Obtain Behavioral Health Expertise and Build a Culture of Integration

Earlier, the Playbook guided you in identifying the patient population in your practice or system that needs integrated care. A variety of behavioral health professionals can provide the required care virtually, in-person, or both.

The first step in obtaining behavioral health expertise is to determine the behavioral health functions that would be most useful for your patient population, considering the nuances of delivering care through different modalities. 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 substance use, 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 practice or systems. Different types of behavioral health providers bring different skills and knowledge to the practice team and who are proficient in delivering care through your chosen modalities (virtual, hybrid, or in-person). Behavioral health providers can be psychiatrists, psychiatric nurse practitioners, psychologists, licensed clinical social workers (LCSWs), marriage and family therapists, or licensed counselors.

There are established integrated behavioral health approaches that provide potential frameworks and evidence-based practices for implementing these functions, such as the Primary Care Behavioral Health (PCBH) model and the Collaborative Care Model (CoCM). Read more about integrated behavioral health functions and approaches in Define Your Vision.

You may also need to map out potential external referral pathways. This includes identifying local or virtual specialists (e.g., psychiatrists for complex medication management, therapists specializing in specific disorders, substance use treatment centers) and developing clear procedures for referring patients if their needs exceed the capacity of your practice's integrated behavioral health team. These referral pathways should consider factors such as patient insurance, access to care, and the level of specialization required.

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, including identifying when referrals are necessary.
• 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. There may also be potential costs associated with external referrals.
• 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. Consider the behavioral health provider's comfort and experience with properly using virtual communication and collaboration tools (if operating remotely) and following established referral protocols.

Behavioral health providers may take on a variety of roles in the care of different populations. To properly tailor the care team to each patient's needs, the care team must clarify the role of the behavioral health provider based on the population identified for integrated services. As a member of the care team, the behavioral health provider may play roles such as these:

• Assess patients diagnosed with behavioral health conditions who have severe initial symptoms.
• Assess patients diagnosed with behavioral health conditions who are not responding to treatment after a reasonable period of time.
• Provide behavioral interventions to patients with a variety of conditions.
• Work with patients who are having trouble with health behavior change.
• Provide behavioral health expertise as part of a team caring for a group of high-risk, complex patients (e.g., patients with chronic medical illnesses, stress-linked symptoms, personal or family crises), sometimes without directly seeing patients.
• Build cooperative relationships with specialty mental health services and substance use disorder counseling and treatment and seek opportunities to improve information exchange and coordinated care.
• Link patients to specialty mental health services and substance use disorder counseling and treatment when patients' needs exceed the care available in the integrated care setting.

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 virtual or in-person "warm hand-offs,"" the arrangement might not be productive.
• If a behavioral health provider is part of a program or entity subject to Confidentiality of Substance Use Disorder (SUD) Patient Records regulations at 42 CFR part 2, they are able to share information with patient consent that adheres to the updated requirements in the rule.

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 workspace.
• 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 with the following empirically-identified core competencies might work well in a primary care setting:¹

1. Interpersonal Communication: The ability to effectively build rapport and share information with patients, families, and other providers.
2. Collaboration & Teamwork: The ability to function as an effective member of an interprofessional team.
3. Screening & Assessment: The ability to conduct brief, evidence-based screenings and arranging further assessments when necessary.
4. Care Planning & Care Coordination: The ability to create and implement integrated care plans and ensuring seamless service access and information exchange.
5. Intervention: The ability to provide a range of brief and longer-term prevention, treatment, and recovery services.
6. Cultural Competence & Adaptation: The ability to deliver services that are culturally relevant and responsive to the needs of consumers and their families.
7. Systems Oriented Practice: The ability to effectively navigate the organizational and financial structures of the healthcare system.
8. Practice-Based Learning & Quality Improvement: The ability to continuously assess and improve individual and team services.
9. Informatics: The ability to utilize information technology to support and enhance integrated healthcare delivery.

Additionally, the following skills have been identified for behavioral health providers and psychiatric consultants:²

• Behavioral Health Providers
  • Applying brief interventions using brief evidence-based treatment strategies: cognitive behavioral therapy, motivational interviewing, solution-focused therapy, and behavioral activation
  • Addressing the full spectrum of behavioral health needs, including common mental health conditions (e.g., depression and anxiety) and lifestyle behaviors (e.g., self-care, social engagement, relaxation, sleep hygiene, diet, and exercises)
  • Developing specialization areas, if needed, including substance use counseling and biofeedback
  • Reinforcing the care plan with primary care providers and summarizing goals and next steps with patients
  • Leading group sessions for patients (e.g., pain groups or diabetes management groups)
• Psychiatric Consultants
  • Being willing to treat and consult on some patients without seeing them
  • Creating shared care plans in a short amount of time and with limited information
  • Focusing on complex patients who cannot be managed alone by the primary care provider and behavioral health provider

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 (or telehealth) 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 work together 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 relationships.

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 a collaborative culture.

To address these concerns, provide trainings for both types of staff to reinforce the goals of integrated 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-person or via virtual office hours) with the team, 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 behavioral health 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.

To optimize the use of integrated behavioral health providers, workflows need to specify the situations in which behavioral health expertise might be brought into the care team and describe each member's role. When establishing member roles, aim to have everyone working to the fullest extent of their training and licensure. Document workflows and make them available to staff for orientation and for reminders.

The "warm hand-off" is a key interaction that can be included in integrated workflows, particularly for onsite behavioral health providers. High-functioning integrated practices commonly allow one provider to interrupt another when needed to refer or communicate about a patient. Warm hand-offs allow for an introduction of the behavioral health provider and may contribute to patients following through with future appointments.

Building upon the integration of behavioral health providers, a comprehensive assessment of the existing care team's roles in managing, treating, and monitoring identified patients is crucial. This evaluation should proactively consider emerging care team roles that can further enhance capacity, alleviate workforce pressures, and mitigate provider burnout. Consider incorporating these commonly added roles:³

• Care Managers: Care managers can play a vital role in coordinating care, providing patient education, managing medication adherence, and offering clinical support under the supervision of a physician or advanced practice provider. A common role in collaborative care, they are typically nurses or psychologists. Their skills in assessment, care planning, and patient advocacy can significantly enhance the efficiency and effectiveness of the care team.^4-7
• Community Health Workers: Community health workers, often from the communities they serve, can build trust and rapport with patients, provide culturally sensitive support, assist with navigating health-related social needs, and facilitate access to resources. Their unique understanding of community needs can bridge gaps in care and improve patient engagement.^8,9
• Peer Support Specialist (PSSs): Peer Support Specialists are individuals with lived experience of mental health or substance use conditions. They can offer invaluable support, hope, and understanding to patients. They can also assist with engagement, provide recovery-oriented support, and help reduce stigma.^8,10
• Pharmacists: Pharmacists can provide expert consultation on psychotropic medications, manage complex polypharmacy, educate patients and providers on medication management, and improve medication adherence, freeing up other prescribers' time.^11-13