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. Author manuscript; available in PMC: 2021 May 1.
Published in final edited form as: Adm Policy Ment Health. 2020 May;47(3):435–442. doi: 10.1007/s10488-019-01002-4

Assessing the integration of behavioral health services in primary care in Colombia

Sergio Castro 1,2, Leonardo Cubillos 1,2, José Miguel Uribe-Restrepo 1,2, Fernando Suárez-Obando 1,2, Andrea Meier 1,2, John A Naslund 1,2, Sophia M Bartels 1,2, Makeda J Williams 1,2, Magda Cepeda 1,2, William C Torrey 1,2, Lisa A Marsch 1,2, Carlos Gómez-Restrepo 1,2
PMCID: PMC7159997  NIHMSID: NIHMS1546548  PMID: 31832852

Abstract

Integration of behavioral health care into primary care can improve health and economic outcomes. This study adapted the Behavioral Health Integration in Medical Care (BHIMC) index to the Colombian context and assessed the baseline level of behavioral health integration in a sample of primary care organizations. The BHIMC was able to detect the capacity to provide integrated behavioral care in Colombian settings. Results indicate a minimal to partial integration level across all sites, and that it is possible to measure the degree of integrated care capacity and identify improvement areas for better behavioral health care provision.

Keywords: Primary health care, Behavioral Health, Integrated care, International collaboration, Substance use disorders treatment

Introduction

Behavioral health disorders account for a significant burden of disease worldwide (Vigo, Thornicroft, & Atun, 2016). Primary care is increasingly recognized as an important setting for health care provision for individuals with behavioral health needs, as it is the first contact point with health care for many individuals. Additionally, 60% of individuals visiting primary care practices have a diagnosable behavioral disorder (World Health Organization [WHO] & World Organization of Family Doctors [WONCA], 2008). Behavioral disorders are associated with an increased risk of suffering from general medical conditions and of premature death (De Hert et al., 2011; Goldberg, 2010; Lin et al., 2010; Walker, McGee, & Druss, 2015). The integration of behavioral health care into primary care is associated with improvements in patient outcomes, a better care experience, and reduced costs (Butler et al., 2008; Friedmann, Zhang, Hendrickson, Stein, & Gerstein, 2003; Hill, 2015; Katon et al., 2006; Kwan & Nease, 2013; McGough, Bauer, Collins, & Dugdale, 2016; Van Ginneken et al., 2013). Hence, the integration of behavioral health care and primary care has become a health priority in many health system reforms worldwide (Crowley & Kirschner, 2015; WHO, 2012; WHO & WONCA, 2008).

Colombia is a middle-income country in northern South America with a complex health care system. The system was initially developed in 1993 with the aim to provide universal coverage and address health inequalities through the implementation of a mandatory social health insurance scheme, as previous health system covered 15.7% of the population (Ruiz Gómez, Zapata Jaramillo, & Garavito Beltrán, 2013). In Colombia’s health system, all citizens are affiliated in either one of two modalities depending on income: Contributory Regime, for workers and their families with an income above a minimum amount; and Subsidized Regime which covers those individuals without the ability to pay.

The system pools and channels funds from general revenue and payroll taxation to provide access to a comprehensive health package known as Plan de Beneficios en Salud (PBS, Spanish for health benefits plan). The affiliated individual choses from public or private insurers (Empresas Promotoras de Salud or EPS in Spanish and meaning health-promoting entity) that manage and distribute the system funds and compete for beneficiaries to receive an annual risk-adjusted per capita premium. The government annually adjusts this premium, ensuring that it matches the expected cost of services utilization within the government-mandated universal health benefit plan. In turn, insurers contract out providers to deliver health care services. Insurers contract out providers (hospitals, clinics, individual physicians) to deliver the health care services included in the PBS. In doing so, insurers utilize a variety of payment mechanisms and fee scales. Providers also seek additional funds for population health that are managed by regional health authorities (Organisation for Economic Co-operation and Development [OECD], 2015).

The first version of the Colombian health care system was developed in 1993, and has been updated through multiple policy reforms until reaching its current version in 2015 (Bernal & Barbosa, 2015; Giedion & Uribe, 2009). This system has achieved universal coverage, nonetheless it is challenged by services fragmentation, access barriers, multiple actors with little coordination, lack of information measurable outcomes, heterogeneity in the quality of care and the limitations for care delivery for non-communicable diseases, including behavioral health disorders (Fajardo-Gonzalez, 2016; Rivera, 2017). Literature on the Colombian health care system is limited to Spanish language publications, qualitative studies, health reports originating from limited information systems, and lack of empirical studies that investigate the health care system or behavioral health aspects of it since its last update.

The 2015 National Study of Mental Health in Colombia (Gómez-Restrepo, Escudero, Matallana, González, & Rodriguez, 2015) shows that behavioral health care access is affected by structural (transportation, availability) and users’ attitudes barriers (low behavioral services demand, low perceived need) (Andrade et al., 2014; González, Enrique Peñaloza, et al., 2016). Therefore, there is significant need in this system to increase the reach of behavioral interventions to improve quality of behavioral health care.

In Colombia, primary care facilities are expected to provide inclusive and comprehensive outpatient services, to meet 90% of patients’ health needs (Organisation for Economic Co-operation and Development [OECD], 2015). A strategy to increase the reach of behavioral health is to implement integrated care, of general medical and behavioral health care, within the primary care setting. However, this integration may require significant changes to support an integrated care system.

The use of instruments to assess levels of care integration and to improve the quality of care process is growing following World Health Organization Innovative Care for Chronic Conditions Framework (Bautista, Nurjono, Lim, Dessers, & Vrijhoef, 2016; World Health Organization [WHO], 2002). The Behavioral Health Integration in Medical Care (BHIMC) Index is a tool developed and extensively studied over the past 10 years to facilitate integration efforts in the US (Chaple, Sacks, Melnick, McKendrick, & Brandau, 2013; McGovern, Lambert-Harris, McHugo, Giard, & Mangrum, 2010; McGovern, Urada, Lambert-Harris, Sullivan, & Mazade, 2012; Sacks et al., 2013). This index is an organizational measure that evaluates behavioral health integration levels (mental health and substance use) within traditional medical care settings, and helps to guide integration efforts.

The BHIMC evaluates policy, clinical practice, and workforce dimensions of integration using 36 benchmark items organized into 7 dimensions (Table 1). Each item is scored on a 5-point scale from “1”: the site does not offer mental health or substance abuse services consistently and is “Minimally integrated” (MI); to “3”: the site offers behavioral health services but inconsistently or favors either mental health or substance use and represents a “Partial Integration” (PI); to “5”: the site addresses mental health and substance use disorders using a systematic and protocol-driven approach and is “Fully integrated” (FI). The tool has a high inter-rater reliability (overall Cronbach’s alpha = 0.89 (range by dimension: 0.17 to 0.87)) with an intra-class correlation coefficient of 0.90 (McGovern et al., 2012).

Table 1.

Behavioral Health Integration in Medical Care dimensions and content.

BHMIC dimension of capability Content
Program Structure

  • Integrated agency mission

  • Licensure or certifications

  • Onsite or offsite services

  • Financial contingencies
Program Milieu

  • Physical, social and cultural environment open to behavioral health concerns

  • Materials accessible
Clinical Process: Assessment

  • Systematic and structured protocol to identify cases, diagnose and develop a treatment plan (problem list)
Clinical Process: Treatment

  • Consistent delivery of services

  • Availability of onsite medications and therapies

  • Narcotic policy & practice
Continuity of Care

  • Chronic disease model including ongoing management and follow-up
Staffing

  • Presence, role, and integration of staff with behavioral health expertise
Training

  • Basic awareness among all staff

  • Advanced expertise in medical-behavioral health interface
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This paper presents the adaptation process of the BHIMC index to the Colombian context, and the results of a baseline measurement from five primary care sites in Colombia.

Methods and Materials

Project DIADA overview

This study is part of the formative work of project DIADA (Spanish acronym for Detection and Integrated Care for Depression and Alcohol use problems), a research and capacity-building initiative funded by the U.S. National Institute of Mental Health (NIMH). The objective of this project is to accelerate the adoption of science-based mental health service delivery in Latin America using mobile health technology. Empirical research suggests that successful mobile health technology adoption should be grounded on integrated models of care (Gagnon, Ngangue, Payne-Gagnon, & Desmartis, 2015; Hoffman et al., 2019) to overcome usage barriers. Thus, we plan to implement a model of care based on a collaborative model to support mobile behavioral health technology.

This project aims to increase the level of behavioral health integration in primary care study sites and provide data for the effective implementation of mobile behavioral health apps. A more detailed description of DIADA is provided at the project website (https://project-diada.org/).

Adaptation process

A working panel conducted the adaptation of the BHIMC to the Colombian context. The panel included one implementation science researcher, one psychiatrist-researcher, one public health advisor, and one senior policy advisor with a vast knowledge of Colombian regulations. We also invited local psychiatrists, BHIMC experts from Dartmouth College, and Ministry of Health stakeholders for specific meetings. The adaptation involved a multistep procedure: identification of items to adapt, translation, field-testing, and performance-testing.

The working panel identified items measuring specific aspects of US health care, classifying them as items referring to 1) the financial structure of the US health care system (billing and incentives); 2) health care settings (facilities); 3) providers availability and certification (some US medical specialties and certifications do not exist in Colombia); 4) policies for the use of psychiatric medications (differences in practice and responsibilities of prescribers); and, 5) medication availability (some medications are not marketed in Colombia). Items were adapted by consensus to the Colombian context. Then, an English- and Spanish-fluent researcher translated and back-translated the tool. The panel evaluated semantic, idiomatic, experimental, and conceptual equivalence between the original BHIMC and the back-translation. Afterwards, we held a workshop with local and policy stakeholders in Bogotá, Colombia for field-testing of the adapted tool.

Finally, we applied the adapted index in our participating sites for performance-testing, according to psychometric attributes (inter-rater reliability with an intra-class correlation coefficient and the tool-internal consistency with Cronbach’s alpha).

Participating sites

We conducted measurements with the adapted BHIMC index in five primary care health facilities in central Colombia: Bogotá, Duitama, Santa Rosa de Viterbo, Armero-Guayabal, and Chaparral.

All of our sites provide primary care services for adults and children, including general adult medicine, pediatrics, obstetrics, gynecology, and preventive medicine. In most sites, health care services are provided by general practitioners, but three sites (Site 1, Site 2, and Site 5) have essential medical specialists that support the provision of those services.

All sites are located within the urban stretch of each town or city, but the population they serve varies greatly. The Bogotá site, in the capital and largest city in Colombia, primarily serves an urban community. The Duitama and Chaparral sites (about 200–250km from Bogotá) serve primarily agricultural, semi-rural communities, and sometimes act as referral sites from dispersed rural health services. Santa Rosa de Viterbo and Armero-Guayabal sites are in small towns with primarily agricultural economic activity and serve rural populations. Armero-Guayabal was one of the sites that received survivors from the Armero tragedy, after the eruption of Nevado del Ruiz volcano in 1985.

Data Collection Procedures

Two trained research assistants (RA) collected BHIMC data. Each assessment lasted 4–6 hours and involved: observations of the clinic milieu and functioning; interviews with agency directors, clinical supervisors, clinicians, support personnel, and patients; and a review of clinic documents. Each RA independently scored the BHIMC benchmarks after the visit, comparing results and discussing discrepancies with a senior member of the team until reaching 100% consensus. Composite scores for each of the seven domains were obtained by consensus between the RA’s. The domain scores were used to calculate the overall score of integrated capacity. Reliability measures were calculated using each RA’s independent scores.

Community dimension

Per stakeholders’ request, we developed a “Community” dimension in the adapted BHIMC. They considered this dimension necessary to assess communities’ potential to increase access to mental health services. Therefore, this 6-item dimension aims to identify how a health care institution relates to the community in which it provides care. Each item is evaluated on a scale from 1 to 5, where a score of “1” denotes no community behavioral health focus; “3” a developing community focus with organizations beginning to establish accountable community goals; and “5” a fully developed behavioral community health program that provides consistent and coordinated care for the community.

Results

Psychometric estimates

The overall inter-rater reliability of the adapted tool across the five sites was 0.90. The internal consistency was 0.9. The internal consistency per dimension was: program structure= 0.75; program milieu= 0.71; screening and assessment= 0.42; clinical treatment= 0.29; continuity of care= 0.79; program staffing= 0.67; and staff training= 0.75.

Integration of behavioral health care

The average behavioral health integration score across the 5 sites was 2.0 (SE 0.18), corresponding to Minimal to Partial integration. The score was lower in sites from small towns and those that serve a primarily rural population (Table 2).

Table 2.

BHIMC scores by dimensions and sites

Site 1 Site 2 Site 3 Site 4 Site 5 Sites mean SE
Program Structure 2.25 3.25 1.75 1.75 2.5 2.3 0.28
Program Milieu 2 3.5 3.5 1 2.5 2.5 0.47
Screening and Assessment 2 2.14 1.57 1.71 2 1.9 0.11
Clinical Treatment 1.82 1.91 1.82 1.55 1.73 1.8 0.06
Continuity of Care 1.6 2.4 1.8 1.4 2 1.8 0.17
Program Staffing 2.2 2.6 1.4 1 1.6 1.8 0.29
Staff Training 2.5 2 1.5 1.5 1.5 1.8 0.20
Total Score 2.05 2.54 1.91 1.42 1.98 2.0 0.18
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In all sites, general physicians and psychologists were expected to deliver primary behavioral health interventions. Only one site had a certified psychiatrist, and none of the physicians had advanced certification to treat substance use disorders. In most sites, physicians refer patients to off-site behavioral health specialists within the network of each patient’s EPS. In most sites, physicians can prescribe medications for mental health disorders, but these are provided to patients at selected EPS offices outside of the hospital. Also, at the time of the BHIMC assessments, there were no medications for the treatment of substance use disorders available in Colombia.

The “Program Structure” domain score had a wide variation across sites, and only Site 2 achieved partial integration. Site 2 recently started an organizational transformation towards integration, starting at the managerial level. However, this transformation had not reached daily clinical practice. Most sites were ambiguous in their description of the health services they aimed to provide, as institution leaders thought that they should be able to manage common health issues, irrespective of their classification as physical or behavioral.

Nevertheless, only the two sites (Site 2 and Site 3) that reached a Partial Integration on the “Program Milieu” dimension were prepared to receive and attend individuals with both behavioral and medical diagnoses in the same setting. These sites had educational materials for substance use disorders. The remaining sites did not anticipate visits from individuals with behavioral disorders and did not display educational materials.

Lack of standard protocols affected the identification of individuals with behavioral disorders; identification was dependent on clinician’s experience. In Site 1, family physicians followed a standard screening procedure for depression, but the procedure was restricted to individuals with chronic conditions. The “Assessment” dimension was affected by insufficient clinical record documentation of behavioral health screening and diagnoses. However, mental health diagnoses were more likely to be documented than substance use diagnosis.

Low scores on “Clinical Treatment” and “Continuity of Care” dimensions reflected the absence of policies and procedures on specific aspects of behavioral disorders management, such as the establishment of treatment plans and monitoring of the use of medications. Although most sites serve as referral sites, their communication with specialized care was limited to information provided in patients’ clinical summaries.

There were few certified behavioral health staff in general health care facilities, in addition to a lack of specialized supervision and peer groups supporting behavioral health care within their communities. Most urban settings had specific training programs and an interest in increasing medical staff’s participation in all types of training, but did not have a specific curriculum and had limited access to external training resources.

The integration of mental health disorders was a priority for most sites. The integration of substance use disorders was a priority only in sites with a high prevalence of these disorders and that were supported by long-standing government policies to identify and manage them.

Results of the “Community” dimension (table 3) indicated a lack of development and integration of the community aspects of behavioral care. Leaders identified a lack of knowledge of logistics and billing strategies as potential barriers to the development and implementation of such services. Sites with the highest scores reported community programs centered on substance use prevention programs, which were usually funded by government entities.

Table 3.

Community dimension scores by site.

Site 1 Site 2 Site 3 Site 4 Site 5 Sites mean SE
Population health registry:
 The organization has records of socio-demographic, morbidity, mortality, geographic, and service registration data, and other characteristics to inform decision making. 2 3 3 1 1 2.0 0.45
Network operation:
 The organization is capable of working with other health organizations and following specific care pathways 3 3 3 3 2 2.8 0.20
Organization participation in the community:
 The organization takes an active role in community behavioral health activities. 1 2 2 1 1 1.4 0.24
Prevention and Promotion in Behavioral Health:
 The organization has a systematic approach to promotion and prevention of behavioral health disorders. 1 1 1 2 2 1.4 0.24
Community Participation in Organizations:
 The community has representation in the decision making levels of the organization. 3 2 2 2 1 2.0 0.32
Participation of families and peers:
 The organization facilitates the connection of peers and family groups around common behavioral health diagnoses. 2 2 1 1 1 1.4 0.24
Total 2 2.17 2 1.67 1.3 1.8 0.15
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Discussion

We adapted and applied the BHIMC index as a tool to assess and guide the integration of behavioral health in primary care in the Colombian context, using a data-driven approach. The observed BHIMC scores reflected that (1) sites offered limited behavioral health care resources for their population, and (2) the capability to provide behavioral health services greatly varied among sites. Overall integration was higher in primary care sites located in urban areas. The largest difference between urban and rural areas was observed for the “Program Staffing” and “Staff training” dimensions. This reflected fewer training opportunities for medical staff on behavioral health care in towns than in cities, contributing to the already pressing burden of barriers of access and communication with specialized care.

We observed that most sites did not provide on-site information about behavioral health disorders and available treatments. Thus, patients may not receive or seek out behavioral health care. This finding is consistent with the 2015 National Survey on Mental Health in Colombia’s analysis (González, Peñaloza, et al., 2016), where the majority of people with behavioral health disorders reported not seeking help due to fear of stigma and lack of knowledge. These barriers are particularly prevalent in rural populations, which was the setting with the lowest BHIMC scores.

We also observed that most sites identified themselves as transition points in the process of care and work as referral agents for specialized care. Thus, clinicians were not familiar with routine screening and outcome monitoring for behavioral disorders. In Colombia, behavioral health specialists are clustered in big cities (Chaskel et al., 2015), and ongoing communication between primary and specialized care is uncommon. Many middle- and low-income countries struggle with trained staff shortage and maldistribution. Rural and underserved areas fail to attract and retain trained clinicians to establish working teams with shared tasks and responsibilities for behavioral disorders care in primary care contexts (Lehmann, Dieleman, & Martineau, 2008; Mbemba, Gagnon, & Hamelin-Brabant, 2016; Miller, Petterson, Brown Levey, et al., 2014; Miller, Petterson, Burke, Phillips Jr, & Green, 2014).

The shortage and isolation of mental health trained personnel outside major urban centers also limits the implementation of behavioral health evidence-based practices and contributed to the variation in scores between urban and rural areas (Amaya et al., 2013; Roselli Cock, 2000). Urban sites also had more behavioral health trainings.

Health care organizations in Colombia are required to deliver services for common conditions, including behavioral health. Building capacity for integrated care for behavioral disorders is an increasing concern following Colombia’s mental health law (“Ley N° 1616 de 2013,” 2013). An increasing number of health organizations are developing an administrative structure to support integration, but the transformation is proceeding slowly. Our findings suggest that the adaptation of the BHIMC could allow these organizations to identify specific areas for improvement, helping them to design and develop a plan and accelerate the integration process.

The systematic use of the BHIMC may contribute to the identification and response to limitations from a disjointed health care system and a shortage of trained behavioral health care providers. Our results imply that health care organizations and EPS need to create sustainable financial strategies and payment mechanisms for models of behavioral care based on teamwork with shared responsibilities, outcome monitoring, and ongoing training. Clinicians will need to redefine their roles to achieve sustainable integration: specialists will need to take on consultant and collaborator responsibilities, while other clinicians will require ongoing training to provide and monitor behavioral health interventions.

An additional contribution of the BHIMC adaptation was the development of the “Community” dimension. Our sites scored poorly on this dimension, suggesting that primary care centers are mostly focused on individual health and may benefit from a better understanding of the potential reach of community based interventions for behavioral health. Moreover, there were large differences between public and private organizations. While public organizations feel responsible for the health status of their community, regardless of their inclusion of behavioral health components in their activities, private hospitals were less likely to view community or behavioral health as their responsibility. Implementing coordinated providers’ networks and pathways of care could strengthen an integrated care model that includes community health activities.

This study was limited by a lack of guidelines on the adaptation of benchmarking tools such as the BHIMC. Thus, we followed general recommendations for scale adaptation, and the adapted tool had similar psychometric attributes to the original tool. The results of the “screening and assessment” and “clinical treatment” dimensions should be analyzed with care because of low internal consistency; nonetheless, the results do not affect overall internal consistency of the adapted tool. Furthermore, the exploration of the items of those dimensions provide significant information to develop an action plan and removing an item to improve internal consistency could affect some aspects of behavioral health integration.

A larger sample size could increase the generalizability of results and help to identify general factors that hinder or facilitate integration in the Colombian context. However, this tool is not necessarily intended for generalization. Rather it is recommended for use on a case-by-case basis, and eventually, shared-learning for adaptation in other settings. The representativeness of our findings may be hampered by the selection of study sites, as they were already interested in increasing their behavioral health resolution capability through DIADA. However, because DIADA had not been implemented at the time of our measurements, our findings are a baseline assessment of resources, barriers, and facilitators to be addressed through the implementation of the project.

We will continue to perform repeated measures of the BHIMC at the same sites, allowing us to determine the sensitivity of the tool to change after the implementation of DIADA. Finally, future studies are required to refine the newly developed “Community” dimension.

Conclusion

The adapted BHIMC index is a practical tool, which we used to measure the level of behavioral health care integration in Colombian primary care settings. This tool may help institutions to develop a plan to achieve or improve their integrated care capacity. Results from this baseline measurement show that the level of integration of behavioral health care into the five Colombian primary care sites is low, with some variation between rural and urban settings. Through the DIADA project, this tool could provide a promising foundation to evaluate and increase the level of integration of behavioral care in other health organizations, and inform organizational and nation-wide policies to improve the quality of behavioral care.

Funding

This research was supported via a grant from the U.S. National Institute of Mental Health (Bethesda, MD, USA, grant no. 1U19MH109988-01; Multiple Principal Investigators: Lisa A. Marsch, Ph.D. and Carlos Gómez-Restrepo, MD). The contents are solely the opinion of the authors and do not necessarily represent the views of the NIH or the United States Government.

Footnotes

Publisher's Disclaimer: This Author Accepted Manuscript is a PDF file of an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.

Conflicts of interest

All authors declare that they have no conflict of interest.

Ethical Approval

This research project was approved by the Institutional Review Board at Dartmouth College in the United States of America and Pontificia Universidad Javeriana in Colombia.

Informed Consent

It is important to note that in this project a treatment intervention was not tested, patients were not interviewed individually, and no personal information or confidential data were requested; instead, clinical and administrative staff were collectively interviewed about the program, and data collection related to the program, not to its staff or subjects. Dartmouth College’s and Pontificia Universidad Javeriana’s IRBs determined that informed consent was not necessary.

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