Table 2.

Barriers and Facilitators to Integration for Clinical, Operational, and Financial Components of BHHs

Component	Sub-Code	Challenges	Facilitators
Clinical	Staff Background	Staff did not have education or experience in both physical and behavioral health Staff were frequently recent graduates that were ill-prepared to work with complex SMI/SUD populations	Have flexibility with provider credentials Staff must be motivated and ready to work with SMI/SUD populations Request for educational programs to include physical and behavioral health components Staff to “bridge both sides” Staff motivated to work with SMI/SUD populations
	Staff Training	Staff did not understand integration or view it as part of their job Shortage of time for training	Training through the context of care, (i.e., “osmosis”) Staff retreats for team building Touring each other’s’ spaces (i.e., “Open houses”) Cross-training and shadowing
Operational	Access and Scheduling	Difficult to get a functional panel size Not enough patients needed/wanted integrated services Fast-paced primary care scheduling did not fit the needs of SMI/SUD populations	Flexible scheduling (e.g., walk-ins, late appointments) Back-to-back primary care and behavioral health appointment scheduling Staff assigned to identify patient barriers to care
	Staff Recruitment and Roles	Lack of behavioral health and primary care clinicians locally and nationally High burnout and turnover Understaffed agencies were difficult to operate Staff were not prepared to work with SMI/SUD populations Unclear role definitions Staff did not execute roles for unknown reasons	Personal growth activities to encourage staff to stay Cross-training for primary care and behavioral health clinicians to increase empathy Requested unfilled roles: IT/data management, nurse care managers, peer support, community health workers, psychiatrist, and integration “champions”
	Communication	Different communication styles between primary care and behavioral health clinicians Shared meetings were expensive with the highest paid staff Primary care and behavioral health electronic health records were not integrated Electronic health record workarounds required staff time Concerns about access to records and privacy of sensitive information (e.g., SUD)	Shared primary care and behavioral health clinician meetings to discuss integration projects and shared cases Primary care and behavioral health clinician huddles to discuss yesterday’s problems and today’s patients Co-location made impromptu communication easier Staff training to ensure that staff understood how and what to communicate Second layer or protection for sensitive information Integrated electronic health records or identified staff member with access to all records
	Metrics	Technology limitations on the ability to record, track, and manage data No integrated electronic health records; pulling data from multiple sources was cumbersome	Data was utilized to improve care Metrics meaningful for SMI/SUD populations User-friendly technology More resources and staff time for data management More data from payers
Financial		Behavioral health home reimbursement rates were equivalent to primary care service rates despite extra services and staff time needed for SMI/SUD individuals Inequity between primary care and behavioral health clinician funding affected the ability to retain staff Concerns about sustainability affected staff motivation to work on integrated care	Financial support increased motivation for integration work A global payment system that accounts for smaller, high-need panels Incentivized metrics meaningful to SMI/SUD populations More data from payers, including emergency department and hospitalization utilization