Patient-Centered Care Through Nurse Practitioner–Led Integrated Behavioral Health: A Case Study

Abstract

Integrated behavioral health can improve primary care and mental health outcomes. Access to behavioral health and primary care services in Texas is in crisis because of high uninsurance rates, regulatory restrictions, and lack of workforce. To address gaps in access to care, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to create an interprofessional team-based health care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. Academic–practice partners identified 5 clinics for an integrated behavioral health care delivery model. From July 1, 2020, through December 31, 2021, a total of 3183 patient visits were completed. Patients were predominantly female (n = 1719, 54%) and Hispanic (n = 1750, 55%); 1050 (33%) were living at or below the federal poverty level; and 1400 (44%) were uninsured. The purpose of this case study was to describe the first year of implementation of the integrated health care delivery model, barriers to implementation, challenges to sustainability, and successes. We analyzed data from multiple sources, including meeting minutes and agendas, grant reports, direct observations of clinic flow, and interviews with clinic staff, and identified common qualitative themes (eg, challenges to integration, sustainability of integration, outcome successes). Results revealed implementation challenges with the electronic health record, service integration, low staffing levels during a global pandemic, and effective communication. We also examined 2 patient cases to illustrate the success of integrated behavioral health and highlighted lessons learned from the implementation process, including the need for a robust electronic health record and organizational flexibility.

In 2008, the Substance Abuse and Mental Health Services Administration began working with state mental health authorities to pilot a model for the integration of behavioral health and primary care services to improve access to care. ¹ This care delivery model has resulted in improvements in primary care and mental health outcomes.^2,3 Specifically, depression scores from the Personal Health Questionnaire 9 (PHQ-9) ⁴ declined in >50% of patients treated in an integrated behavioral health model in a demonstration project supported by the Colorado Health Foundation from 2011 to 2015. ²

In this case study, “behavioral health” refers to mental health and substance use treatment. Access to behavioral health and primary care services in Texas is in crisis.^5,6 Texas has a large, diverse, and growing population but ranks 51st in the nation in access to care.^5-7 Of 254 counties in Texas, 30 have no primary care provider, 176 have no psychiatrist, ⁸ and 95 have no licensed psychologist. ⁹ The shortage of primary care physicians in Texas is expected to increase by 67% by 2030, and the shortage of psychiatrists is expected to increase by 13%. ¹⁰ Engaging nurses and nurse practitioners in integrated behavioral health to fill these gaps is one solution to this anticipated shortfall. A model of using family nurse practitioners with psychiatric mental health nurse practitioners and registered nurses, all practicing to the full extent of their education and licensure, can deliver comprehensive, integrated, patient-centered behavioral health care.^11,12

To address these gaps in health care providers, a partnership formed among a large local mental health authority in central Texas, a federally designated rural health clinic, and the Texas A&M University School of Nursing to launch an interprofessional team-based care delivery model led by nurse practitioners in rural and medically underserved areas of central Texas. In Texas, a local mental health authority is a community mental health center for a defined geographic area that coordinates and allocates behavioral health services and develops related policies. ¹³

Purpose

The purpose of this case study was to describe the first year of implementation of an integrated health care behavioral health primary model in rural central Texas and identify barriers to implementation, challenges of sustainability, and lessons learned. We also describe the experience of 2 patients who benefited from these services. To our knowledge, this is the first description of this model.

Methods

The School of Nursing and local mental health authority identified 5 clinics for an integrated behavioral health care delivery model: 4 with the local mental health authority and 1 with a family nurse practitioner–owned certified rural health clinic (Figure). The first clinic with the local mental health authority was a school-based clinic led by a family nurse practitioner and cofunded through an independent school district. The local mental health authority provided counseling support and telebehavioral health services to address mental health conditions, including substance use, for students, families, and employees of the school district. At the beginning of the COVID-19 pandemic, this clinic was forced to close, and the school reallocated funding support. The School of Nursing and the local mental health authority prioritized the remaining 3 clinics for integration of primary care services where existing comprehensive mental health services had been well established, while a replacement school-based clinic was launched at a new location. Three clinics are located in federally designated rural areas, and the other 2 clinics are in medically underserved areas of Texas. The Texas A&M University Institutional Review Board (IRB2020-0650D) reviewed the study, determined that the research did not constitute human participant research, and waived formal review.

Figure.

Locations of integrated behavioral health clinics in Texas, 2020-2021.

The rural health clinic partner had existing primary care services but no mental health services; as such, telehealth equipment (ie, computers, audio/video equipment) was added to integrate behavioral health from the local mental health authority into this location. Family nurse practitioner faculty from the School of Nursing were designated to serve as primary care providers in an interprofessional team-based approach with mental health providers, which included psychiatrists, psychiatric mental health nurse practitioners, licensed professional counselors, behavioral health consultants, licensed social workers, care coordinators, registered nurses, and others. Students in the bachelor of science in nursing program and the master of science in nursing–family nurse practitioner program were incorporated into the clinics for workforce development. Telehealth best practices were incorporated in care delivery and in the curriculum through exposure during clinical rotations.

This case study used multiple data sources, including documents, direct observations, and interviews. Program staff and participants gathered data (eg, the interprofessional health care team and administrators who were instrumental in behavioral health integration). The program manager and project director then analyzed data for themes by using grounded theory. The program received funding in July 2020; therefore, data collection occurred from July 1, 2020, through December 31, 2021, through program meeting minutes and funder report documents, including noncompete continuation reports, uniform data system reports, and annual progress reports. The program coordinator scheduled monthly joint team meetings with key personnel identified from all facilities. Programmatic goals drove team meeting agendas, implementation challenges, and rapid-cycle quality improvement opportunities. The project director and the program coordinator analyzed meeting minutes and reports for barriers to implementation, challenges to sustaining integration, and successes throughout implementation.

Data were gathered through interviews, trainings, short stand-up meetings (“huddles”), and informal conversations with program staff throughout program implementation. Notes included verbal and observed interactions with staff and patients who were receiving care from the integrated behavioral health clinics. We organized meeting minutes, huddle notes, reports, interviews, and observations into 3 main categories: (1) barriers to implementation, (2) challenges to sustaining integration, and (3) successes throughout implementation (Table 1).

Table 1.

Integrated behavioral health themes identified in a review of a behavioral health care delivery model at 5 clinics in central Texas, July 2020–December 2021

Theme	Items
Barriers to implementation	• School-based clinic closures during the emergency response to the COVID-19 pandemic • EHR designed for behavioral health did not meet the needs of documentation for primary care services • Primary care evaluation and management/Current Procedural Terminology codes not accessible in the EHR • High staff turnover from COVID-19 and resistance to change • Growing pains of rapid expansion
Challenges to sustainability	• EHR designed for behavioral health did not meet the needs of documentation for primary care services • Immunizations not available to effectively serve pediatric population • Inadequate staffing • Unfunded and underfunded patient population • Lack of high-speed internet access in rural areas
Successes	• Holistic patient-centered care that addresses social determinants of health • Improved patient outcomes (eg, blood pressure control) • Delivery of telehealth services to rural health clinic • Professional development of staff • Opening 5 integrated behavioral health clinics in a year • Establishing workgroups from various departments to collaborate on and improve process issues • Seamless collaboration with family nurse practitioners

Abbreviation: EHR, electronic health record.

Outcomes

From July 1, 2020, through December 31, 2021, a total of 3183 visits were completed in the 5 integrated behavioral health clinics; the patient population was predominantly female (n = 1718, 54%) and Hispanic (n = 1750, 55%), with 1050 (33%) living at or below the federal poverty level and 1400 (44%) uninsured (Table 2). Three common themes emerged through data analysis: (1) barriers to implementation, (2) challenges to sustaining integration, and (3) success throughout implementation.

Table 2.

Outcome of implementing integrated behavioral health clinics as determined by the number of primary care provider visits per clinic, Texas, July 2020–December 2021

Clinic	Program year 1 (July 1, 2020–June 30, 2021)	Program year 2 (July 1–December 31, 2021)	Total
Rural health clinic	872	1085	1957
LMHA clinic 1	105	303	408
LMHA clinic 2	101	512	613
LMHA clinic 3	66	117	183
LMHA clinic 4	—	22	22
Total	1144	2039	3183

Abbreviation: LMHA, local mental health authority.

Barriers to Implementation

The top 3 barriers to implementation were the electronic health record (EHR) system, the number of uninsured/unfunded clients, and staff turnover as a result of burnout from the COVID-19 pandemic.

The EHR was identified as a barrier to implementation and a challenge to sustainability. The EHR was designed for behavioral health and adapted to include primary care services, limiting its ability to be conducive to the practice of primary care. Although the PHQ-9 assessment for depression and CAGE Adapted to Include Drugs assessment for substance use disorder were administered at each visit with appropriate interventions, the EHR in the primary care module did not allow for documentation of the completed assessments. In addition, few billing and procedure codes were available and applicable for primary care. This barrier was not identified until the primary care integration began and limited the ability of primary care providers to increase their patient load and capture visit codes and billing. A family nurse practitioner took the lead on working with the EHR vendor to address these issues, improve templates for documenting visits, and include appropriate evaluation and management codes and Current Procedural Terminology codes, a process that is being continually refined. To address the challenge of sustainability, it is recommended that behavioral health providers and primary care providers be able to navigate through the EHR and document individual and shared visits appropriately. The increase in telehealth primary care because of the COVID-19 pandemic created additional challenges to patients residing in rural communities. Patients without effective broadband internet and Wi-Fi access had to commute to the clinic for every consultation visit, which was inconvenient and sometimes impossible because of limited transportation resources. As a result, some visits were converted to telephone communication. Within 1 year, 5 integrated behavioral health clinics were launched, creating rapid change in an existing local mental health authority amid volatility induced by the COVID-19 pandemic. Staff referred to the stressor of rapid change because of the new processes and adaptations necessary to integrate behavioral health and primary care.

Additionally, the lack of a sustainable funding stream was identified as a threat to sustainability. The local mental health authority received state and federal support for mental health services for priority populations who were uninsured but not for primary care services. Many patients treated by the local mental health authority and rural health clinic who were referred for services were not insured, which affected funding. Finally, the COVID-19 pandemic brought added stressors to the health care workforce. A resistance to change during the pandemic was identified and dubbed by leadership as “growing pains.”

Sustaining Integration

The second barrier to implementation was challenges to sustaining integration. The top 3 challenges to sustaining integration were the inability of the EHR to capture data on primary care quality, an insufficient number of primary care providers to serve the pediatric population, and insufficient clinic staffing. As of December 2021, only 1 integrated behavioral health clinic offered immunizations and was open for comprehensive pediatric services. Without the ability to offer vaccines and child wellness examinations, the integrated behavioral health clinics are limited to pediatric episodic visits. To meet the demands of the communities served, the clinics must expand primary care access to pediatric populations, which will also serve to increase revenue and outreach. Lastly, recruiting and retaining qualified staff should be a priority. The local mental health authority had >50% turnover of registered nurses during the COVID-19 pandemic. Nurses experienced in psychiatric mental health are sparse, and even minimal turnover creates disruptions in care. Stressors related to increased clinic demands, increased home demands, and the lure of travel nurse salaries impacted staffing. To solve this problem, targeted education and support activities to address burnout, as well as active recruiting of qualified professionals for an interprofessional integrated behavioral health team, are under way.

Successes

The final theme identified was the successes that have been achieved through implementation of an integrated behavioral health model. The top 3 items identified were the opening of 5 integrated behavioral health care clinics in a short time frame, an increased number of patients who have benefited from integrated behavioral health care, and the professional development of staff as they learn new roles and collaborative integration. Family nurse practitioners observed an increase in the number of patients who benefited from the integrated care provided, as described in the following case study examples.

Patient 1

A 48-year-old non-Hispanic White woman, accompanied by her husband, visited the integrated behavioral health clinic to establish care. The couple had recently relocated to central Texas for employment. They were living in a hotel because they could not afford to rent, and they were running out of money to pay for their hotel room. The patient had a history of arthritis, severe depression, bipolar disorder, anxiety, and panic disorder. While being seen by the primary care nurse practitioner for her arthritis, which was inhibiting her social and employment activities, her husband found out that he had been fired from his job. Both became very upset and expressed feelings of hopelessness. The patient’s PHQ-9 score was 22, indicating severe depression. The behavioral health consultant was included in the primary care visit with the social worker, and the patient’s psychosocial issues were addressed immediately. The couple were navigated to an affordable apartment. Because the couple lacked personal transportation, consideration was given to proximity to grocery stores and opportunities for employment. The nursing staff gave the husband some ideas on where to apply for a job locally. The mental health provider also saw the patient and began pharmacologic treatment and counseling, and the primary care nurse practitioner treated her arthritis. On follow-up, the patient was engaged in social activities, connected to a local church, and participating in the choir. Her appearance, countenance, and affect had improved; in fact, many staff members felt like she was “glowing.” Her PHQ-9 on follow-up was 6, indicating the depression was being managed, and she continues to receive integrated behavioral health care services.

Patient 2

A 55-year-old non-Hispanic Black man with a history of hypertension, type 2 diabetes, hyperlipidemia, and schizophrenia was an established patient with the local mental health authority and had not had consistent access to primary care. The patient receives weekly psychiatric medication injections and was connected to primary care services at one of these weekly visits when he presented with hypertension. His blood pressure was 155/94 mm Hg, and his point-of-care glucose measurement was 400 mg/dL, indicating poorly controlled hypertension and diabetes mellitus. He reported that he had not received oral medication refills in more than a year and was previously prescribed “oral blood pressure pills and insulin shots.” The integrated behavioral health clinic staff called the patient’s outpatient pharmacy and discovered that the insulin had not been refilled for 7 months. The patient is single, lives alone, and has mild cognitive impairment. In the past, his primary care medications had been administered under the supervision of his mother, but due to her own failing health, she was admitted to a skilled nursing facility and transitioned as a long-term care resident. The patient is enrolled in Texas Medicaid but did not qualify for home health care. The primary care nurse practitioner started once-weekly insulin injections timed with the patient’s psychiatric medication injections. In addition, an antihypertensive medication patch was prescribed and applied at weekly visits to improve home medication adherence. The social worker and behavioral health consultant coordinated a diabetic diet delivered to his home through the local Meals on Wheels program, and the registered nurse performed weekly glucometer tests and reinforced dietary counseling. On follow-up, the patient’s point-of-care glucose measurement was 160 mg/dL, and his blood pressure had improved to 130/70 mm Hg. He stated that he felt much better and had started helping mow lawns with friends.

Lessons Learned

The launch of an integrated behavioral health primary care delivery model is a large undertaking, and many lessons were learned. Through review of documents and observations, the following lessons will be considered as the project moves forward and other integrated behavioral health clinics are implemented. First, it will be important to identify a robust EHR that can be easily adapted to multiple settings to meet the demands of the integrated model. Doing so will allow for a proactive approach for adequate billing and payer mix to ensure sustainability. The need for adaptable and flexible staff and organizational support will be integral to endure continuing change and foster resilience. Organizational champions must be identified early on with strong rapport between mental health and primary care. The local mental health authority conducts mental health services very well, but primary care was new to the authority. The primary care nurse practitioners were adept at primary care but challenged with an EHR that was created for the mental health system. As with many other health care systems during the COVID-19 pandemic, important stressors were identified; however, the program managed a necessary pivot to telehealth in the primary care setting and to provide continuity in access to care despite the closure of other clinic resources. Moving forward, it will also be important to establish an effective communication stream with the inclusion of meetings, email communication, and telephone conversations. This communication stream will include training to help minimize staff frustration and increase effective communication. As integrated behavioral health processes are improved, staff are more likely to perceive a climate of stability and experience less burnout. Finally, all data reports will be managed monthly to collect data for analysis and continuous, rapid-cycle quality improvement throughout the remainder of the project.

This case study had 2 limitations. One limitation was the lack of quantitative data to reveal other implementation challenges and sustainability barriers. Additionally, the EHR limitations impacted the ability to track and measure aggregate patient outcomes. The need exists for a mixed-methods approach to review implementation of nurse practitioner–led integrated behavioral health as a part of future research and exploration.

Despite national support, achieving full integration of behavioral health and primary care has challenges, and little information in the literature supports best practices in implementation. Avoiding known challenges to implementation and sustainability while celebrating success will foster implementation of integrated behavioral health.