craske M, Fan MY, Roy-Byrne P. Incremental cost-effectiveness of a collaborative care intervention for panic disorder. Psychol Med. 2006 Mar;36(3):353-63. https://doi.org/10.1017/s0033291705006896. Accessed September 23, 2022.
58. Woltmann E, Grogan-Kaylor A, Perron B, Georges H, Kilbourne AM, Bauer MS. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-analysis. American Journal of Psychiatry. 2012 Aug;169(8):790-804. https://doi.org/10.1176/appi.ajp.2012.11111616. Accessed September 23, 2022.
59. Rollman BL, Belnap BH, Mazumdar S, Houck PR, Zhu F, Gardner W, Reynolds CF 3rd, Schulberg HC, Shear MK. A randomized trial to improve the quality of treatment for panic and generalized anxiety disorders in primary care. Arch Gen Psychiatry. 2005 Dec;62(12):1332-41. https://doi.org/10.1001/archpsyc.62.12.1332. Accessed September 23, 2022.
60. Asarnow JR, Rozenman M, Wiblin J, Zeltzer L. Integrated Medical-Behavioral Care Compared With Usual Primary Care for Child and Adolescent Behavioral Health: A Meta-analysis. JAMA Pediatr. 2015;169(10):929-937. https://doi.org/10.1001/jamapediatrics.2015.1141. Accessed September 23, 2022.
61. Cully JA, Stanley MA, Petersen NJ, Hundt NE, Kauth MR, Naik AD, Sorocco K, Sansgiry S, Zeno D, Kunik ME. Delivery of brief cognitive behavioral therapy for medically ill patients in primary care: a pragmatic randomized clinical trial. Journal of General Internal Medicine. 2017 Sep;32(9):1014-24. https://doi.org/10.1007/s11606-017-4101-3. Accessed September 23, 2022.
62. Butler M, Kane RL, McAlpine D, Kathol RG, Fu SS, Hagedorn H, Wilt TJ. Integration of mental health/substance abuse and primary care. Database of abstracts of reviews of effects (DARE): Quality-assessed reviews. York (UK): Centre for Reviews and Dissemination (UK); 1995. https://www.ncbi.nlm.nih.gov/books/NBK76532/. Accessed September 23, 2022.
63. Ivey SL, Shortell SM, Rodriguez HP, Wang YE. Patient engagement in ACO practices and patient-reported outcomes among adults with co-occurring chronic disease and mental health conditions. Med Care. 2018 Jul;56(7):551-556. https://doi.org/10.1097/MLR.0000000000000927. Accessed September 23, 2022.
64. Bombard Y, Baker GR, Orlando E, Fancott C, Bhatia P, Casalino S, Onate K, Denis JL, Pomey MP. Engaging patients to improve quality of care: A systematic review. Implement Sci. 2018 Jul 26;13(1):98. https://doi.org/10.1186/s13012-018-0784-z. Accessed September 23, 2022.
65. Agency for Healthcare Research and Quality. A Call for Action to Achieve Health Equity. https://www.ahrq.gov/news/blog/ahrqviews/achieve-health-equity.html. Accessed September 23, 2022.
66. Blount A. Patient-centered primary care: Getting from good to great. Switzerland: Springer; 2019. Chapter 5, When the doctor-patient divide is a chasm. Accessed September 23, 2022.
67. Salsberg E, Richwine C, Westergaard S, Martinez MP, Oyeyemi T, Vichare A, Chen CP. Estimation and comparison of current and future racial/ethnic representation in the US health care workforce. JAMA Netw Open. 2021;4(3):e213789. https://doi.org/10.1001/jamanetworkopen.2021.3789. Accessed September 23, 2022.
68. Wyse R, Hwang WT, Ahmed AA, Richards E, Deville C. Diversity by race, ethnicity, and sex within the US psychiatry physician workforce. Academic Psychiatry. 2020 Oct;44(5):523-30. https://doi.org/10.1007/s40596-020-01276-z. Accessed September 23, 2022.
69. American Psychological Association. Demographics of U.S. psychology workforce [Interactive data tool]. https://www.apa.org/workforce/data-tools/demographics. Accessed September 23, 2022.
70. Cheeseman Day J, Christnacht C. Women hold 76% of all health care jobs, gaining in higher-paying occupations. https://www.census.gov/library/stories/2019/08/your-health-care-in-womens-hands.html. Accessed September 23, 2022.
71. Women in the labor force: A databook. Washington, DC: U.S. Bureau of Labor Statistics; 2019 Dec. Report 1084: Table 18, Median usual weekly earnings of full-time wage and salary workers, by detailed occupation and gender, 2018 annual averages (numbers in thousands). https://www.bls.gov/opub/reports/womens-databook/2019/home.htm. Accessed September 23, 2022.
72. Morgan R, Tan HL, Oveisi N, Memmott C, Korzuchowski A, Hawkins K, Smith J. Women healthcare workers' experiences during COVID-19 and other crises: A scoping review. Int J Nurs Stud Adv. 2022 Dec;4:100066. https://doi.org/10.1016/j.ijnsa.2022.100066. Accessed September 23, 2022.
73. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians' experiences in the workplace. Journal of Homosexuality. 2011 Nov 1;58(10):1355-71. Accessed September 23, 2022. https://doi.org/10.1080/00918369.2011.614902. Accessed September 23, 2022.
74. Eliason MJ, Streed Jr C, Henne M. Coping with stress as an LGBTQ+ health care professional. Journal of Homosexuality. 2018 Apr 16;65(5):561-78. https://doi.org/10.1080/00918369.2017.1328224. Accessed September 23, 2022.
75. Waliany S. Health professionals with disabilities: Motivating inclusiveness and representation. AMA J Ethics. 2016;18(10):971-974. https://doi.org/10.1001/journalofethics.2016.18.10.fred1-161. Accessed September 23, 2022.
76. Nong P, Raj M, Creary M, Kardia SLR, Platt JE. Patient-reported experiences of discrimination in the us health care system. JAMA Netw Open. 2020;3(12):e2029650. https://doi.org/10.1001/jamanetworkopen.2020.29650. Accessed September 23, 2022.
77. Abramson CM, Hashemi M, Sánchez-Jankowski M. Perceived discrimination in US healthcare: Charting the effects of key social characteristics within and across racial groups. Preventive Medicine Reports. 2015 Jan 1;2:615-21. https://doi.org/10.1016/j.pmedr.2015.07.006. Accessed September 23, 2022.
78. McNeill SG, McAteer J, Jepson R. Interactions between health professionals and lesbian, gay and bisexual patients in healthcare settings: A systematic review. Journal of Homosexuality. 2021 Jul 23:1-27. https://doi.org/10.1080/00918369.2021.1945338. Accessed September 23, 2022.
79. Scott Collins K, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse communities, common concerns: Assessing health care quality for minority americans. New York, NY: The Commonwealth Fund; 2002 Mar. https://www.commonwealthfund.org/publications/fund-reports/2002/mar/diverse-communities-common-concerns-assessing-health-care. Accessed September 23, 2022.
80. Phelan SM, Bauer KW, Bradley D, Bradley SM, Haller IV, Mundi MS, Finney Rutten LJ, Schroeder DR, Fischer K, Croghan I. A model of weight-based stigma in health care and utilization outcomes: Evidence from the learning health systems network. Obes Sci Pract. 2021 Aug 27;8(2):139-146. https://doi.org/10.1002/osp4.553. Accessed September 23, 2022.
81. Bazargan M, Cobb S, Assari S. Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. The Annals of Family Medicine. 2021 Jan 1;19(1):4-15. https://doi.org/10.1370/afm.2632. Accessed September 23, 2022.
82. Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: Documenting racial bias in the electronic health record: Study examines racial bias in the patient descriptors used in the electronic health record. Health Affairs. 2022 Feb 1;41(2):203-11. https://doi.org/10.1377/hlthaff.2021.01423. Accessed September 23, 2022.
83. National Academies of Sciences, Engineering, and Medicine. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press; 2003. https://doi.org/10.17226/12875. Accessed September 23, 2022.
84. Iezzoni LI, Rao SR, Ressalam J, Bolcic-Jankovic D, Agaronnik ND, Donelan K, Lagu T, Campbell EG. Physicians' perceptions of people with disability and their health care. Health Aff (Millwood). 2021 Feb;40(2):297-306. https://doi.org/10.1377%2Fhlthaff.2020.01452. Accessed September 23, 2022.
85. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015 Apr;16(4):319-26. https://doi.org/10.1111%2Fobr.12266. Accessed September 23, 2022.
86. Office of the Surgeon General; Center for Mental Health Services; National Institute of Mental Health. Mental Health: culture, race, and ethnicity: A supplement to mental health: A report of the Surgeon General. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2001 Aug. Chapter 1, Introduction. https://www.ncbi.nlm.nih.gov/books/NBK44246/. Accessed September 23, 2022.
87. Willems S, De Maesschalck S, Deveugele M, Derese A, De Maeseneer J. Socio-economic status of the patient and doctor-patient communication: Does it make a difference? Patient Educ Couns. 2005 Feb;56(2):139-46. https://doi.org/10.1016/j.pec.2004.02.011. Accessed September 23, 2022.
88. Fiscella K, Goodwin MA, Stange KC. Does patient educational level affect office visits to family physicians? J Natl Med Assoc. 2002 Mar;94(3):157-65. https://doi.org/10.1016/j.pec.2004.02.011. Accessed September 23, 2022.
89. The Pew Charitable Trusts. African Americans often face challenges accessing substance use treatment. https://www.pewtrusts.org/en/research-and-analysis/articles/2020/03/26/african-americans-often-face-challenges-accessing-substance-use-treatment. Accessed September 23, 2022.
90. Manatt, Phelps & Phillips, LLP. Medicaid's role in addressing social determinants of health. Princeton, NJ: Robert Wood Johnson Foundation; 2019 Feb. https://www.rwjf.org/en/library/research/2019/02/medicaid-s-role-in-addressing-social-determinants-of-health.html. Accessed September 23, 2022.
91. County Health Rankings & Roadmaps. County Health Rankings model. https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model. Accessed September 23, 2022.
92. Substance Abuse and Mental Health Services Administration. Trauma and violence. https://www.samhsa.gov/trauma-violence. Accessed September 23, 2022.
93. Centers for Disease Control and Prevention. Adverse childhood experiences (ACEs). https://www.cdc.gov/policy/polaris/healthtopics/ace/index.html. Accessed September 23, 2022.
94. Centers for Disease Control and Prevention. About the CDC-Kaiser ACE study. https://www.cdc.gov/violenceprevention/aces/about.html. Accessed September 23, 2022.
95. Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011-2014 behavioral risk factor surveillance system in 23 states. JAMA Pediatr. 2018;172(11):1038-1044. https://doi.org/10.1001/jamapediatrics.2018.2537. Accessed September 23, 2022.
96. Rariden C, SmithBattle L, Yoo JH, Cibulka N, Loman D. Screening for adverse childhood experiences: Literature review and practice implications. J Nurse Pract. 2021 Jan;17(1):98-104. https://doi.org/10.1016/j.nurpra.2020.08.002. Accessed September 23, 2022.
97. Anda RF, Porter LE, Brown DW. Inside the adverse childhood experience score: Strengths, limitations, and misapplications. American Journal of Preventive Medicine. 2020 Aug 1;59(2):293-5. https://doi.org/10.1016/j.amepre.2020.01.009. Accessed September 23, 2022.
98. Barton T, Donnellan J, Harootunian L, Harris J, Hartnett T, Hoagland GW, Newell B, Nguyen M, O’Gara B, Parekh A, Werber Serafini M, Burgos A, McDonough D. Tackling America’s mental health and substance use crisis requires integrated care. Washington DC: Bipartisan Policy Center; 2021 Mar. https://bipartisanpolicy.org/report/behavioral-health-2021/. Accessed September 23, 2022.
99. Greenberg-Worisek AJ, Kurani S, Finney Rutten LJ, Blake KD, Moser RP, Hesse BW. Tracking Healthy People 2020 internet, broadband, and mobile device access goals: An update using data from the health information national trends survey. J Med Internet Res. 2019 Jun 24;21(6):e13300. Erratum in: J Med Internet Res. 2022 May 26;24(5):e39712. https://doi.org/10.2196%2F13300. Accessed September 23, 2022.