What is the Aim for this Lexicon?
The aim of the Lexicon is to describe the functions which define integrated behavioral health in primary care practices to clarify what to implement and what to expect. This definition or "Lexicon" is the AHRQ Academy answer to "what is integrated behavioral health?"
Why define integrated behavioral health (IBH)?
The general concept is intuitive; "practice teams of primary care and behavioral health clinicians1 working together with patients and families". But at the level of specific functions, behavioral health integration can suggest different things to different people, who use different terms for the same basic ideas.
What to implement has historically been a source of ambiguity or confusion for clinicians, staff, and operations managers. What to expect has been a source of ambiguity or confusion to patients, families, researchers, and policymakers .
A shared definition of what behavioral health integration looks like in action (the functions routinely taking place) makes it clearer to all what to implement and what to expect. A definition widely shared in the field enables effective communication and concerted action among clinicians, care systems, health plans, payers, researchers, policymakers, healthcare leaders, and patients working for effective, widespread implementation on a meaningful scale.
- For patients and families. "What should I expect from integrated behavioral health in my own doctor's office? How would I know whether the care my family received was integrated?"
- For communities associated with or served by practices. "What can we expect from practices who say they integrate behavioral health? To what extent can we expect practices to collaboratively engage with us to tailor care to our specific needs, priorities, and context?"
- For employers or other purchasers of health plans. "What exactly am I buying when integrated behavioral health care is part of covered insurance benefits? What do I tell my employees they can expect from this benefit?"
- For health plans. "What should I require clinical systems to provide to health plan members and what will I look at to see if it is being provided? What are the functions that I need to price?”
- For clinicians and medical groups. “What exactly must I implement to create genuine behavioral health integrated with primary care and to advertise myself as practicing integrated behavioral health? What are the core functions everyone must have and what do I do locally or adapt?”
- For policymakers and healthcare leaders. “What functions and features of integrated behavioral health need to be supported by our policies and business models? And for what public benefit?”
- For researchers. “What functions will need research on implementation or outcome effectiveness? What functions require and form the basis for metrics? What terms should I use so that my research becomes part of a broader pool of knowledge?”
The AHRQ Academy expert panel (the National Integration Academy Council) developed this functional definition or "Lexicon" in 2013. Ten years later the same AHRQ panel (with substantially broader and different membership) updated the Lexicon in its present form to reflect shifts in basic definitions and in the literature supporting them, and for conversion into a web-based resource. In both decades, the expert panel consisted of a mix of clinician, care system, financial, government, and agency leaders, as well as patient representatives.
Sponsor: Agency for Healthcare Research and Quality, the main U.S. agency dedicated to the advancement of primary care; a scientific organization oriented to the use of such science by implementers, researchers, policymakers, and the public .
Definitional basis. A systematic consensus among leaders in the field (members of the AHRQ National Integration Academy Council) that included clinicians, researchers, administrative leaders, and patient representatives. Consensus definitions in emerging scientific fields were reached in 2013, and the Lexicon was written in that formal language and structure, reviewed and approved by AHRQ, and posted to the Academy for Integration of Behavioral Health and Primary Care website.
Purpose: To establish a definition shared by the broad field of what behavioral health integration looks like in action (the functions routinely taking place). To make it clear to all what to implement and what to expect. Such a definition widely shared in the field enables effective communication and concerted effort among clinicians, care systems, health plans, payers, researchers, policymakers, healthcare leaders, and patients, for effective, widespread implementation on a meaningful scale. This definition is a way to avoid the confusion and ambiguity about what to implement, what to expect, or what to support via operations, finance, and policy.
The Lexicon is not a self-assessment checklist or toolkit, but has formed the definitional basis of such tools as the AHRQ integrated behavioral health playbook and the Practice Integration Profile (PIP).
Audience: Practices, care systems, clinicians, health plans, researchers, policymakers, healthcare leaders, and patients working for effective and widespread implementation of integrated behavioral health (IBH) on a meaningful scale. The main audience in mind is primary care practice, knowing the definitions can be adapted for other contexts.
Structure: Six defining functions of IBH, including three overarching clinical functions (the "how to" functions) and three overarching organizational functions (the "supported by" functions). Each function is described by what should be common across all implementations and what may be different while still meeting the definition. The Lexicon also includes common strategic choices made during implementation and levels of maturity along the implementation spectrum (from having little or nothing in place to having a fully mature system).
Who else has defined or characterized integrated behavioral health? For what purposes or audiences?
The 2013 AHRQ Academy definition was detailed and formulated on behalf of the national field rather than for a local program, organization, stakeholder, model of care, or research study. Since then, other groups have recognized the same need for shared definitions, language, and conceptual basis for practice self-assessments and development. Several groups with specific purposes and audiences have created such definitions and tools. These are compatible with, and similar to, the AHRQ Academy functional definition, but tend to focus more specifically on their specific audiences.
Rather than experience all these definitions and tools as confusion or cacophony, the reader should take each in its own context and recognize how these have become like a “family” of specific tools, evolving over time to move the field forward. The AHRQ Lexicon takes its place within this ecology of definitions and tools, as a general definition of functions created by expert consensus.
Sponsor: The National Council for Mental Wellbeing and the Medical Director Institute, a membership organization of mental health and substance abuse treatment organizations.
Definitional basis for CHI. Adaptation of the previously published General Health Integration (GHI) Framework for behavioral health organizations2 expanded to integration in both physical health and behavioral health settings. CHI builds on and advances seven previously published IBH frameworks, including AHRQ's; the Eight Domains in CHI are similar and compatible with the six defined functions of IBH in the AHRQ Lexicon.
Purpose: To "establish a broad and practical framework to guide bidirectional integration (integration of primary health into behavioral health settings and behavioral health into primary health settings)…adapted to child and adult populations, small and large providers, rural and urban locations, and organizations with varying levels of resources." To "help providers, payers and population managers to measure progress in organizing delivery of integrated services, referred to as 'integratedness.'"
Audience: Mental health and substance use treatment organizations; physical health treatment organizations (e.g., primary care clinics and federally qualified health centers), policymakers interested in a guide for measuring and implementing integrated service delivery for payers, and providers at the state and local levels.
Structure: Eight domains of integration with steps that progress to greater integratedness, including significant emphasis and detail on sustainable financing and payment methods. The framework includes self-assessments, measurable elements, and connections of elements to value.
Sponsor: The Substance Abuse and Mental Health Services Administration (SAMHSA) National Center of Excellence for Integrated Health Solutions, via the National Council for Mental Wellbeing.
Definitional basis for IPAT: The 2013 SAMHSA-HRSA Standard Framework for Levels of Integrated Healthcare, which is a six-level description of IBH from minimal to full collaboration and practice transformation.
Purpose: To help practices self-assess their level of integration on eight basic functions of IBH and identify where their level of integration lies along the six-level continuum.
Audience: Healthcare practices aspiring to or involved in integrating behavioral health. Implicitly written for medical practices incorporating behavioral health, but adaptable to mental health practices incorporating medical care.
Structure: A qualitative self-assessment to assess and categorize practices along the six-level integration continuum. Focuses on qualitative change across all elements, which are difficult to assess in real settings.
Sponsor: The Eugene S. Farley, Jr., Health Policy Center and Practice Innovation Program, University of Colorado Anschutz Medical Campus in partnership with Well Being Trust.
Source or definitional basis. Adapts the Bodenheimer 10 building blocks of high-performing primary care3 for the special case of integrated behavioral health.
Purpose: "To align expectations across payers, providers, and patients for behavioral health integration in primary care (BHI)". Use to develop "…alternative payment models supporting flexible approaches to BHI so that payers know how additional support is being used, providers are able to choose their approach based on patient needs and local resources, and there are standardized care delivery expectations for patients."
Audience: Practices, payers, providers, patients, and policymakers interested in how functions and expectations for integrated behavioral health can be clarified and supported.
Structure: Ten building blocks, each with specified "foundational care delivery expectations" (recommended requirements for any integrated practice) and "additional care expectations by selected components". Building blocks include, leadership, data-driven quality improvement, team-based care, patient and family engagement, population management, access, comprehensiveness, and care coordination.
Sponsor: The Montefiore Care Management Organization and the National Council for Mental Well-being, with support from The New York Community Trust.4
Definitional basis for IBH: Stakeholder input and literature review, incorporating other integration models such as the Organizational Assessment Toolkit (OATI), Integrated Practice Assessment (IPAT), Behavioral Health Integration Capacity Assessment (BHICA), Practice Integration Profile (PIP), and the AHRQ Lexicon, which has similar domains.
Purpose: To supply an "organizing model that assists practices and policymakers to prioritize the steps of integration implementation and the need for both technical assistance and funding for key program elements," as well as "advancing integration of general health in behavioral health settings."
Audience: Behavioral health clinics and their organizing entities wishing to build general healthcare into behavioral health settings, including those in primary care who may become part of those behavioral health settings. While intended for behavioral health clinics, it is a general framework that "considers behavioral health and non-behavioral health conditions and all chronic conditions as falling in the broad category of improving general health."
Structure: "A series of concrete implementation steps that behavioral health organizations can employ to advance evidence-based integration practices." Eight domains appear on one axis, with characteristics of implementation at different levels of development from preliminary to advanced; it is referred to as a "continuum-based framework for integration."
Sponsor: The SAMSHA-HRSA Center for Integrated Health Solutions; focused on building capacity to address the needs of beneficiaries dually eligible for Medicare and Medicaid.
Definitional basis for IBH: The AHRQ Lexicon two-sentence definition is cited as the anchoring definition.
Purpose: To help behavioral health organizations evaluate their ability to implement IBH. Includes potential approaches suited to specific populations, how organizational infrastructure could support greater integration, organization strengths and challenges with different approaches, and how to set prioritized goals for IBH efforts.
Audience: Behavioral health organizations (e.g., mental health clinics or systems) actively planning to implement or facilitate greater integration of primary care and behavioral health care.
Structure: A self-assessment of served population and needs for IBH, existing infrastructure (three approaches: coordinated care, co-located, or build primary capacity in-house), and financing.
Sponsor: The UMass Chan Medical School, Center for Integrated Primary Care.
Source or definitional basis: Domains and questions derived from the AHRQ Lexicon definition for IBH.
Purpose: To help practices assess performance with IBH, compare themselves to other practices, and evaluate their practice's IBH in relation to the Triple Aim of care, experience, and financial factors.
Audience: Practices or systems of practices.
Structure: A self-assessment of practice IBH performance in six domains (workflow, workspace, clinical services, integration methods, identification of need, and patient engagement) plus an aggregate score.
Sponsor: The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) and the National Council for Behavioral Health (now the National Council for Mental Wellbeing).
Definitional basis. "Designed by a team of experts" from the SAMHSA-HRSA Center for Integrated Health Solutions; with acknowledgement of private consultant contributions.
Purpose: To provide "a compendium of tools that lay out a path for organizations to assess their readiness for integration, as well as benchmarking opportunities for those organizations well down the line in integration efforts".
Audience: Practices interested in behavioral health integration, whether behavioral health practices integrating medical care or medical practices integrating behavioral health care ("bi-directional integration").
Structure: Composed of four "building block" self-assessment tools: partnership checklist, customer views of the organization, administrative readiness, and customer-oriented continuous quality improvement. Each tool has its own developmental response set that assesses readiness for integration; with optional tools for change management.
The AHRQ Lexicon is compatible with the other definitions and tools, and in many cases was part of their literature sources or adapted definitions. The task is not to choose among them as if competing definitions, but to recognize when one or another fits a particular purpose.
Distinctive characteristics of the AHRQ definition:
- Main audience is primary care. Written with a focus on integrating behavioral health with primary care settings, but readily adaptable to integration with specialty medical care or “bi-directional” integration where primary care is brought into behavioral health settings.
- A clear definition of required functions. Includes a general definition of the field and the defining functions of IBH; what needs to be implemented and maintained. This includes, a) what takes place clinically and b) what organizational support functions are required for sustainability.
- A definition that includes both commonalities and differences. That is, what is common across all implementations and what might differ based on strategic choices or level of integration maturity.
- Short and streamlined defining statements. Concise definitions with higher levels of specificity and examples, and available for easy navigation in a web-based format.
- Created within and for a scientific organization. Formal definitional and consensus methods and review were used in its development. As an AHRQ product, it is produced on behalf of the broad field, not any one stakeholder. Its development and methods are outlined here.
The AHRQ Lexicon is not created as an operating model, or a set of specific ways to accomplish integration. It is not a toolkit, developmental process, or self-assessment checklist. Other resources provide those and are based on the AHRQ Lexicon (e.g., the AHRQ integrated behavioral health playbooks and the Practice Integration Profile (PIP).
Use this definition to answer the question, "What is integrated behavioral health?" This question is asked often because behavioral health integration can mean many different things to people in different roles and with different priorities. Use the definition here to reduce confusion and ambiguity about what to implement and what to expect.
Begin with the two-sentence definition:
"The care that results from a practice 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.9
This care may address mental health and substance use 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."
When implementers want more than what is in the Introduction page, go to Parts 1 and 2.
Part 1: The functional definition. Describes what one should expect to see in common across practices (the defining functions) in enough detail to begin implementing them.
Part 2: The common differences encountered. Describes the differences that exist between practices in strategic choices or integration maturity. This is a vocabulary for legitimate differences between practices, in enough detail to evoke local conversations and make choices based on the level of maturity of these functions at present or being aspired to.
Taken together, these convey a picture of what to implement and what to expect. Further specificity is available via navigation within the page to "read more" or by links to examples or appendices. Such pages address possible care team composition, business and financial models, measurement frameworks for various desired outcomes, and the place of IBH in health equity.
Parts 1 and 2 are the template for designing an implementation. They also pose decisions to make, given the clinic or system's population, resources, and interests. Design a local plan that accomplishes these functions and makes these decisions on what to do and how well based on the time you begin. The "Playbook" on the AHRQ site is a self-guided process to create such a plan and implement it.
Different people in different roles in a practice may want different kinds of answers to "what is integrated behavioral health?" Be prepared to answer the "what is IBH?" question for different people in different roles. Part of working with these definitions and being a good communicator is being comfortable with a wide range of different, but compatible and accurate answers, depending on who is asking and what they want to know.10 All answers tailored to who is asking can still express the core of the AHRQ definition. Examples are below.
Behind the question
What is the benefit?
To expand our clinic team to do better (and feel better) with the behavioral health dimension of our practice, things our patients already bring with them that we often do not have the time or experience to do as well as we want.
Nurse, MA, other team member
How will this change my work and who I work with?
A behavioral health clinician is on our clinic team rather than using an outside referral, working in clinic (or virtual) space with us and is part of huddles, care planning, and charting. They are on our team like everyone else, which helps patients and helps us.
What operational changes are there to make?
A behavioral health clinician works on our team from empty exam rooms, offices, other clinic space, or a telehealth terminal11 in a remote location, participating in our huddles, scheduling and EHR system, coding, and team roster; another role on our primary care team and schedule.
What supervision and business model are needed?
A licensed behavioral health provider has their own professional supervision but is accountable to our leaders for teamwork, citizenship, scheduling, care processes, revenue for codes when appropriate, and their contribution to clinic performance.
Quality improvement lead
What is the QI opportunity and obligation?
Many possibilities. Integrated behavioral health processes for:
How will this help me and my family?
Your doctor has partners in the clinic trained to help patients with personal, family, stress-related, mental health, or healthy behavior needs for improved health and medical care. This role providers a stronger medical team when needed, right here in the clinic where we all know each other, and we know you.
How will this affect our mission, reputation, and viability?
Our mission is to improve health. Behavioral health is also health, intertwined with medical conditions and care. We are implicitly "scored" on behavioral health contributors to good primary care via clinical outcomes, patient experience, cost of care, and provider satisfaction.
What follows are the defining functions of IBH shown at 3 levels: in two sentences, in one page, and in more detail with supporting appendices. These comprise the functions any behavioral health implementation plan needs to accomplish. But there is more to designing and implementing than a general definition.
Be able to move from this general definition to locally tailored implementation. The functional definitions do not prescribe a specific granular implementation or operating "model" of integration . A practice must make decisions about its foci for IBH and the level of development of these functions that is feasible at any given time. There is more to adapt for local goals and conditions than can be accommodated in any universal detailed prescription for implementation.
Just as a great definition of "airliner" does not include the mechanical drawings for any specific airplane, the functional definition of integrated behavioral health does not include exactly what to implement in your own clinic. Yet, the functions described in the AHRQ definition need to be accomplished by an implementation appropriate in focus for your local context, just as the basic architecture of any airplane must enable it to fly. The "Playbook" is designed as a self-guided way of turning defining functions into specific local implementation .
Use the Lexicon to improve your leadership and credibility as an advocate for IBH. Using a consistent vocabulary for what functions are required and what might be different from practice to practice is reassuring to clinicians and implementers and leads to consistent patterns of action toward implementation. Being able to cite this definition as a product of AHRQ on behalf of the entire field can establish its credibility and anchor it among all the other definitions and resources your team may encounter.
1 Primary care and behavioral health clinicians. The use of the word “clinician” in this short definition is to be read as inclusive of nursing, medical assistant, pharmacy, care management, and others who provide patient care in an integrated primary care team, not only physicians and behavioral health clinicians. A short definition loses its brevity if all possible team members are listed and so “clinician” serves as an umbrella term.
2 Chung H, Rostanski N, Glassberg H, Pincus H. Advancing Integration of Behavioral Health into Primary Care: A Continuum-Based Framework. New York, NY: United Hospital Fund; 2016. https://media.uhfnyc.org/filer_public/a6/8e/a68eb9d0-514c-4198-8225-c1c195264c28/framework_052616_final1.pdf. Accessed August 23, 2023.
3 Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12(2):166-71. https://www.doi.org/10.1370/afm.1616. Accessed August 23, 2023.
4 Smali E, Talley RM, Goldman ML, Pincus HA, Woodlock D, Chung H. A Continuum-Based Framework as a Practice Assessment Tool for Integration of General Health in Behavioral Health Care. Psychiatr Serv. 2022;73(6):636-41. https://www.doi.org/10.1176/appi.ps.202000708. Accessed August 23, 2023.
5 Goldman ML, Smali E, Richkin T, Pincus HA, Chung H. A novel continuum-based framework for translating behavioral health integration to primary care settings. Transl Behav Med. 2020;10(3):580-9. https://www.doi.org/10.1093/tbm/ibz142. Accessed August 23, 2023.
6 Kessler RS, Auxier A, Hitt JR, Macchi CR, Mullin D, van Eeghen C, et al. Development and validation of a measure of primary care behavioral health integration. Fam Syst Health. 2016;34(4):342-56. https://www.doi.org/10.1037/fsh0000227. Accessed August 23, 2023.
7 Hitt JR, Brennhofer SA, Martin MP, Macchi CR, Mullin D, van Eeghen C, et al. Further Experience with the Practice Integration Profile: A Measure of Behavioral Health and Primary Care Integration. Journal of Clinical Psychology in Medical Settings. 2022;29(2):274-84. https://www.doi.org/10.1007/s10880-021-09806-z. Accessed September 6, 2023.
8 Rose GL, Weldon TL, McEntee ML, Hitt JR, Kessler R, Littenberg B, et al. Practice integration profile revised: Improving item readability and completion. Fam Syst Health. 2023;41(2):201-6. https://www.doi.org/10.1037/fsh0000723. Accessed August 23, 2023.
9 Communities. This definition may increasingly be broadened from "patients and families" to "patients, families, and communities" via collaborative engagement of practices with their served communities. This facilitates integrated behavioral health tailored to the specific needs, priorities, context, and disparities. As an aspirational step, it is not regarded here as essential to the core definition, but this Lexicon describes it in several places.
10 Peek CJ. What Is Integrated Behavioral Health? In: Gold SB, Green LA, editors. Integrated Behavioral Health in Primary Care: Your Patients Are Waiting. Cham: Springer International Publishing; 2019. p. 11-32. https://www.doi.org/10.1007/978-3-319-98587-9_2. Accessed August 23, 2023.
11 About spatial arrangement and telehealth. With widespread use of secure telehealth, e-visits, and virtual team communications, the concept of "spatial arrangement" or "co-location" has shifted. This new technology (and its acceptance) means team functions that in the past required physical presence no longer do so. The concept of "spatial arrangement" is retained here but must now include well-integrated virtual spaces, including the possibility of behavioral health, or other professionals, consulting virtually with one or more practices. The technology, its range of secure use, how it is used, and even the language for describing electronically connected teamwork, has been rapidly evolving. For this Lexicon, the original concept of "spatial arrangement" continues, as it is an important dimension of team function, but now includes electronic "presence" as an option for co-location my change, accordingly. Research comparing virtual and physical presence may emerge.