Advancing Integrated Healthcare: A Step by Step Guide for Primary Care Physicians and Behavioral Health Clinicians

Introduction

Primary care providers (PCPs) often act as the first line of response for their patients who present with mental health concerns and many individuals with chronic illness also suffer from behavioral health issues.¹ However, primary care providers frequently lack the time and training to be able to effectively diagnose and treat behavioral health issues. Thus, the fields of medicine and psychology have moved to integrating behavioral health providers within primary care settings and team-based approaches in primary care. How a PCP practices integrated medicine can vary by levels of integration ranging from standard referrals for behavioral health needs to full integration of a behavioral health clinician within a an integrated health care team. Research has shown that a team-based approach to care delivery can not only result in improved quality of care, productivity and efficiency, but also an increase in satisfaction among both patients and clinicians.^2,3 The importance of a behavioral health clinician (BHC) on an integrated health care team cannot be understated. Experienced BHCs offer a broad and deep range of clinical and research interventions and skills that benefit patients, providers, and health care systems. In fact, many of the interventions and skills offered by BHCs address some of the most prescient medical and psychological needs of our patients including chronic pain and nutritional health. Further, BHCs bring a skill set aimed at addressing the programmatic and practice outcomes necessary for practice improvement. Despite the evidence-base supporting interprofessional practice (IPP), providers are often hesitant to incorporate BHCs due to multiple factors, which we discuss.^4,5 However, the move toward IPP is crucial for all PCPs in order to provide best care. Our aim with this article is to help PCPs who work at any level of integration to take steps toward increased IPP by utilizing critical clinical examples.

What is Interprofessional Practice?

Interprofessional practice (IPP) is defined as collaborative practice that occurs when healthcare providers work with others from their own profession, with others from outside their profession and with patients and their families.⁶ IPP serves as the umbrella under which multiple levels of interprofessional care exist. Providers who work collaboratively should share common goals and more effectively coordinate care according to patient needs thus resulting in higher quality care. Many PCPs utilize some kind of interprofessional practice by working with nursing staff, providing referrals for patients, or seeking consultation from individuals outside of their profession. However, true interprofessional team-based care occurs when care is delivered by intentionally created, work groups who are recognized by themselves and others as having a collective identity and shared responsibility for a patient or group of patients.⁷ Today, many organizations are moving to an integrated care model where tightly integrated, on-site teamwork operates with unified care plans as a standard approach to care for designated populations. An organization that is providing integrated care would utilize organizational integration involving medical, psychological, social, and other services. Such care would also include ‘altitudes’ of integration (i.e., integrated treatments; integrated program structure; integrated system of programs; integrated payments.)^8,9

What are the Benefits of IPP?

The benefits of IPP have been well documented and reported over the last 50 years of study. Research has demonstrated that in acute and primary care settings patients are more satisfied with their care, more accepting of care, and demonstrate improved health outcomes when they receive care from an interprofessional team.¹⁰ Additional benefits of IPP include improvements in access to healthcare, appropriate use of specialists, and outcomes for individuals suffering from chronic diseases as well as declines in patient complications, length of hospital stay, provider tension and conflict, turnover, hospital admissions, clinical error rates, and mortality rates.^{10,11,12,13,14,15}

The benefits of IPP can be summed up easily by the Institute for Healthcare Improvement’s (IHI) Triple Aim Framework. The IHI Triple Aim is a framework that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions: improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care. However, as institutions began to adopt the Triple Aim model, it quickly became clear that good patient care was dependent upon providers also being properly cared for. High rates of burnout among clinicians and staff remain widespread.¹⁶ In 2014, Bodenheimer et al.¹⁷ proposed the Quadruple Aim Framework in which organizations optimize health system performance by simultaneously pursuing improving the patient experience, improving the health of populations, reducing the per capita cost of health care, and improving the work life of healthcare providers.

While many organizations have turned toward the Quadruple Aim to improve health system performance, many PCPs continue to look to improve their own practices or organizations but often find themselves at a loss of where to start. Because PCPs often act as the first line of response for their patients who present with mental health concerns, the introduction of a BHC to primary care practice would have immediate benefits for providers and patients alike and thus is a logical place to start with IPP. One of the most fundamental aspects of successfully enhancing IPP includes understanding the difference between the roles and functions of traditional therapy versus behavioral health care in integrated practices. Traditionally, the terms “mental health” or “behavioral health” conjure the idea of outpatient care located in a siloed environment away from the primary care practice. Traditional therapy can be time-limited, yet is often a longer-term commitment that tend to conjure images of Freud, couches, hour-long sessions, and unscientific talk therapy that has little to nothing to do with one’s medical care. Not only is this view of therapy inaccurate, it reflects very little of what a BHC does within a primary care practice. According to Robinson & Reiter,¹⁸ when electing to hire or work with a BHC, the ideal knowledge, skills, and attitudes may be summarized as: “The BHC works in the primary care clinic as a regular team member and delivers brief, consultation-based services to patients and primary care providers (PCP). The BHC works with individuals, groups and families, providing evidence-based behavioral interventions for both mental and physical health conditions in patients of all ages.” The sample roles elucidated above fit with this BHC definition.

How are Levels of Integration Defined?

Integration of health care can occur at multiple levels and is often used to describe how health care components are brought together.⁹ The original levels of integration framework was proposed by Doherty, et al.¹⁹ and served as a foundation for classification of integration levels based on how and where services and collaboration took place. This framework established a continuum that moves from collaboration to integration of healthcare delivery. More recent work has built upon this framework to propose six levels of collaboration that lead to integration of care beginning with coordinated care, moving to co-located care, and ending with integrated care. Within each of these main categories there are two levels, illustrated in Table 1.⁹

Table 1.

Levels of Integration Defined

Coordinated Care Key Element: Communication		Co-Located Care Key Element: Proximity		Integrated Care Key Element: Practice Change
LEVEL 1	LEVEL 2	LEVEL 3	LEVEL 4	LEVEL 5	LEVEL 6
Minimal Collaboration	Basic Collaboration at a Distance	Basic Collaboration Onsite	Close Collaboration Onsite with Some System Integration	Close Collaboration Approaching an Integrated Practice	Full Collaboration in a Transformed/Merged Integrated Practice

PCPs can begin to utilize these levels of integration by assessing their own practice using this collaboration-to-integration table as a template. At Level 1, BHCs and PCPs work at separate facilities, separate systems and rarely communicate about cases. When communication occurs, it is usually based on a particular provider’s need for specific information about a mutual patient. Basic Collaboration, or Level 2, occurs when PCPs and BHCs maintain separate facilities and separate systems while utilizing each other as resources. Communication may occur periodically and is generally driven by specific issues. Levels 3 and 4 comprise Co-located Care. At Level 3, BHCs and PCPs are co-located in the same facility, but may not share the same practice space. Because of increased proximity, communication occurs more regularly and occasionally providers will meet to discuss share patients. At this level, the referral process is often more successful due to the co-location of providers. Providers may feel as if they are part of a larger team, however, decisions are still made at the individual provider level. Level 4 is marks the beginning of integration through some shared systems. This level also includes closer collaboration among PCPs and BHCs, all appointments being scheduled by the primary care front desk, and shared medical records. The move into fully Integrated Care involves Levels 5 and 6. At Level 5, providers begin to function as a true team, with frequent communication between team members. As a team, they will purposefully seek to recognize and address any barriers to care that currently exist for their patients. Full integration may not yet be possible for the team, however, all providers have knowledge of the different roles team members need to play and have begun to change their own practice based on this knowledge. Full Collaboration in a Transformed/Merged Practice, or Level 6, involves the greatest amount of practice change as multiple practices will have combined into a single transformed or merged practice. Both providers and patients view a level 6 organization as a single health system and have applied the principle of treating the whole person to all patients.⁹

Behavioral Health Needs in an Integrated Health Care Model

Each year the Monitor on Psychology produces a Trend Report as an annual guide to changes ahead for psychologists in patient care, research, technology, social justice and more. These trends, put together within an integrated care model, can provide a stepwise model of integration for PCPs looking to improve patient and provider outcomes by increasing IPP through the addition of a BHC. In order to aid PCPs in their attempts to increase IPP, three significant and time consuming psychological trends, non-drug pain management, nutritional health, and programmatic outcomes/data management, will be explored at each level of integration. To demonstrate how integration could occur, three collaboration-to-integration tables are created to describe this process.^20,21,22

Non-Drug Pain Management

The over prescription of opioids to manage chronic pain has created increased incentive for physicians to examine non-drug treatments for pain. BHCs, and in particular psychologists, are prepared to treat chronic pain patients in a biopsychosocial model using an integrated approach.²⁰ Table 2 examines how PCPs can assess their current level of integration and how to take steps toward increased integration specifically with non-drug pain management.

Table 2.

Levels of Integration and Non-drug Pain Management

Coordinated Care Key Element: Communication	LEVEL 1	Begin to ask: Who do I know in the community? How do I find them?
	LEVEL 2	Know what qualifications you are looking for in BHC Identify qualified BHCs accepting patients in community Consider if patients follow up with referral and how you will get feedback from referral source
Co-Located Care Key Clement: Proximity	LEVEL 3	Build infrastructure for feedback and integration into patient’s healthcare plan What is access like? How to increase access?
	LEVEL 4	Have feedback infrastructure Explore reimbursement options and what costs would be of having BHC within practice Have administrative conversations Develop vision for full integration
Integrated Care Key Element: Practice Change	LEVEL 5	BHC in practice BHC shares CBT techniques with the core team in psychoeducation sessions (i.e., motivational interviewing, symptom management) Physicians begin to use some of techniques themselves patient visit (i.e., reframe, identifying catastrophic thinking)
	LEVEL 6	BHC in practice Shared medical record warm hand offs Team has shared knowledge of how to use behavioral goals, self-management skills, reinforce pacing, etc.

Nutritional Health

What we eat and how we eat it can influence our physical and our mental health. BHCs are prepared to address nutritional health through the assessment of behavioral patterns in order to help patients make successful changes.²¹ Table 3 examines how PCPs can assess their current level of integration and how to take steps toward increased integration specifically with nutritional health.

Table 3.

Levels of Integration and Nutritional Health

Coordinated Care Key Element: Communication	LEVEL 1	Assess what you know about nutritional health. What resources available in clinic? What free technology is available?
	LEVEL 2	Ask who do I know in the community and how do I find them? Know which providers have a background in nutritional health: Board Certified Specialist in Renal Nutrition (CSR) Board Certified Specialist in Pediatric Nutrition (CSP) Board Certified Specialist in Sports Dietetics (CSSD) Board Certified Specialist in Gerontological Nutrition (CSG) Board Certified Specialist in Oncology Nutrition (CSO) Identify qualified RD/RDN accepting patients in community Consider if patients follow up with referral and how you will get feedback from referral source
Co-Located Care Key Element: Proximity	LEVEL 3	Build infrastructure for feedback and integrate into patient’s healthcare plan What do you know about coverage for nutrition? What specific behavior change do you want the BHC and patient to work on and how will you follow up with that?
	LEVEL 4	Have feedback infrastructure Explore reimbursement options and costs of having BHC within practice What does your feedback from BHC look like? Does it include electronic communication with patients? Can they upload photos of meals? Share healthy meal plans and recipes?
Integrated Care Key Element: Practice Change	LEVEL 5	BHC in practice BHCs use knowledge of process of behavioral change, Consider how barriers and routines in patient environment can accelerate to decelerate change Barriers are shared in treatment planning
	LEVEL 6	BHC in practice Shared medical record Warm hand offs Team has shared knowledge of how to use: Motivational interviewing How to monitor antecedents, behaviors, and consequences Physicians using some techniques themselves in the visit: Addressing barriers Discussing electronic communication and behavior tracking

Programmatic Outcomes and Data Management

While psychologists are easily accepted as experts in behavioral health, they are often overlooked when it comes to evaluating outcomes and managing data. Doctoral level psychologists receive training in research methodology and statistical analysis that prepare them to be able to answer important evaluative questions when it comes to practice and patient outcomes. Table 4 illustrates how PCPs can assess their current level of integration and how to take steps toward increased integration specifically with regard to evaluating outcomes and data management identifying and influencing change in practice operations.

Table 4.

Levels of Integration and Programmatic Outcomes

Coordinated Care Key Element: Communication	LEVEL 1	Assess what you know about how evaluate outcomes and manage patient data What resources available in clinic? What free technology is available?
	LEVEL 2	Begin to track your referral data How many referrals to BHCs are being made? Which BHCs are being utilized the most?
Co-Located Care Key Element: Proximity	LEVEL 3	How many patients are following up with the referral to clinician in the system? Move beyond tracking usage and consider asking quality and satisfaction questions Do your patients report satisfaction in working with this clinician?
	LEVEL 4	Begin to work patient behavioral health goals into interactions with BHCs What behavioral health goals have been set for your patients? Is your utilization data positively correlated with better patient outcomes?
Integrated Care Key Element: Practice Change	LEVEL 5	Develop a plan to review your IPP practices Does the data reflect that warm hand offs are increasing utilization? Are patients reporting that all team members have knowledge of their behavioral health goals?
	LEVEL 6	Goals for patients (utilization, access, health outcomes) are set in a team meeting and tracked over time Quality metrics for patient satisfaction are developed and analyzed along with patient outcomes Team member satisfaction (burn out, perceptions, etc.) are also assessed and used to inform practice policy and procedure

Conclusions

The evidence supporting increased interprofessional practice has clearly demonstrated that IPP is crucial to achieve the best patient outcomes, reduce costs, improve population health, and improve the work life of health care providers. This article encourages PCPs to begin to assess their current level of health care integration within their organization and then to predict the growth in integration with the addition of a BHC to their healthcare team. Many of the interventions and skills offered by BHCs address many of the most prescient medical and psychological needs of our patients including chronic pain and nutritional health. Further, BHCs bring a skillset aimed at addressing the programmatic and practice outcomes necessary for practice improvement. The tables provided allow PCPs to examine next steps in integration and therefore a pathway to improve the wellbeing of the communities they serve.