Part 2: How integrated practices might differ from one another

A range of care team functions and expertise can be mobilized to address the needs of particular patients and target populations

Foundational—The basic functions for integrated behavioral health in context of primary care:

• Triage—identification of those with needs for integrated behavioral health
• Behavioral activation and self-management
• Psychological support and crisis intervention
• Accessible mental health and substance use interventions tailored to primary care
• Accessible behavioral health pharmaceutical interventions
• Common chronic and complex illness care where behavioral health factors play a role
• Accessible, easy-to-understand community resource connections
• Follow-up, outcome monitoring for timely adjustment of care and coordination
• Cultural competency (understanding the concerns of minority communities)

Foundational plus—other functions tailored to the clinic population:

• Triage—identification and tracking, employing EHR reports and registries, and coordination of care
• Complex or specialized behavioral health therapies needed for the population
• Complex or more specialized pharmacologic interventions for the population

Extended functions—specialized expertise for clinic population:

• Specialized disease experts
• Specialized population experts
• Specialized care managers, coordinators, or community health workers
• Experts from school, vocational, spiritual, corrections, other areas of intersection with care

Types of arrangements for creating a shared working environment among clinicians¹

This is about both physical and virtual working environments or shared "spaces"²

Mostly separate working environments

• Behavioral health and medical clinicians spend little time with each other practicing in shared physical or virtual (telehealth) "space".
• For face-to-face or virtual visits, the patient sees clinicians in separate buildings or separate telehealth arrangements.

Partially shared working environment

• Behavioral health and medical clinicians sometimes work in shared physical or virtual spaces, spending some but not all their time in a shared working environment.
• Patient may often need to move between separate primary care to behavioral health office or telehealth "spaces".

Fully shared working environment

• Behavioral health and medical clinicians share the same physical or virtual clinical space, spending much of their time seeing patients in such a shared working environment.
• Patient is able to see (simultaneously or sequentially) both kinds of clinicians in the same room or via telehealth modality when useful.

Type of clinical collaboration employed

Referral-triggered periodic exchange

• Information exchanged periodically with minimally shared care plans or workflows.

Regular communication and coordination

• Regular communication and coordination, usually via separate systems, tools, and workflows, but with care plans coordinated to a significant extent.

Full collaboration and integration

• Fully shared treatment plans and documentation, regular communication, shared clinical workflows and medical record, with automated tools that ensure effective communication and coordination.

Methods for identifying individuals who especially need integrated behavioral health³ for biopsychosocial assessment and care

Patient or clinician

• Patient or clinician identification done in a non-systematic fashion.

Health system indicators (other than screening)

• Demographic, registry, claims, utilization referral, health disparities, or other system data that point at risk for complex needs or special needs likely to require behavioral health perspective.

Universal identification or screening processes

• All or most patients or members of clinic panel are screened or otherwise identified for being part of a target population.

Target populations or settings selected

Practices may establish different target populations or settings for integrated behavioral health at different times depending on:

Life stage

• Prenatal, children, adolescents, adults, elderly, end of life.

Types of clinical symptoms or situations

• Mental health conditions, medical and chronic conditions, stress-linked physical symptoms, substance use, prevention and wellness.
• Acute life stress, complex or high risk/cost cases, health disparities linked to race, ethnicity, culture, language, social context, or lack of trust or connection with health system.

Locus of care

• Primary medical clinic, medical specialty clinic, specialty mental health or substance use clinic, hospital or rehabilitation, schools or vocational settings, availability and level of engagement with community resources.

Degree that integrated care is narrowly targeted to specific populations or situations⁴

Targeted

• Designed for specific populations based on disease or diagnosis, prevention, risk level, stage of life, social or care complexity, racial or other identified minority group, or other specific situation.

Non-targeted

• Designed generically for any patient deemed to need integrated care for any reason.

Extent protocols are in place for engaging patients identified as needing integrated care

Protocols not in place (undefined or informal)

• Up to individual clinician and patient whether and how to initiate or engage with integrated behavioral healthcare. No protocol for how to respond when patients are identified as needing integrated care, or how to establish goals, an appropriate team and roles, and a main contact person. This is an unacceptable approach; practices need to establish specific protocols.

Protocols in place

• Standard ways to respond to patients identified via demographic, registry, claims, utilization referral, health disparities, social context, or other system data as likely to require behavioral health care.

Extent that shared care plans are created and implemented for patients identified as needing integrated behavioral health

• Proportion of patients in priority populations with shared care plans in place
  • Less than 50% of cases: Insufficient consistency and reach; an unacceptable state requiring significant improvement.
  • More than 50% but less than 100%: An interim state that calls for improvement.
  • Nearly 100% of the time: Full reach indicative of fully developed and standardized processes, which is the desired state.
• Degree that shared care plans are followed
  • Less than 50% of the time: Insufficient consistency and reach; an unacceptable state requiring significant improvement.
  • More than 50% but less than 100%: An interim state that calls for improvement.
  • Nearly 100% of the time: Full reach indicative of fully developed and standardized processes, which is the desired state.

Level of systematic follow up on shared care plans for patients in target groups—ongoing effectiveness and patient acceptance—reach and consistency

• Less than 50% of the time: Insufficient consistency and reach; an unacceptable state requiring significant improvement.
• More than 50% but less than 100%: An interim state that calls for improvement.
• Nearly 100% of the time: Full reach indicative of fully developed and standardized processes, which is the desired state.

Level of patient expectation for integrated behavioral health— an understanding they can seek care for a wide range of issues, including behavioral and psychological

Little or no understanding or expectation

• Insufficient reach of understanding and expectation to enable integrated behavioral health programming to start, function, be recognized, and accepted in this practice. This is an insufficient state, and the practice needs to build such an expectation.

Expected only in pockets

• Partial but substantially incomplete patient understanding and expectation for integrated behavioral health. The practice should provide clarification and conduct personalized communication to raise awareness of the benefits of integrated care.

Widely expected as routine

• Almost universal patient understanding and expectation for integrated behavioral health as a standard of care; there is recognition, and demand for integrated care from patients, and they engage with these services.

Level of collaborative engagement with served communities—to understand the specific needs and priorities within the greater social context or to address social determinants and disparities^5,6

Little or no collaborative engagement

• Insufficient ongoing collaboration between the practice and communities to tailor integrated behavioral health to the specific needs, priorities, and situations of patients in the context of communities and their resources. Little to no relationships in the community to inform care.

Collaborative engagement in pockets

• Partial but substantially incomplete collaboration between the practice and communities to tailor integrated behavioral health to the specific needs, priorities, and situations of patients in the context of communities and their resources. Relationships in the community are new or few and therefore limited in their ability to inform care.

Wide and consistent collaborative engagement

• Ongoing and substantial collaboration between practice and communities to help tailor integrated behavioral health to the specific needs, priorities, and situations of patients in the context of communities and their resources. Relationships in the community are numerous and well-established.

Level of leadership or administrative alignment and prioritization

Misaligned 

• Integrated behavioral health care may be one among several initiatives, but conflicts with other organizational priorities, resource allocations, incentives, and habits. Such tensions may or may not be articulated openly. An unacceptable state; the practice needs to pursue alignment of business operations with a clear purpose.

Partially aligned

• Some alignment achieved, but with constructive ongoing work needed to identify and resolve tensions between priorities, incentives, habits, and standards. An interim state requiring on-going improvement. 

Fully aligned

• Constructive balance achieved between priorities, incentives, and standards. Integrated behavioral health functions are prioritized and fully designed into processes and incentives. Emerging conflicts are routinely addressed and respected as part of continuous improvement. The mature and desired state to be proactively sustained.

Level of practice operations reliability and consistency

Non-systematic

• Referral, communication, and other processes are non-standard and vary with each clinician and clinical situation. This is an unacceptable state; systematic process design and improvement are needed.

Substantially consistent, standard, and understood

• Standard flows established for most processes, but without consistency and influenced by clinician preferences. These processes are not yet standardized enough to be reliable. This is an interim state; further process improvement is needed.

Standard work

• The whole team operates as a system in a standardized and expected way that achieves reliability and prevents errors.

Level of business model support for integrated behavioral health

Behavioral health integration not supported

• The business model does not yet support integrated behavioral health functions of this practice. If these functions are maintained, it is by diverting resources not designated for these purposes or through unsustainable sources of funding such as grants or philanthropic gifts. This is a common initial state the practice should work to improve.

Partially supported

• Some, but not all, functions of integrated behavioral health are routinely supported by the business model, while others, if in place, depend on unsustainable sources of funding. This is an interim state on the path to full support.

Behavioral health integration fully supported

• The business model has found ways to fully support the integrated behavioral health functions selected and built for this practice. No diversion of funds marked for other purposes nor unsustainable sources of funding are required. This is the aspirational or desired state where integrated care is financially sustained. 

Scale of practice data collected and used to improve the integrated behavioral health aspect of the practice—for both tracking and shaping patient care and quality improvement

Minimum—less than 40% of patients

• A system for collecting and using practice data for a limited number of patients or situations to improve quality and effectiveness (of integrated behavioral health), especially at the individual patient level. This is an initial state the practice should work to improve.

Partial—40%-75% of patients

• Significant, but less than full collection and use of practice-based data for decision-making to improve quality and effectiveness and reporting at the system or unit level. This is an interim state on the path to full data use. 

Full—76% -100% of patients

• Routine data collection on integrated behavioral health with most patients—with internal reporting of "triple aim" outcomes and their use in decision-making to improve effectiveness at the system, unit, or community/population level. This is the aspirational or desired state where practice data is used to its fullest extent.

Breadth and level of outcomes expected based on program scale or maturity⁷

Pilot scale

• Limited expectations for a limited set of outcomes for a limited group of patients: A pilot is a demonstration of feasibility or test of effectiveness with a limited number of patients or clinical scope. This is a common initial state the practice should work to improve.

Project scale

• Significant, but not full-scale outcomes expected at this scale. Multiple promising pilot programs with high visibility are combined to address a larger, but still not full-scale population. This is an interim state on the path to a full scale program.

Full-scale

• A full-scale program with broad-based outcomes expected. It is an enduring way of operating that includes the entire population of patients. Integrated care is no longer offered as a standalone project but as part of mainstream practice operations. This is the aspirational or desired state where the greatest improvement in outcomes is expected.