Establish Protocols to Identify Patients Who Could Benefit From Integrated Care

There is evidence that integrating behavioral health services into primary care might benefit people with:

• Common mental health conditions such as depression and anxiety.^1,2
• Common chronic medical conditions such as diabetes and heart disease, with or without co-morbid mental health conditions.³

Patients with other conditions also might benefit from integration of behavioral health services, but the evidence is not as strong. These conditions include:⁴

• Chronic pain;
• Substance use problems; and
• Stress-related symptoms.

Taken together, patients with these conditions make up a large proportion of the patient population of any primary care practice and many specialty practices. The choice of which conditions to focus on initially will depend on factors unique to your setting, such as the available behavioral health expertise and the characteristics of your population.

Screening is one of the most common methods for identifying patients who might benefit from integrated behavioral health services. The table below outlines the U.S. Preventive Services Task Force (USPSTF) recommendations for mental health and substance use screening in primary care settings. You can use these recommendations to help determine which screenings to implement in your practice. Pay close attention to the "Rating" column. A "Grade A" indicates a high certainty that the net benefit of the service (in this case screening) is substantial, and a "Grade B" indicates moderate certainty. A "Grade I" signifies insufficient evidence to recommend for or against screening, meaning the balance of benefits and harms is not yet clear. USPSTF Grades A and B mandate insurance coverage under the Affordable Care Act.

Once you've identified the health condition(s) you will administer screening(s) for, you'll need reliable and validated tools to conduct those screenings. A few commonly used screening tools are listed below. See Measures for a more comprehensive collection of publicly available screening tools.

• Patient Health Questionnaire-9 (PDF - 168.81 KB)
• Generalized Anxiety Disorder Scale (GAD-7) (PDF - 69.15 KB)
• Drug Abuse Screening Test (DAST) (PDF - 85.90 KB)

Registries are another common way to identify patients. A disease registry is a database, often integrated within an electronic health record, with information about patients who have a specific diagnosis. Registries can be designed to flag patients who meet specific criteria for mental health or substance use concerns, even if they haven't been formally diagnosed or have not yet expressed a need. This can be based on positive screening results, specific diagnoses from past visits, or even claims data indicating potential needs. Once patients are actively engaged in integrated care, your practice or health system can systematically track patient symptoms (e.g., using repeated PHQ-9 or GAD-7 scores), treatment adherence, and overall progress. This longitudinal view helps care teams quickly identify if a patient is not improving as expected, allowing for timely adjustments to the care plan. Learn more about selecting and using registries to identify patients for integrated behavioral health services. Additional ways to identify patients include reviewing problem lists or schedules, health record data, patterns of utilization or claims data, provider notes, and patient requests if captured in health records or patient portals.

When identifying patients with anxiety and major depressive disorder, the USPSTF recommends that primary care providers:^5-8

• Have adequate systems and clinical staff in place to ensure accurate diagnosis, treatment with evidence-based care, and appropriate follow-up.
• Provide these functions through a wide range of clinician types and settings, including primary care, referral to specialty setting, or collaborative care (a form of integrated behavioral health) in both settings.

When identifying patients with unhealthy drug and alcohol use, the USPSTF recommends that primary care providers:^9,11

• Can offer or refer to services for accurate diagnosis, effective treatment, and appropriate care.

The USPSTF also recommends providing behavioral counseling for all sexually active adolescents who are at increased risk for sexually transmitted infections (Grade B)¹² and providing education or brief counseling to prevent the initiation of tobacco use among adolescents (Grade B).¹³

To reliably build integration into the workflow for your target population, the general approach is similar regardless of how you define that population. Your answers to the following key questions will help inform your approach:

• Who is your identified target population?
• Who on the staff will reach out to them and when?
• How will the involvement of a behavioral health provider be proposed?

The introduction of integrated behavioral health services to the patient needs to be done thoughtfully, given the stigma that continues to be associated with behavioral health care. Emphasize the behavioral health provider's skills and abilities in addressing the patient's problem, rather than the provider's specific discipline. For example, describing the behavioral health provider as a "team member who is an expert on managing stress" or a "team member who is good at helping people with their diabetes" may be more successful than saying that the patient should see a counselor.

Staff members who understand the goals of integration can play an important role in connecting patients with integrated behavioral health services. For example, practice staff may learn things about patients that might suggest a benefit from integrated care (e.g., life circumstances, stress, or even symptoms or problems that the patient may not want to raise with his or her medical provider).

A systematic review and expert panel have identified food insecurity, housing instability, and transportation barriers as the most critical health-related social needs that need to be addressed in primary care.¹⁴ Screening is one method for identifying patients who might benefit from connections to community resources and social support services to address these health-related social needs.

The table below outlines the U.S. Preventive Services Task Force (USPSTF) recommendations for screening for health-related social needs. You can use these recommendations to help determine which screenings to implement in your practice. Pay close attention to the "Rating" column. A "Grade A" indicates a high certainty that the net benefit of the service (in this case screening) is substantial, and a "Grade B" indicates moderate certainty. A "Grade I" signifies insufficient evidence to recommend for or against screening, meaning the balance of benefits and harms is not yet clear. USPSTF Grades A and B mandate insurance coverage under the Affordable Care Act.

Use the following steps to brainstorm how to effectively link patients to these vital supports:

• Identify health-related social needs: Determine prevalent health-related social needs affecting your patients (e.g., food insecurity, housing insecurity) using screening tools (e.g., the PRAPARE tool) and available data (e.g., a community health needs assessment).
• Map your community resources: Identify community-based organizations and agencies offering relevant services, and create a resource directory including organization details, services, criteria, and referral processes.
• Develop referral pathways: Define how to identify patients needing support (e.g., screening tools) and establish referral processes electronic, in-person, etc.), including information sharing (with consent).
• Build relationships: Establish clinic relationships with CBOs through activities like cross-training, and collaborate to address barriers, seek funding, and share data (within regulations) to improve care.
• Explore expanding the care team: Explore the option of adding care managers or patient navigators to facilitate connections to community resources and provide ongoing support for patients with complex needs.
• Integrate referral system into electronic health record (EHR): Collaborate with your information technology staff to integrate the referral system into the electronic health record (EHR). This will streamline the process of documenting referrals, tracking patient progress, and ensuring seamless communication between care team members and community organizations.
• Integrate services, if possible: Embed social support into clinic workflows, define care team communication, and provide staff training while addressing burnout.

Now that you have selected your target population and brainstormed a general approach for reaching those patients, it is time to develop standard workflows and protocols for reliably identifying and engaging your target population. Use the following steps to guide your workflow development:

1. Reflect on your goal and your current performance toward that goal. For example, assess your current depression screening rate and set a goal for improving that rate
2. Assess your current workflow for behavioral health screening (e.g., depression screening).
3. Use a multidisciplinary team of staff and providers to map out the current workflow and brainstorm ways to improve it.
4. Use small tests of change in cycles to try promising new approaches. For example, the Plan-Do-Study-Act (PDSA) process can help guide improvement by systematically testing changes.
5. As you learn from each successive small test of change, try your workflow on a larger scale with the goal of finding an approach that can work across your organization.