Table 1.

Description of Integration and Implementation Approach by Practice

Clinic 1 (partially implemented) is a primary care Federally Qualified Health Center (FQHC). This practice is partnering with a local nonprofit, community-based prevention, mental health, and addiction agency to colocate one licensed clinical psychologist in the practice 5 days a week. The psychologist provided brief, targeted behavioral health care to patients, with a particular focus on providing behavioral health support to patients with diabetes. Primary care physicians in the practice referred patients to the psychologist, with the front desk scheduling these appointments, and when needed, they engage the psychologist during a patient’s visit for an introduction or warm-handoff, or to seek this professional’s advice regarding the best treatment path for the patient (eg, see psychologist, see mental health provider, seek specialty treatment outside the practice). The psychologist had a private office in the practice that is located in close proximity to some of the primary care pods and farther from others, as this is a large practice. In addition, this practice also contracted with the same organization to colocate a mental health professional. This professional was an unlicensed social worker and was supervised by a licensed professional located at the mental health organization. This person provided traditional mental health services for patients with more serious and persistent mental illness, typically meeting with patients for 50-minute visits and for 12 weeks or more, as needed. This practice had written protocols in place for introducing the psychologist and mental health provider to patients and for making care transitions/referrals to these professionals. Not long after implementation of the BH e-Suite, the practice lost a critical team member who knew the tool well and was a consistent user. When this individual left, so did the institutional knowledge on tool usage. Although new behavioral health clinicians (BHCs) used the tool, use was superficial (eg, for documentation purposes only).

Clinic 2 (fully implemented) is a primary care FQHC that employs two licensed clinical social workers (LCSW) to provide brief behavioral health care to their patients. The LCSWs shared an office that is adjacent to the primary care team’s location in the practice. They did not have a private office to see patients, but generally did so in a medical examination room. Typically, the LCSWs were engaged by a primary care physician when the patient was in for a medical visit; the physician or medical assistant would go find the LCSW, who conducted a brief assessment and intervention and established a plan for following up with the visit. LCSWs would see patients, as needed, for brief visits. These visits are scheduled by the LCSW with the patient. The LCSWs played a central role in screening and brief intervention for substance use, as this had been a practice focus, and had developed protocols and a committee that reviews prescriptions for controlled substances. The practice had clear protocols for these workflows. Prior to expansion of the LCSW workforce in this practice, there was a colocated mental health professional, but this role has been phased out, and LCSWs assisted in transitioning patients to care at a local community mental health center (CMHC) for patients with more serious and persistent mental illness and substance use care need. Tool uptake was initially slow, due in part to internal billing negotiations. Once implemented, additional BHCs joined the staff and all used the tool extensively and fully.

Clinic 3 (did not implement) is a FQHC-CMHC hybrid. It is a county health department health center that includes primary care, mental health care, developmental disabilities services, environmental health, and other health-related community services. The units in this health center functioned autonomously, with the primary care practice located on the 1st floor and the mental health practice located on the 2nd floor. The CMHC served the county and took referrals from other organizations in the county, and primary care physicians in the building referred patients with mental/behavioral needs to the mental health unit in the same way other organizations in the community do. This health center does not currently employ BHCs to work closely with the primary care team. This practice had prior experience embedding BHCs with primary care, but just prior to implementation of the BH e-Suite these clinicians left the clinic and were not replaced. In addition, this health center does not have written protocols or other documentation in place to describe how medical, behavioral, and mental health care might be integrated for patients. The clinic experienced a great deal of turnover during the study.

Clinic 4 (partially implemented) is a primary care FQHC. This practice partnered with a local nonprofit, community-based prevention, mental health, and addiction agency to colocate one licensed clinical psychologist in the practice 5 days week to provide patients with brief, targeted behavioral health care, with a particular focus on providing behavioral health support to patients with diabetes. The psychologist had a private office and treated patients there, but s/he also had a workstation that is within close proximity to the primary care team. In addition to accepting referrals from the primary care physicians in the practice, physicians engaged the psychologist via warm-handoff so that s/he could provide brief services to patients in the medical examination rooms, as needed. The physicians also sought this professional’s advice regarding the best treatment path for patients (eg, in-clinic psychologist, in-clinic mental health provider, out-of-clinic specialty treatment), as needed. The practice also employed a colocated mental health provider who cares for patients with more serious and persistent mental illness who need longer visits (50-minutes) and a longer treatment course. This role was filled by a psychology practicum student from a local university where s/he received supervision for this work. This practice developed workflow for their integrated approach, specifying the roles for the front desk, medical assistants, physicians, psychologists, and mental health provider. At the time the BH e-Suite was launched, the practice experienced turnover among clinical staff that was quite disruptive. Operations did stabilize and the BH e-Suite was used by BHCs, but these professionals did not use all functionality.

Clinic 5 (fully implemented) is a primary care FQHC that employed one unlicensed social worker (MSW) to provide brief behavioral health care to their patients. The MSW shared an office with the practice’s Epic specialist. This professional did not see patients in their office but in medical examination rooms. Typically, the MSW was engaged by a primary care physician when the patient was in for a medical visit; the physician or medical assistant will go find the MSW, who will do a brief assessment and intervention and establish a plan for following up. MSW also helped when patients need to be referred to outpatient mental health and substance use care. MSW would see patients, as needed, for brief visits. These visits were scheduled by the MSW with the patient. In addition, the MSW played a central role in screening and brief intervention for substance use, as this has been a practice focus. The practice had clear protocols for these workflows. The BHC role was new to this practice. Tool implementation was limited in part due to access issues (the BHC had difficulty in accessing certain functionality). Documentation was the primary focus of tool usage.

Clinic 6 (did not implement) is a FQHC primary care branch of the county health department. This practice hired one LCSW to work in this practice to deliver integrated care. This was the practice’s first BHC, and this person was hired a few months prior to the start of the study. The LCSW provided both brief therapy to patients as well as more traditional mental health care to patients who need it. To accommodate both types of patients, the LCSW took referrals and was engaged in warm-handoffs by the primary care physicians when the LCSW was available. The LCSW shared an office with a diabetes counselor and this office was located next to the medical examination rooms and a couple rooms away from the primary care provider office. The LCSW saw patients in his/her office or in a medical examination room, depending on space availability. This practice did not have written protocols or workflows for care integration. This BHC was excited about the BH e-Suite but practice leadership was not.