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 "champions" to lead the team. Successful implementation requires strong champions at both the clinical and leadership levels.^1-4

• Clinical Champion: Identify a respected provider who is passionate about integrated care and can drive the clinical vision, engage colleagues, and advocate for the model within the care team.
• Leadership Champion: Secure a champion from practice or health system leadership who has the authority to allocate financial resources, remove barriers, and ensure organizational buy-in and support for the integration efforts. Strong leadership approval and ongoing support, particularly from financial leadership, are crucial for sustainability.

These champions, working collaboratively, will be critical to the success of the implementation efforts. You may find that these roles emerge from existing staff or require specific appointments.

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?
  • A need to provide better support for patients with substance use disorders and promote their recovery?
  • 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?

Clear, effective communication with all the stakeholders involved may help with this task. Think about how to effectively message the needed changes, following the key elements outlined in this guide for discussing complex care. One useful way to do this is to create a stakeholder map, listing each stakeholder group and what matters to them. Then ask, how does integrated behavioral health care line up with the priorities of key stakeholder groups?

Implementing integrated care in your practice may require changes to operations, workflows, and staffing. To find out where you, your team, and other staff fall on the continuum, download and complete the Integration Playbook Self-Assessment Checklist (PDF - 405.6 KB).

Support from leadership, providers, and staff is essential to the success of an integrated care program. Depending on the size of your organization, several levels of leadership may impact the success of the program.

• Senior leadership, including chief executive officers, medical directors, behavioral health directors, and other similar executive roles, is important because they can provide direction and broadcast messages about integrated behavioral health care. Resources are often allocated at this level.
• Midlevel operational leaders, including practice managers, nurse managers, behavioral health program coordinators, billing managers, and other similar administrative roles, 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, providers, or staff are asking "Why integrated care?" you will need to garner their buy-in and support by clearly communicating how integrated behavioral health aligns with what matters most to them. Engaging them effectively at this stage will help you with converting them into active champions for integration:

Clinical Benefits:

• Improved Access to and Utilization of Behavioral Healthcare: Integrated behavioral health can increase access to and use of behavioral health services in both primary care and specialty mental healthcare settings.^5-7
• Improved Quality of Care: Integrated behavioral health can enhance coordination of care, patient monitoring, and treatment tailoring and increase adherence to evidence-based practices.^8-10
• Improved Patient Outcomes: Integrated behavioral health can lead to enhanced access to services, better management of co-occurring conditions, increased treatment adherence, and reduced symptoms.^6,8,11-17

Financial Benefits:

• Reduced Healthcare Utilization and Costs: Integrated behavioral health can decrease unnecessary hospitalizations and emergency department visits, lower overall healthcare expenditures for patients with chronic conditions and behavioral health needs, and improve efficiency in primary care settings.^9,18-20
• Alignment with Value-Based Care: Integrated behavioral health aligns with the shift towards value-based care (and vice versa) by addressing the co-occurrence of mental and physical health issues and necessitating payment and billing approaches that combine medical and behavioral health benefits into a single payment pool.^21-25
• Return on Investment: A 2018 report that Milliman prepared for the American Psychiatric Association(PDF - 0.65 MB) suggests substantial potential cost savings (based on conservative financial models) of $38-68B annually in healthcare expenditures across commercial, Medicare, and Medicaid payers. In a systematic review of 30 studies on the Collaborative Care Model (CoCM), an evidence-based behavioral health integration approach, many studies concluded a cost-effective or cost-neutral impact.²⁶ Several individual practices and health systems have estimated or reported dollar amounts, including:
  1. A large, private primary care health system: A study examining 25 Kaiser Permanente Washington primary care sites in this large integrated health system found that the cost of implementing evidence-based behavioral health integration strategies, including population-based screening and assessment, amounted to approximately $5 per primary care visit with screening, or $38 per visit where depression, suicidal thoughts, and/or substance use disorders were identified. The study concluded that these implementation costs, when spread across patients screened, were comparable to commonly used diagnostic assessments in primary care.²⁷
  2. A large, public primary care health system: A budget impact analysis on the CoCM for opioid use disorder (OUD) in a 100,000-member Medicaid system estimated the cost per patient treated with a panel size of 85 at $2,547. With this panel size, the program would approximately breakeven, with about a 14% chance of spending more than $200 per patient and a 14% chance of gaining more than $200 per patient. If the panel size was expanded to 120, the cost per patient declined to $2,145, suggesting a likely positive financial balance (cost savings). The analysis concluded that the costs of a CoCM program are likely to be offset by savings if 25% of OUD patients receive treatment with a panel size of about 85, while achieving better patient outcomes.²⁸
  3. A large primary care clinic: A study evaluating the implementation of an integrated behavioral health care program with embedded behavioral health providers in a large primary care residency-based Family Medicine outpatient clinic in the Southeast found that, over a one-year period, the average total cost per patient was $5,113 before and $5,462 after exposure to embedded behavioral health providers. The analysis indicated a relatively cost-neutral impact.²⁹

Operational Benefits:

• Increased Patient Satisfaction: Integrated behavioral health fosters greater patient engagement and empowerment, improves communication and collaboration between patient and providers.^8,11-13
• Increased Provider Satisfaction: Integrated behavioral health increases provider satisfaction due to better support and resources for the behavioral and emotional aspects of care, especially for high-risk, complex patients.^30,31

Systems Benefits:

• Alignment with Whole-Person Care: Integrated behavioral health integrates services for mental health, substance use, and health-related social needs within primary care settings, fosters collaboration among interdisciplinary teams, and emphasizes patient-centered care by tailoring care plans and involving patients in decision-making. These changes are integral to addressing the interconnectedness of mental, physical, and social health needs.^32,33

As defined in the Integrating Behavioral Health and Primary Care Lexicon, integrated behavioral health involves "a practice team of primary care and behavioral health providers working together with patients and families, using a systematic and cost-effective approach, to provide patient-centered care for a defined population. This care may address mental health and substance use conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization."³⁴

While thinking about your vision, it is important to understand that there are different integrated care approaches. While various integrated care approaches exist, they all facilitate the six defining functions necessary for effective integrated behavioral health. Think of these functions (described below) as the essential ingredients, and there are different recipes (approaches and models) that you can implement that utilize these ingredients in varying amounts and ways.

Clinical Functions — How Integrated Behavioral Health is Done:

• Teamwork: Care teams draw on a range of behavioral health and primary care expertise and role functions to meet the needs of the practice population. Team members have clearly identified roles, and patients, family, or caregivers are invited to be a part of the team. Coordinated or shared operations, workflows, and practice culture support medical providers and staff providing patient-centered behavioral health care. There is also formal or on-the-job training to function in this way.
• Biopsychosocial Assessment and Care: Instead of separately evaluated, understood, and treated physical and mental health conditions, care teams create shared care plans that integrate physical and behavioral health. These shared care plans are informed by comprehensive biopsychosocial assessments that identify the specific physical health conditions, mental health concerns, substance use issues, and health-related social needs that the plan needs to address. Team members take responsibility for whole-person care and act with knowledge of specific social and environmental challenges that affect health in the communities they serve.
• A Systematic Clinical Approach: Care teams use an explicit and systematic clinical approach to identify members of the clinic population who need or may benefit from integrated behavioral and medical care and at what level of severity or priority. Team members engage in shared decision-making with patients to create a unified care plan in a shared electronic health record that contains assessments and plans for biological/physical, psychological, cultural, social, and organization of care aspects of the patient's health and health care

Organizational Support Functions — How Integrated Behavioral Health is Supported:

• Connections with Served Populations or Communities: The organization actively engages with and understands the needs of its community and patient population, and the community and patients understand the benefits of integrated behavioral health.
• Alignment of Leadership, Operations, and Business Model: There is a shared vision for integrated behavioral health across the organization, and operational systems, management practices, and financial models consistently and reliably support the functions of integrated behavioral health.
• Continuous Collection of Data that Enables Learning from Experience: The organization routinely collects, examines, and reports practice-based quality improvement or program evaluation data and uses that data to improve clinical, patient experience, and provider experience outcomes.

Tools like The Building Blocks of Behavioral Health Integration (PDF - 4.9 MB) from the University of Colorado can help you identify relevant integrated behavioral health functions and implementation strategies.

Integrating behavioral health into your practice involves implementing the defining functions of integrated behavioral health to provide whole-person, patient-centered care. These functions are not tied to a single model or approach but represent essential elements that can be adopted and adapted based on your organization's needs and resources. While various models offer structured frameworks for integration, the focus should be on understanding and implementing the clinical functions in a way that best suits 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 blended models and approaches, integrating various aspects to meet their unique needs. Rather than viewing these models and approaches as distinct and separate entities, they are exploring how the essential components of each can be integrated into more holistic integrated behavioral health frameworks.³⁵

As you consider the approaches and models below, keep in mind that a range of behavioral health issues may be present in your medical setting. The scope of your integrated behavioral health services will depend on the types of behavioral health issues you encounter and are able 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? The scope of your integrated behavioral health services will also depend on practical considerations. Are you able to hire behavioral health providers? Do you have available practice space for the additional appointments? Understanding the needs and resources within your medical setting will help you evaluate and select the most suitable approaches for implementing the clinical functions of integrated behavioral health.

Tools like the National Council's Integration Practice Assessment Tool (IPAT) - (PDF - 288 KB) can help you evaluate your practice's readiness and identify relevant functions and implementation strategies.

1. Primary Care Behavioral Health (PCBH)

The PCBH model integrates behavioral health consultants directly into the primary care team, offering patients rapid access to brief, focused interventions for a wide array of behavioral health and health-related concerns.^36-38

• Teamwork: Patient-centered care teams are comprised of a primary care provider (PCP), a behavioral health consultant (BHC), and a psychologist or psychiatrist for consultation, if needed. The PCP is often a physician, PA, or nurse practitioner. The BHC (also referred to as a generalist behavioral health provider) is often a psychologist, psychotherapist, LCSW, or licensed professional counselor (LPC) and can be co-located or remote.
• Biopsychosocial Assessment and Care: The BHC is readily available within the primary care clinic for same-day consultation or brief appointments via a warm hand-off by the referring PCP. BHCs conduct brief, focused assessments to understand the presenting concern and its context.
• A Systematic Clinical Approach: The BHC offers support and brief behavioral health interventions for clinic patients, often using focused (15-30 minute) exam room visits to assist with specific symptoms or functional improvement. Care plans are developed collaboratively with the PCP and patient. The BHC and PCP may meet formally after each patient's first visit to discuss the shared care plan. Both the BHC and PCP follow up with each patient until functioning or symptoms begin improving, with the BHC offering longer appointments with the patient after the initial warm hand-off, when necessary. Once the patient improves, the PCP may resume sole oversight of care but can re-engage the BHC at any time, as needed. Patients not improving are referred to the psychologist or psychiatrist for consultation or to a higher level of care. If that is not possible, the BHC may continue to assist until improvements are noted.

Evidence from randomized controlled trials and systematic reviews indicates that PCBH improves coping strategies, adherence to recovery planning, and medication use in adults with depression,¹³ depression symptoms and mental health functioning in veterans,³⁹ and healthcare utilization across various populations, although its impact on overall health status compared to other active treatments is not significantly different.⁵ Emerging evidence suggests PCBH results in improvements in functioning, depression, and anxiety in adults;⁵ weight, BMI, and tobacco use in adults;⁴⁰ and chronic pain in veterans.⁴¹ PCBH may also reduce visits in pediatric emergency departments and pediatric primary care practices.^42,43

Read more about Primary Care Behavioral Health at the American Psychological Association.

2. Collaborative Care Model (CoCM)

CoCM integrates behavioral health treatment within primary care using a team-based approach and emphasizes measurement-based care, algorithmic treatment adjustments, systematic follow-up using patient registries, and stepped care based on patient progress.^44,45

• Teamwork: The care team includes a PCP, a behavioral health care manager (BHCM), and a psychiatric consultant. The BHCM, often a social worker or psychologist trained in care coordination and brief behavioral health interventions, facilitates communication among all team members and acts as the lead contact person for the patient once introduced via a warm hand-off or referral by the PCP.
• Biopsychosocial Assessment and Care: The BHCM or PCP, often a physician, PA, or nurse practitioner, administers the screening and assessment tools and implements brief behavioral health interventions. The PCP oversees all aspects of the treatment plan including prescribing medication. The psychiatric consultant, often a psychiatrist or PA or APRN with psychiatric training, triages patients and creates a treatment plan with medication recommendations for the PCP (usually without seeing the patient).
• A Systematic Clinical Approach: The entire care team uses patient registries in conjunction with electronic health records to manage caseloads and track patient outcomes. The psychiatric consultant and BHCM also meet regularly to conduct a systematic caseload review, during which they use the patient registry to consider the entire caseload, identify select patients for individual case reviews, and adjust treatment for those patients who are not improving as expected. The psychiatric consultant may also suggest treatment modifications, in-person consultations, or specialty mental health services for clinically challenging patients.

Robust evidence from a systematic review of 79 RCTs and a meta-analysis of over 20,000 patients demonstrates that CoCM leads to significantly greater improvement in outcomes for adults with depression and anxiety compared to usual care.^11,46 Several meta-analyses and systematic reviews show that CoCM is also effective for depression, anxiety, or behavioral problems in older adults,^47-49 racial/ethnic minorities,⁵⁰ women,⁴⁷ adults without insurance,⁴⁷ and children and adoelscents.^12,51 CoCM remains effective when delivered remotely via telehealth communication.^52-54 It also shows promise in improving pain-related outcomes and addressing opioid-related behaviors,⁵⁵ and decreasing depressive symptoms in patients with multimorbidity involving depression and either cardiovascular disease, diabetes, or pain.⁵⁶

Read more about Collaborative Care at the AIMS Center at the University of Washington.

As you consider integrating behavioral health, focus on the clinical functions outlined above and how they align with your organization's behavioral health needs, available resources, and community context. The described models offer different ways to implement these functions, but you have the flexibility to pick and choose the elements that best fit your unique circumstances.^35,57-59

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?
   • Outline how this future state will align with the priorities of senior leadership, mid-level operational leaders, and frontline clinical and operational leaders.
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)?
   • Which of the defining functions of integrated behavioral health will be prioritized in your vision?
   • What is your scope of services (e.g., behavior change counseling, stress-related symptoms, substance use, severe mental illness) and anticipated approach (e.g., PCBH, CoCM, or a blended model), and how will their implementation be measured?
   • How will you measure the effectiveness of your chosen scope of services and approach?

Here are some examples of vision statements:

Our primary 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 primary 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.