Establish Operational Systems to Support Integration

Operational systems include workflows and protocols to identify patients' needs and subsequently manage, treat, and monitor them in a way that is clear to providers and reduces errors and oversights. Every practice setting has workflows to manage its patient panel. Workflows related to integration should specify how to:

1. Identify patients who might benefit from integration.
2. Engage patients in integrated care.
3. Communicate about shared patients.
4. Monitor patients, including adjustments to treatment.

These workflows should indicate not just what needs to be done, but also who is responsible for doing what and how the team will work together. A range of care team functions and expertise will need to be mobilized to address the needs of particular patients. Keep in mind that one narrowly defined workflow will not be ideal for all patients all the time. Build workflows that have core features but can be tailored for particular patients and populations. For example, use similar communication and documentation processes but involve different team configurations or different clinical interventions. Flexible implementation is essential.

To get started:

1. Define the target population: Refer back to your Game Plan to ensure a precise understanding of the patient population you aim to initially serve through integrated care and how that population may change or expand over time.
2. Define the roles of providers and staff: See Obtain Behavioral Health Expertise and Build a Culture of Integration to identify the roles of current providers and staff who will manage, treat, and monitor the identified patients. Keep in mind the following foundational functions for integrated behavioral health in the context of primary care:¹
   • Identification of patients 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)

Successful implementation of integrated behavioral health necessitates interconnected operational systems. At the core is an electronic health record system capable of providing patient-reported outcomes data from digital screening and assessment tools, facilitating shared care plans, enabling secure HIPAA-compliant interprofessional communication for team coordination and virtual consultations, incorporating behavioral health-specific templates, and supporting data exchange.² Efficient patient flow will rely on a scheduling and appointment management system that allows for coordinated scheduling, diverse appointment types, referral tracking, and waitlist management. Furthermore, a billing and financial management system will need to accommodate integrated billing codes, potential split billing scenarios, and the tracking of reimbursement for integrated behavioral health care services. Beyond these foundational systems, effective integrated behavioral health can benefit from streamlined referral processes supported by an electronic referral management system with tracking capabilities and an internal provider directory. These interconnected operational systems collectively form the technological backbone needed for efficient and effective integrated behavioral health service delivery.

To get started:

1. See Leverage Technology for Integrated Behavioral Health for more information.

See Track Patients and Monitor Their Outcomes and Collect and Use Data for Quality Improvement for more information.

To bolster patient engagement and education in integrated behavioral health, existing systems, especially the EHR and patient portals, can be optimized to provide readily accessible and understandable information.⁴ This includes secure access to integrated health summaries, clear explanations of care plans, and a comprehensive library of tailored educational materials on both physical and behavioral health. Enhancing patient portals with features that allow for secure communication with providers regarding educational content and incorporating platforms dedicated to delivering digital resources like videos and interactive modules can further empower patients with knowledge. Streamlining the integration of patient education resources within the provider's EHR workflow is also critical, enabling seamless sharing of relevant information to improve patient understanding and adherence to treatment recommendations.

To get started:

1. See Educate Patients and Families About Integrated Care for more information.

Designate workspace that maximizes ease of contact between behavioral health and medical providers and staff and that supports both exchange of information and convenient dialogue with patients. Locating the behavioral health provider physically in the clinical area seems to be an important factor in the success of an integrated program.⁵ This facilitates informal conversations about patients and helps bring the behavioral health provider into the care team for patients who could benefit from behavioral health services.

When not seeing patients, the behavioral health provider can be available to medical staff. This is particularly helpful when they recognize a patient needing behavioral health services and want to make a "warm hand-off." Configure the behavioral health provider's schedule so it includes unscheduled time for communication and warm hand-offs. Aim to find the right balance of access, productivity, and flexibility that the integrated program can sustain.

For remotely based behavioral health providers, establish reliable virtual communication channels and implement scheduled virtual huddles to facilitate timely information exchange and proactive patient discussions with the medical team. Streamlined protocols for virtual warm hand-offs, integrated EHR access with communication tools, and a flexible behavioral health provider schedule that accommodates urgent consultations are also essential. Additionally, consider dedicated virtual "office hours" for medical staff and provide comprehensive technology support and training to ensure effective virtual collaboration.

To get started:

1. See Obtain Behavioral Health Expertise and Build a Culture of Integration for more information.

When adopting a new operational system, it is important to start small. Have one or two providers try the new system with a few patients, expand it to more providers and more patients as "bugs" are worked out and confidence is gained. Pay attention to what works and what doesn't as you expand the operational system. Give providers and staff an opportunity to provide suggestions on how to enhance the new system. This will allow you to identify workflows that maximize patient and provider outcomes before proceeding to wider implementation.

Make sure to train all staff in the new integration processes and associated billing procedures. Recognize that adjustments will be needed during the transition to a new integrated environment.

Measurement is an important part of implementation. As new workflows are implemented, you should measure key process steps and components to ensure that you are doing what you intended. The workflow you are redesigning will determine the process measures you will use.

Workflows are generally connected to desired patient outcomes. In most situations, these include clinical, functional, satisfaction, quality of life, and economic outcomes. Workflows that are not leading to desired outcomes in these targeted areas should be modified. Try to measure something about the intended impact—some desired outcome of your system—to see if what you are doing is having the impact you expected. The metrics incorporated into the operational system can be used to determine if the transition has succeeded and to identify areas for improvement.

Establishing operational systems to support integrating behavioral health into your primary care setting can feel complex. Fortunately, you don't have to navigate the process alone. Practice facilitation offers a valuable form of external support that can significantly enhance your implementation efforts, lead to significant improvements in care delivery and provider confidence, and build your practice's capacity for ongoing quality improvement.⁶

Practice facilitation can provide immense benefits to primary care practices — even those affiliated with larger health systems — particularly in overcoming barriers to implementing evidence-based practices and developing quality improvement capacity in primary care settings.⁷ See AHRQ's Practice Facilitation Resources, based on AHRQ's widely-used Primary Care Practice Facilitation Curriculum.

What is Practice Facilitation

At its core, practice facilitation involves a trained individual, the practice facilitator, working directly with your practice in a longitudinal and trusting relationship. Their primary goal is to build your practice's ability to implement evidence-based practices, in this case, the integration of behavioral health and primary care. While the specific qualifications and effectiveness of facilitators in integrated care settings require further study, their potential to support health systems is significant.⁸

How Can Practice Facilitation Support Your Integrated Behavioral Health Efforts?

Practice facilitators can provide a range of crucial supports, including:

• Guidance and Coaching: Facilitators bring expertise in quality improvement methodologies and can guide your team through the steps of planning, implementing, and sustaining your integrated behavioral health program. They act as coaches, helping you identify challenges and develop effective solutions tailored to your practice's unique context.
• Workflow Redesign: Integrating behavioral health often requires adjustments to existing workflows. Facilitators can help you analyze your current processes and identify opportunities to seamlessly incorporate behavioral health screenings, warm hand-offs, communication protocols, and collaborative care models.
• Team-Based Care Development: Successfully integrating behavioral health relies on effective teamwork. Facilitators can assist in defining clear roles and responsibilities for medical and behavioral health providers, fostering strong communication and collaboration within your care team.
• Data Utilization for Improvement: Understanding your data is crucial for monitoring the impact of your integrated program and identifying areas for improvement. Facilitators can help you identify relevant metrics, establish data collection processes, and use data to drive continuous quality enhancement.
• Resource Navigation: Practice facilitators are often knowledgeable about available resources, tools, and best-practice guidelines related to integrated behavioral health. They can connect you with valuable information and support to streamline your implementation.
• Change Management Support: Implementing new practices can be challenging. Facilitators are skilled in change management strategies and can help your team navigate the transition, address resistance, and build buy-in for integrated behavioral health.

Considering Practice Facilitation for Your Practice:

As you begin to establish your operational systems for integrated behavioral health, consider the potential benefits of engaging with a practice facilitator.

1. Do you have dedicated staff with expertise in quality improvement and behavioral health integration? If not, a facilitator can bridge this gap.
2. Are you confident in your ability to design and implement new workflows that effectively integrate behavioral health? A facilitator's experience can provide valuable insights.
3. Are you familiar with coding, billing and payment models that sustain behavioral health integration? A facilitator can help educate your staff on the appropriate billing codes and provide guidance on navigating payment models and integrating integrated behavioral health billing into existing workflows.
4. Do you have a clear plan for collecting and using data to monitor the success of your integrated program? Facilitators can guide this process.
5. Would external support and coaching help your team navigate the changes involved in integrating behavioral health? A facilitator can provide valuable guidance and encouragement.

Exploring practice facilitation resources early in your planning can lay a strong foundation for a successful and sustainable integrated behavioral health program, ultimately leading to improved care for your patients and a more integrated and effective practice. Look for local, regional, or national organizations that offer practice facilitation services, keeping in mind that programs tailored to your specific context, potentially at the state level, may be particularly effective.