Q&A: Framework helps primary care practices integrate behavioral health

ByErin Michael

A new framework provides primary care physicians with a concrete set of processes and structures for integrating behavioral health into practice, according to research published in Translational Behavioral Medicine.

Researchers developed the IBH Cross-Model Framework using a mixed-methods approach that qualitatively and quantitatively evaluates and defines components of integrated behavioral health care based on several existing and well-documented models.

Quote from Stephens on integrated behavioral health

The final framework includes a set of five principles, 25 clinical processes and nine structures that are needed to support behavioral health in primary care clinics.

Healio Primary Care spoke with Kari A. Stephens, PhD, an associate professor and director of Clinical Research Informatics in the department of family medicine at the University of Washington, to learn more about the importance of the framework, what it entails and more.

Q: Why was this framework needed?

A: Many practices are struggling to understand the definition of what integrated behavioral health is, what it looks like and what it should look like on the ground. Many competing models have different nuances to them that I think can be confusing to practices as they try to figure out which model is best for them. What we strove to do is define integrated behavioral health in primary care across the various models, based on the best science, and create a universal definition of integrated behavioral health.

There have been studies, including one that the Agency for Health Research and Quality (AHRQ) funded by Deborah Cohen, PhD, at AHRQ, that looked at several highly performing integrated behavioral health sites. Every site has its own version of integration and none fell squarely within the published models of integrated behavioral health. Therefore, it’s important to provide a definition that gives a good sense of what those different processes and structures are in integrated behavioral health, while at the same time, not be prescriptive because practices need freedom and flexibility to figure out how to implement these processes and structures in a way that makes the most sense to them.

Q: What are the major components of this framework?

A: This framework was based on a model of quality care that Avedis Donabedian, MD, MPH, published back in 1988 that really talks about the fact that processes and structures work together to create good outcomes. This model very specifically targeted putting together a definition of what processes of integrated behavioral health look like across models, and what structures then are needed to support those processes. Processes and structures are the two major components of the model. Within the processes, we identified five different principles. Those principles are well-echoed across most other published models that are specific to integrated behavioral health. In general, those principles are, first, making sure that we have really good patient-centered care. The second principle is treatment to target, meaning defining clear goals and using measurement to track care, so treatment can be adjusted to make sure that the target is being met. The third principle is using evidence-based behavioral treatments within integrated behavioral health, and that can include behavioral/mental and medical care. The fourth principle is providing really efficient team care across the entire primary care team, ensuring efficient and comprehensive integrated behavioral health care. The last principle is targeting population-based care, ensuring we reach the most patients, while targeting the patients most in need.

Those five principles are further defined by 25 different processes that illustrate, on the ground, what integrated behavioral health looks like in practice. Nine core structures were also defined as necessary to support these processes. They include basic structures, such as having a behavioral health provider at the practice, financial strategies for paying those providers and staff, and electronic tools for monitoring who to triage and track.

Q: How feasible will it be for PCPs to adopt the IBH Cross-Model Framework?

A: We worked with a group called Minnesota’s MN Health Collaborative, which adopted this model and named it in their Advancing the Integration of Behavioral Health in Primary Care Call to Action. We were approached by that group to have our framework evaluated for its relevance to the work they were doing. Not only did we get some lovely feedback, but they actually went so far as to name it as their community standard, which blew us away in a really nice way. That told us that our framework not only resonated well, but was quite feasible to adopt.

Practices and the health care systems are the ones who choose and support integrated behavioral health. When we talk about trying to significantly invest in integrated behavioral health, or improve or evolve it so it is sustainable in a practice setting, it requires leadership buy-in within the health system. That involves, absolutely, the PCPs who are a part of that leadership, but also the administrative leaders within the practices who are looking out for the whole health of the organization. Health care systems have to look at whether or not they have these structures in place and if they don’t, how are they going to put them in place. Within Minnesota, for example, part of their process was to adopt this framework as their community standard, and then do an environmental scan to understand where they were diminished in relationship to this framework. They then prioritized what they were going to put in place. Some health care systems decided that they needed to create behavioral health provider leadership positions, such as a director of behavioral health integration, to expand their behavioral health provider workforce. Some prioritized changing triage and communication practices across their teams. The framework was used to guide their choices in how to move towards establishing more robust processes and structures, but each health care organization chose their own set of targets for change.

Q: Why is it important for PCPs to integrate behavioral health into their practice?

A: Our partner in this paper in Minnesota — the Institute for Clinical Systems Improvement — surveyed several of their PCPs, and they identified two different areas of importance to integrated behavioral health in their practices: improving patient care and their own quality of life at work. In terms of improving patient care, it helps them provide more expert care for their patients; it helps them meet quality goals that they might have in their practice, like quality metrics that are part of value-based care contracting; it helps them support better access to quality care; and it also improves the physical health of their patients through behavior changes that also reduce mental health-related symptoms.

In terms of providers’ own quality of life at work, it helps reduce their personal anxiety about treating mental health concerns, because they have support right there on site; it increases their own mental space, to know that they have access to that care for patients who are in need and can more easily follow through with those services; and then it helps PCPs stay on schedule with their day.

When we think about a PCP’s busy day, if they have somebody who needs extra time, other patients can be affected if their PCP is running far behind and is not able to see everybody with that same amount of attention. Integrated behavioral health can help keep PCPs efficient in being able to reach their whole population. [PCPs] can either hand off these patients to behavioral health providers or triage them down the road and not feel like they have to meet all of those needs in that exact moment in the clinic.

Q: What additional research is needed to validate the benefits of integrating behavioral health services in primary care?

A: Research in integrated behavioral health is needed in several areas. I think the question that practices have on the ground is, “If we have X amount of resources to put towards integrated behavioral health, where should we put it?” We don’t know how to answer that question very well yet. We need to understand how contextual factors at the clinic and provider levels affect patient outcomes. We need to understand what subsets of processes and structures are sufficient to support delivery of evidence that will lead to improved patient outcomes within those contextual settings. We need understand what kinds of supports are needed within and outside of practices to help with practice change (e.g., toolkits, practice facilitators). And we need to improve the definition and capture of patient outcomes that we track to evaluate whether integrated behavioral health is effective. Overall, we expect to hit the quadruple aim — improve patient outcomes, patient satisfaction, and provider satisfaction, all while reducing overall healthcare costs.