Obtain Behavioral Health Expertise and Build a Culture of Integration

Earlier, the Playbook guided you in identifying the patient population in your setting that needs integrated care. A variety of behavioral health professionals can provide the required care.

The first step in obtaining behavioral health expertise is to determine the behavioral health functions that would be most useful for your setting’s population. The primary diagnoses or clinical needs of your patient population will help inform your decision. For example, consider the proportion of patients with complex medication needs, comorbid mental health or other behavioral health conditions that interfere with self-management behaviors, and unexplained physical health symptoms. Common behavioral health functions include:

• Assessment (e.g., mental health, substance abuse);
• Brief behavioral intervention;
• Psychotherapy;
• Medication management;
• Consultation to team members; and
• Introduction of second-, third-, and fourth-line interventions for complex, treatment-resistant patients.

Next, look for behavioral health providers capable of the functions you think will be most valuable for your setting. Different types of behavioral health providers bring different skills and knowledge to the practice team. Behavioral health providers can be psychiatrists, psychiatric nurse practitioners, psychologists, licensed clinical social workers (LCSWs), marriage and family therapists, or licensed counselors.

The following factors may influence your decision about the type of behavioral provider to bring into the care team:

• Patient demographics: What age range does your practice serve? What are the preferred languages of your patients? Be sure the person you bring in has experience with your population.
• Financial considerations: Some behavioral health providers may be more expensive to hire than others. Some provider types may be in short supply in your area, and certain behavioral health services may not be billable to some of your payers.
• Fit with your setting: At this stage, refer back to your vision and game plan to ensure that your staffing plan matches your target population and overall vision.

Will you hire a behavioral health provider or collaborate with a consultant? Do you need the services of a behavioral health generalist or a specialist? The answers depend on the patient population you serve, the vision for your practice, and the available resources. Here are some things to consider:

• If a contractor has concerns about exchanging information or problems with collecting a copayment for billing for short patient contacts after “warm hand-offs,” the arrangement might not be productive.
• If you cannot obtain onsite behavioral health services, consider using telehealth.
• If a behavioral health provider is defined as a substance abuse specialist, the rules about sharing information with colleagues (42CFR) can be a problem. This is not an issue, however, if the provider is a “behavioral health generalist.”

Historically, behavioral health providers have worked in different settings than medical professionals. Integrated behavioral health work differs from specialty behavioral health work in several ways:

• Physical aspects of the work space.
• Length and number of sessions with patients.
• Communication with other members of the care team.

Because of these differences, not every behavioral health provider will be a good fit to work in a medical setting. During the selection process, try to evaluate how well the behavioral health provider can adjust to the integrated work style and how well he or she seems to fit with your staff and medical providers. Successful integrated behavioral health providers often display a “cross-cultural competence”—competence in the medical culture and the cultures of their patients. 

Characteristics of Behavioral Health Providers Who Might Work Well in a Medical Setting

Behavioral health professionals who might work well in a medical setting (in no particular order):

1. Want to take a team approach to patient care.
2. Are interested in helping a patient “function” better.
3. May be dissatisfied with specialty mental health practice.
4. Can work fairly autonomously, yet know when to coordinate care and seek help.
5. Think it’s better to spend 10 minutes with a patient than none.
6. Are comfortable with the medical workplace (e.g., noise, rooms with sinks).
7. Have received training in brief behavioral interventions.
8. Are willing to help patients of any age.

The best candidates tend to be behavioral health professionals who (in no particular order):

1. Have worked in school-based settings and understand their role in different organizational structures.
2. Have had a private practice using cognitive behavioral therapy methods, but are now looking for a collaborative team-based setting.
3. Have previously worked in integrated medical settings.
4. Demonstrate appropriate confidence in their skills.
5. Actively use and believe in acceptance and commitment therapy (ACT).
6. Have a good sense of humor.
7. Have been a supervisor or manager in the past and are ready for a different kind of challenge OR are early career professionals who are really excited about making this their career and are willing to commit to learning and growing with the program.
8. Have an ability to get along with many people, including other providers, and deal creatively with the challenge of connecting with providers.
9. Are not shy and can adequately market themselves.

Above all, focus on the candidate’s flexibility and fit with the practice.

After choosing the behavioral health professional, you must prepare the practice to integrate the new team member. This includes credentialing with health plans, maximizing physical workspace arrangements, scheduling to improve behavioral health access, standardizing documentation processes, and addressing privacy and confidentiality issues. These steps are discussed in detail in Establish Operational Systems to Support Integration.

Having behavioral health functions readily available to meet patient’s needs requires a culture of collaboration, where it is normal to collaborate and to be available to do so. To guide the development of this culture, think about integration startup activities, the challenges of cultural change, and how to build relationship

Your startup activities should include an orientation for all practice staff so they understand the purpose of integration and are prepared for any changes in their work as a result of the new program. A rigorous orientation, conducted in-house or through online resources, can greatly enhance team members’ skills and support for providing integrated care. It is vital to familiarize medical providers and staff with the proactive role of the integrated behavioral health provider in targeted patient intervention.

The integrated behavioral health provider also will need an orientation to their new role in the medical setting. The transition from specialty mental health practice to primary care behavioral health is substantial. Encourage bidirectional feedback and communication between the behavioral health providers and the care team.

Addressing your practice’s changing culture will ensure that everyone understands and buys into an integrated approach and works collaboratively through the transition to meet the needs of your patients. Understand that you may face many challenges during this cultural shift.

Historically, behavioral health providers have worked in different settings than medical professionals. The culture of primary care tends to be fast paced, while the mental health culture tends to be more reflective and focused on the long term. Behavioral health practices tend to have longer patient visits and less time pressure than traditional medical practices. In addition, misunderstanding and stigma associated with behavioral health care might influence how primary care staff react to integration. These differences may make the addition of a behavioral health provider a challenge to collaborative culture.

To address these concerns, provide trainings for both types of staff to reinforce the goals of integrated ambulatory care.

Relationship-building is an important aspect of bringing a behavioral health provider into the care team. The behavioral health provider can be an ambassador for the service by getting to know practice staff and spending time with them when not busy with patient care. Encourage the behavioral health provider to spend time in the clinical area, so medical providers and staff can easily engage in “warm hand-offs” or simply ask questions. Encouraging the behavioral health provider to be open to questions can highlight how he or she can be helpful in the integrated ambulatory care setting.

Additional strategies to foster positive working relationships include the following:

• Encouraging a collaborative environment. Behavioral health providers may need support in prioritizing patients. Providers should work together to ensure that patients who are most in need of behavioral health care receive it. 
• Hosting “brown bag” sessions around the skills/services that the behavioral health provider can offer the team. These might take the form of informal discussions of patient problems to highlight how the behavioral health provider can be helpful or more formal presentations on topics identified by providers and staff.
• Reinforcing the goals of behavioral health integration. It is important to make sure that all staff members understand the goals of integration and how it works. Regular communication and ongoing training during implementation are essential.