Define Your Vision

Identify staff members to serve on the planning and implementation team. Ensure that the team represents all staff roles to better understand how operational changes will affect everyone involved.

Identify a “champion” to lead the team. The champion will be critical to the success of the implementation efforts. You may find that a champion emerges from existing staff.

It is important for the planning and implementation team to reflect on the desire to achieve changes in the behavioral health aspect of your medical practice. Consider the following questions:

• What is driving you to work on integrating behavioral health now? What problems are you trying to solve? Do you want to address:
  • Poor access to behavioral health care for your patients?
  • Poor outcomes for common behavioral health or chronic medical conditions?
  • A need for assistance with complex psychiatric medication management?
  • Unmet social service needs among your patients?
• What resources are available to integrate behavioral health now and in the foreseeable future? Consider personnel, funding, and the capacity of frontline staff to transition to integration.
• Who is feeling distress with the behavioral health aspect of your practice right now? Consider patients, providers, and other staff.
• Who has aspirations for the behavioral health aspect of your practice in the future? What are these aspirations?

A stakeholder map may help with this task. To create a stakeholder map, list each stakeholder group and what matters to them. Then ask, how does integrated ambulatory care line up with the priorities of key stakeholder groups?

Implementing integrated care in your practice may require changes to operations, workflows, and staffing. Find out where you, your team, and other staff fall on the continuum:

Support from leadership, providers, and staff is essential to the success of an integrated ambulatory care program. Communicate how integrating behavioral health into the practice aligns with what matters to each of them.

Depending on the size of your organization, several levels of leadership may impact the success of the program.

• Senior leadership is important because they can provide direction and broadcast messages about integrated primary care. Resources are often allocated at this level.
• Midlevel operational leaders play a role in acquiring resources and problem-solving during implementation. They are especially critical in helping with issues that may emerge in larger multi-site organizations.
• Frontline clinical and operational leaders help staff adjust to changes in workflow and are involved in solving day-to-day implementation problems.

If your leaders are asking “Why integrated care?” you may need to provide them with background information on the potential impact of integration.

Potential benefits of behavioral health integration include:

• Better access to behavioral health care for ambulatory care patients.
• Better communication and coordination between medical and behavioral health providers.
• Assistance for ambulatory care providers and staff with the behavioral and emotional aspects of care, especially for high-risk, complex patients.
• Better outcomes for patients with common behavioral health conditions and possibly for those with physical health conditions such as chronic illness.

The impact of behavioral health integration on the cost of care is not yet clear. A recent report that Milliman prepared for the American Psychiatric Association (PDF - 0.65 MB) suggests substantial potential cost savings based on conservative financial models.

While thinking about your vision, it is important to understand that there are different integrated care approaches. Approaches for integrating behavioral health in primary or ambulatory care share a common goal, but may use different operating models. Ultimately, how you integrate behavioral health depends on your organization’s behavioral health needs and available resources. The local familiarity or acceptability of different approaches may also influence your decision. What works for one organization may not work for another. Many organizations use a blended approach, integrating aspects of various models to meet their unique needs.

A range of behavioral health issues may be present in your medical setting. Therefore, the scope of desired behavioral health services depends on the types of behavioral health issues you want to address. Do you want to focus on behavior change counseling for improved health (e.g., diet, stress, and physical activity)? Stress-related symptoms? Substance use problems? Comorbid depression and anxiety? Severe mental illness? Behavioral and emotional aspects of chronic illness?

Here are six examples of common approaches for integrating behavioral health into primary care:

1. Collaborative Care
   Collaborative Care (CC) focuses on tracking identified patient populations in a registry and implementing measurement-based treatment. The care team includes a primary care physician, a mid-level care manager on site, and a consulting psychiatrist. In a review of 79 randomized controlled trials comparing CC with routine care or alternative treatments for depression and anxiety, the CC model achieved improved outcomes compared to routine care. Read more about Collaborative Care at the University of Washington.

2. Combined Federally Qualified Health Center-Community Mental Health Center
   This approach involves a generalist behavioral health provider who provides rapid access to behavioral interventions. This provider may address a wide range of behavioral health problems. Although this approach is widely used, there is less systematic evidence of its effectiveness compared to CC. Read how Cherokee Health Systems incorporates a behavioral health consultant in primary care.

3. Federally Qualified Health Center and Community Mental Health Center Partnerships
   This approach is characterized by close collaboration between behavioral health and primary care, with whole-person care provided in both settings. Patients may move between settings over time depending on acuity and based on a four-quadrant model. Missouri has fostered these partnerships along with Medicaid health homes and has seen significant quality improvement and cost reduction. Read more about Medicaid Health Home implementation in Missouri (PDF - 2.12 MB).

4. Comprehensive Primary Care
   Comprehensive primary care is a team-based approach that includes behavioral health in primary care settings. The SHAPE (Sustaining Healthcare Across Integrated Primary Care Efforts) project in Colorado is testing a global payment method in six primary care practices. Read more about the SHAPE program.

5. Integrated Comprehensive Health Systems
   These systems assume responsibility for all patient care and feature a whole-person approach with inpatient, outpatient, and specialty care. Examples include Intermountain Healthcare in Salt Lake City, UT, and Group Health in Washington. Read about Intermountain Healthcare.

6. Massachusetts Child Psychiatry Access Project
   The goal of the Massachusetts Child Psychiatry Access Project is to improve access to child psychiatry services when fully integrated care is not available. Key components include universal behavioral health screening, telephone child psychiatry consultations within a defined period of time, access to face-to-face child psychiatry appointments if needed, and support for primary care providers and families, such as accessing community resources.

If you have not done so already, define your vision for integrated care in your setting. Creating a formal vision statement can help. This vision statement should clearly communicate your purpose and goals. You may need a short sentence or several sentences to capture your goals for integrated care. The following questions can help guide the development of your vision:

1. What is your desired future state? What things are different in your desired future state compared to now?
2. Who will be affected by the vision?
   • Outline the expected benefit for the identified patients and how care will be different for them.
   • Outline the expected benefit for the providers/staff and how operations will be different.
3. What outcomes do you expect? How can you measure these outcomes (e.g., clinical outcomes, patient experience, cost, and utilization)?
   • Are there any measures in place that can evaluate the things you expect to change and the overall success of your behavioral health vision?
4. How will you measure the reach of behavioral health services and processes (e.g., referrals, productivity, appointment no-shows)?

Here are some examples of vision statements:

Our ambulatory care practice has the capacity to:

• Address and resolve comorbid behavioral health and medical symptoms with better patient experiences and lower cost than before, including patients with complicated, high-cost conditions.
• Proactively identify patients who need well-integrated behavioral health and medical care using targeted screening, health system data, or other methods.
• Deliver targeted behavioral health services for selected, at-risk populations that have been identified.
• Support medical team recognition, assessment, and treatment of uncomplicated behavioral health issues with a behavioral health provider available for consultation to achieve “treat-to-target” goals.
• Manage or control total ambulatory care costs through well-integrated services and population health management methods.
• Expand and diversify behavioral health services and community connections to eventually meet prevalence-based behavioral health needs in the community.