Part 1: A functional definition

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 Scope of integrated behavioral health. Definition and functions here are for behavioral health integrated in primary care. But very similar definitions and functions can be made for behavioral health in specialty care settings such as in oncology, neurology, cardiology, endocrinology, occupational health, sports medicine, or other specialties.

3 A team has tasks that require interdependent and collaborative efforts.^a Outcomes commonly desired from teams include: clinical outcomes superior to "usual care", conservation of expensive physician or other clinician labor, and reduced clinician workload on activities that could be done by others.^b Put another way, team outcomes superior to "usual care" involve appropriate use of professionals and staff for patient assistance, diagnostic assessments, and intervention; these should be based on background, training, and skills that lead to maximum clinical and functional benefit while conserving health related resources.

• A small interdependent team defined at the level of each patient has been referred to as a "clinical microsystem" that forms to meet particular patient and family needs—typically led by a physician or advanced practice provider with some combination of team members in roles such as nursing, care coordination, social work, behavioral health, pharmacy, physical therapy or others. This microsystem changes as the needs of the patient and family shift even as its members often remain embedded in a larger organization or system.^c
• Some team roles or members will likely be the same in a practice and across patients with common needs, while other team roles or individuals will vary with regard to access and dedicated time based on practice population characteristics and desired targeted outcomes.
• "Team" as used here does not require that all team members are from the same organization or "network". However, for some people, "team" may connote professionals that work in the same organization or unit (e.g., a clinic) rather than those brought in from disparate organizations for a particular patient. The term "collaboration" could be used by those who wish to restrict "team" to members of one clinic or organization.

4 Range of team expertise: a table of examples (PDF - 2.1 MB).

5 Suitable range of expertise. What is "suitable" cannot be specified in advance here because a) it depends on the choice of target conditions, populations, or clinical or other situations, and b) practices are often not in a position to secure all the team members that would be ideal. The purpose of "suitable" here is to require that the practice learn and establish, as well as it can, the range of expertise needed to be helpful to their target populations. It does not require having the "ideal" slate of team members.

6 Typical scope of care that teams must address includes: Chronic illness care, acute care, common physical symptoms associated with stress without serious disease present, acute life stresses, wellness and prevention, health behavior change, and mental health/substance abuse dimensions of the total care of patients.

7 Range of basic roles for patients, family, and caregivers include: 1) being a participant in a healing relationship; 2) providing information on needs, preferences, values, and priorities during shared decision-making, as well as customizing care (family members may need permissions as well as willingness); 3) being the source of control,^d and 4) taking an active role or "ownership" of health.

8 Patient engagement has been defined as "actions individuals must take to obtain the greatest benefit from the health care services available to them."^e This focuses on the behaviors of individuals that are critical to health outcomes, rather than those of professionals or institutions. Domains include finding safe, decent care from among the alternatives; communication with professionals; organizing and paying for health care; participation in treatment decisions and treatment; promoting health knowledge, health behaviors, and preventive care; and planning for end of life. In this view, "engagement" is an active inquiry and set of behaviors by individuals, not merely "compliance."^f

9 Patients need to know who is on the team and why, especially when a BH team member is added. The patient should experience the addition of team members (such as a behavioral health clinician) as value-added for their care. This occurs through, 1) helping the patient understand why their situation and plan needs other professionals to be involved, and 2) the patient seeing current providers endorse the credibility and work of the new clinician(s).

10 Shared workflows: Working from shared workflows, protocols, and office processes goes beyond spatial proximity or "co-location," which does not by itself establish shared workflows. Shared workflows could be regarded as "shared process space" in contrast to "shared physical space".

Co-location does not ensure collaboration. Collaboration has to do with the interactions of clinicians, not their physical location. For example, there can be co-located practices that are not as effective as practices with collaborative arrangements of shared protocols and workflows where some providers are not physically located in the clinic. Shared workflows and protocols could take place among closely collaborating clinics and clinical partners, not only those co-located in the same physical space. Although not a requirement, co-location (shared physical space) is good to have because:

• It helps clinicians and staff establish relationships with one another.
• It promotes communication, spontaneous interdependent function, and consultation.
• It allows patients to observe the interaction and behavior of the team in action.
• It reduces barriers to patient access and follow-through that result from traveling from one place to another. From the patient perspective, value in shared space comes from not having to go to a different place for part of their care, even if the clinicians are linked by workflows and communication.
• Telehealth visits may also lower barriers associated with multiple locations, especially after clinicians and patients have developed initial face-to-face relationships.

11 Shared practice culture refers to identity, purpose, and roles as a clinician in the context of interdependency; customs (as expressed in workflows) for communication, interruptions, and confidentiality; a shared picture of what it means to be patient-centered, how you relate to each other's power and influence; and how you engage in clinical systems. Behavioral health in primary care takes on much of the overt style and practice culture of primary care.^g Demonstrable commitment to building a shared practice culture (when accompanied by specific plans and timeframes) is an acceptable interim state on the way to actually having a shared practice culture.

12 About shared working environment of physical and/or virtual "space". With widespread use of secure telehealth, e-visits, and virtual team communications, the concept of "spatial arrangement", "shared space" or "co-location" has shifted. New technology (and its acceptance) has meant that team functions that required physical presence in the past no longer do so. The concept has shifted from "shared space" meaning physical space, to a shared working environment that includes well-integrated virtual spaces, including the possibility of a behavioral health or other professional 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 and now includes electronic as well as physical presence to maintain key team functions. Read more about this in part 2, differences between practices.

13 Formal or on-the-job training for the clinical roles and relationships of integrated care is required for successful integrated behavioral health. It is based on the common practical observation that clinicians are often not trained for such collaboration in practice. Specific training is needed at this point in history, but as this collaborative practice spreads, more clinicians will be exposed to it.

14 Francesc B-C, Anthony LS, Ronald ME. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. The Annals of Family Medicine. 2004;2(6):576. https://www.doi.org/10.1370/afm.245. Accessed September 11, 2023.

15 Total health outcomes include both "medical" and "behavioral health outcomes. "Outcomes are defined as the impact of a healthcare service or intervention, and can include events or results in:

• Patient health status or quality of life.
• Patient, provider, and population attitudes and behavior.
• New evidence, research, prevention strategies, treatments, and care models.

For example, patient-reported outcomes (PROs) are one type of outcome that offer a complementary perspective to that of clinician assessments and may provide greater insights into health status, function, symptom burden, adherence, health behaviors, and quality of life".^h

16 Whole person health and biopsychosocial care. As defined by the National Institutes for Health (NIH), “whole person health involves looking at the whole person—not just separate organs or body systems—and considering multiple factors that promote either health or disease. It means helping and empowering individuals, families, communities, and populations to improve their health in multiple interconnected biological, behavioral, social, and environmental areas. Instead of treating a specific disease, whole person health focuses on restoring health, promoting resilience, and preventing diseases across a lifespan”. ⁱ

A “biopsychosocial” model of health and care is an earlier construct that is somewhat narrower in scope than “whole person health” but is considered synonymous by most clinicians (Thomas et al, 2018) and often used interchangeably.

17 Hayley T, Geoffrey M, Justin R, Megan B. Definition of whole person care in general practice in the English language literature: a systematic review. BMJ Open. 2018;8(12):e023758. https://www.doi.org/10.1136/bmjopen-2018-023758. Accessed September 11, 2023.

18 Definitions of common terms such as mental health, behavioral health, substance use, primary care, and different kinds of integrated care (some version of the “family tree of terms”) to appear in an appendix. 

19 Identifiable subsets of a clinic panel for whom integrated behavioral health is made available, e.g., age group, disease or condition, gender, culture or ethnicity, or other identified subset of the population. This means that a team may focus its integrated behavioral health work on a particular subset of the entire practice panel rather than all patients who come to the clinic.

20 Primary care engagement with communities and public health: The Practical Playbook II: Building Multisector Partnerships That Work. Michener JL, Castrucci BC, Bradley DW, Hunter EL, Thomas CW, Patterson C, et al., editors: Oxford University Press; 2019 01 Jun 2019. https://doi.org/10.1093/med/9780190936013.001.0001. Accessed August 23, 2023.

21 Community engaged healthcare model. Barker SL, Maguire N, Gearing RE, Cheung M, Price D, Narendorf SC, et al. Community-engaged healthcare model for currently under-served individuals involved in the healthcare system. SSM - Population Health. 2021;15:100905. https://doi.org/10.1016/j.ssmph.2021.100905. Accessed August 23, 2023.

22 Community-engaged primary care. Michener J. Community Engagement: A Core Component of Primary Care. Durham, NC: National Academy of Medicine; 2022. https://www.nationalacademies.org/documents/embed/link/LF2255DA3DD1C41C0A42D3BEF0989ACAECE3053A6A9B/file/DECC57A626D99D59E65FD2761D14C434244CC1AFCB93?noSaveAs=1. Accessed August 23, 2023.

23 Identification as an integrated behavioral health function is primarily aimed at distinguishing those who specifically need integrated behavioral and medical care at a particular level of intensity or priority. However, understand that population-level identification takes place in the larger context of all care such as universal screening or medical screening, and not only individuals requiring integrated behavioral health.

24 Identification is for case-finding, for behavioral health integration is a broader concept than universal screening for conditions. For example, the need for treatment of mental health/substance use conditions, behavioral factors (or mental health conditions) embedded in chronic illness care, common physical symptoms or complaints not attributed to disease processes, health behavior change, social interferences with care, and how the organization of care or clinician-patient relationships may complicate or interfere with care.

25 Identification of individuals whose care plans require blended behavioral health and medical expertise. A table containing common examples can be found in the original 2013 Lexicon (PDF - 2.1 MB).

26 Engaging patients also includes exploring what patients can do to participate in their own care, such as being a prepared communicator, tracking their own progress, and other patient engagement behaviors.^e,f Engaging patients also means clarifying the reasons for inclusion of the behavioral health clinician on the team and the use of a shared record—exploring its benefits and risks as seen by both patient and provider.

27 Shared decision-making has emerged as a systematic discipline with its own literature, roles, goals, tools, and protocols.^j,k,l Definitions and requirements have become clearly articulated.^m

28 Promotora: a community member who receives training to provide basic health education in the community without being a professional health care worker. Promotores de salud, also known as promotoras, is the Spanish term for “community health workers”.ⁿ

29 Dialogue with patient on information sharing and confidentiality. Clinicians should prepare for the possibility that a patient may not initially want a shared record. Primary care involves sharing of information, but the clinician has a responsibility to initiate dialogue with the patient that explains why a shared record is important and to listen to patient concerns and negotiate a resolution. This could be applicable to privacy issues for HIV, STDs, reproductive health, mental health and other conditions and life situations.

The general principle is that the patient came to the primary care clinic to get health care, which in this practice is integrated and therefore charted for the team to view (and potentially others if the patient releases information). The patient does not have to enter a fully integrated primary care clinic; this may not be the choice for everyone. And of course, every patient has a right to refuse providers outside the practice having access to their medical information.

30 Evidence-based: Medical, psychological, and counseling treatments or techniques are to be supported by research evidence as much as possible, knowing this is a constantly unfolding story with different levels and kinds of support for different things. Clinicians should be able at any time to point at support and rationale for what they are doing.

31 Shared decision making: Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361-7. https://www.doi.org/10.1007/s11606-012-2077-6. Accessed August 23, 2023.

32 Leadership. A particular practice within a large organization may be ready to integrate behavioral health care, but different clinics within that same organization may be at different points of readiness. These practices are not likely fully independent of the larger organization, which may affect how far a particular practice can go in making the changes required.

33 Office processes "consistently and reliably" support integrated care. Institutionalizing highly consistent and reliable office processes that routinely support the functions of integrated behavioral health is for most practices a developmental path, rather than something established all at once. If not yet fully consistent or reliable, what you see in place is the aspiration plus gradual improvement.

34 Operational and management support for functions may often require local clinic leaders to engage higher level organizational leaders for specifics that enable implementation. Even with everyone embracing the vision of integrated behavioral health, it is not always apparent what specific policies or processes are required to support the functions. It can be an iterative process between local implementers and higher-level organizational leaders.

35 A sustainable business model. At this time in history, dominant business models are often regarded as not sustainable of integrated behavioral health or primary care in general. The section on levels of the developmental path is a way of looking at the level of business model support for integrated behavioral health and how sustainability might be defined along with examples of payment or non-payment revenue that might be in the mix.

36 Learning Health System. Agency for Healthcare Research and Quality (AHRQ). About Learning Health Systems. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); 2019. https://www.ahrq.gov/learning-health-systems/about.html. Accessed August 23, 2023.

37 Practice-based data. Quality improvement, program evaluation, or other data is collected ideally in a form amenable to publication, but the essential function is the practice learns and changes in response to data it routinely collects.

38 Collection of uniform demographic data such as race/ethnicity and language as outlined in the Affordable Care Act Section 4302. The law requires that data collection standards for these measures be used, to the extent practicable, in all national population health surveys, but they could also be adapted by practices for their own local demographic profiles.

39 For minority or underserved populations it may be necessary to look at information such as improved engagement with the practice, rates of follow-through, or actual availability of services in the population.^o

40 Alignment of reported outcomes and patient goals. To have the best value for patients, outcomes reported can be services they want to receive.

41 Quadruple aim. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-6. https://www.doi.org/10.1370/afm.1713. Accessed August 23, 2023.