Health Equity and Behavioral Health Integration

Purpose

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

     

Background

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

Definitions

  • 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).

Reducing Stigma

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.

  1. 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
  2. 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)
  3. 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)
  4. Determine and implement strategies to get buy-in and funding from leadership, providers, staff, and patients
  5. 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.

  1. Assess current workplace culture - you can develop a new assessment tool or use an existing assessment tool.
  2. 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

  1. Assess current policies and training - this assessment worksheet provides a health equity lens (PDF - 621 KB).
  2. Make updates to include policies and trainings that promote, facilitate, and build capacity for:

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

  1. Select a screening tool for social determinants of health - this guide has steps for developing a customized screening program (PDF - 711 KB)
  2. Implement screening for social determinants of health - this guide has strategies for engaging patients about their social risks and needs
  3. 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

  1. Select an ACEs screening tool - this guide has steps for selecting a screening a tool (PDF - 268 KB)
  2. Implement screening for ACEs and other trauma - this guide has steps for implementing an ACEs screening program
  3. 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

  1. 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)
  2. 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.

  1. Review current data collection efforts - this guide has ideas and questions for addressing health equity in evaluation efforts (PDF - 600 KB)
  2. 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.
  3. 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)

Additional Resources

Data on Disparities in Health and Healthcare

References

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