Defining and measuring core processes and structures in integrated behavioral health in primary care: a cross-model framework

Abstract

A movement towards integrated behavioral health (IBH) in primary care continues to grow, among an accumulating evidence base for its effectiveness for improving care. However, healthcare organizations struggle to navigate where to target their limited resources for improving integration. We evaluated a cross-model framework of IBH core processes and structures. We used a mixed-methods approach for evaluation of the framework, which included (a) an evaluation survey of national experts and stakeholders, (b) crosswalks with common IBH measures, and (c) a real-world usability test. Five core IBH principles, mapping to 25 processes, and nine clinic structures were defined. Survey responses from 29 IBH domain and policy experts and stakeholders resulted in uniformly high ratings of importance and variable levels of feasibility for measurement, particularly with respect to electronic health record (EHR) systems. A real-world usability test resulted in good uptake and use of the framework across a state-wide effort. An IBH Cross-Model Framework of core principles, processes, and structures generated good acceptability and showed good real-world utility in a state-wide effort to improve IBH across disparate levels of integration in diverse primary care settings. Findings identify feasible areas of measurement, particularly with EHR systems. Next steps include testing the relationship between the individual framework components and patient outcomes to help guide clinics towards prioritizing efforts focused on improving integration.

INTRODUCTION

In 2008, the Agency for Health Research and Quality (AHRQ) Behavioral Health Integration Evidence report observed that we do not know what elements of integrating medical and behavioral care contribute most to improvements in patient care [1]. Over a decade later, health care organizations continue to trend towards adopting different models of integrated behavioral health (IBH) [2], without concrete guidance on which core elements across models matter most.

Mounting evidence shows that different approaches to primary care–based behavioral interventions are effective with specific mental health, substance, and medical conditions [3]. However, given the lack of clearly defined and measurable elements of IBH, evaluating models and providing guidance about how to implement integration is challenging. Primary care–focused healthcare organizations are struggling to wade through model specific implementation guides, with no clear direction on which elements of IBH to prioritize first.

Four prevalent models of providing behavioral health care in medical settings dominated the field over the last 20 years: (a) co-locating behavioral health into a primary care practice with minimal engagement in practice flow [4,5]; (b) integrating behavioral health care and services into practice workflow, often described as the primary care behavioral health (PCBH) integration model [6]; (c) integrating a behavioral health care manager and psychiatric consultation into practice workflow, often described as the Collaborative Care Model [5,7]; and (d) embedding randomized control trial derived interventions aimed at specific conditions or risks, often described as the behavioral medicine model [8]. Young and colleagues reviewed common elements identified in integrated care models [9]. We attempt to contrast them with elements common to these four models (Table 1).

Table 1 |.

Common elements across four leading integrated behavioral health models

	Co-Location [4]	Primary Care Behavioral Health [3,6,31]	Collaborative Care [5,7]	Behavioral Medicine [5,8,32]
In practice
Behavioral health clinician	X	X
Care management responsibilities		X	X
Available for warm handoffs		X	X
Evidence supported treatments		X	X	X
Training all members of practice team		X	X
Population based care		X	X	X
Stepped care		*	X
Automated identification and treatment protocols
Processes integrated into work flow		X	X
Shared electronic record		X

X indicates the element is considered a minimal requirement to the mode.

^*PCBH can include stepped care approaches.

Despite reasonable evidence that these models are efficacious, dissemination lags behind [10]. Changing care in individual primary care practices is often a slow and labor intensive process. Exemplar practices often have unique, blended combinations of components of various models of IBH [11]. Practices often lack resources (i.e., time, bandwidth, and funding) to establish and improve IBH, nor do they know which model or which components of models fit best with their practice. Although overlaps and distinctions exist across the models, identification of core elements that have greatest impact remains unclear [12]. Resource limited primary care organizations need guidance about what changes to their practice may be feasible and have a reasonable probability of improving care.

Multiple efforts have tried to identify key IBH processes within each method of delivering IBH and others have attempted to measure the degree of integration of IBH overall [13]. The most systematic effort to comprehensively describe IBH, regardless of method of integration, was generated by Peek and colleagues, the “Lexicon for Behavioral Health and Primary Care Integration” [14]. It used a descriptive psychology approach to identify a theory of IBH that suggested elements of an idealized model of IBH.

In an effort to operationalize Peek and colleagues’ theory of IBH, Kessler and colleagues developed and validated the Practice Integration Profile (PIP) assessing processes and structures associated with the stated domains in the Lexicon [15]. The PIP is a 30-item self-assessment of six key domains associated with the Lexicon. Although a range of check-lists adapted to the various methods of IBH exist [13], such as the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) Toolkit which focuses only on behavioral health provider adherence related processes [16], the PIP is the only empirically validated measure of broad IBH processes and structures across the practice [17]. Although the PIP is aimed at self-assessment with good psychometric properties, it does not provide a comprehensive listing of all IBH processes and structures across well-established models, and its descriptions of each item are brief.

National Committee for Quality Assurance (NCQA) has developed criteria for Distinction in Behavioral Health, allowing NCQA Patient Centered Medical Home (PCMH) certified practices to achieve certification with a Behavioral Health Distinction as part of their PCMH activities [18]. The Distinction in Behavioral Health Integration module includes 18 criteria across four competencies related to behavioral health integration including workforce, information sharing, evidence-based care, and measuring and monitoring. NCQA PCMH certification criteria have been used to measure primary care practice transformation [19], but like the PIP, do not offer adequate definitions of IBH elements to guide clinics towards improving IBH.

In 2013, the Substance Abuse and Mental Health Services Administration (SAMHSA)—Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions released “A Standard Framework for Levels of Integrated Healthcare,” suggesting the use of the Integrated Practice Assessment Tool (IPAT) check-list to generate a national standard of integration ranking with six levels of collaboration/integration from Minimal Collaboration to Full Collaboration [20]. Limitations of the IPAT include (a) the subjective placement of practices on the continuum of its six levels, (b) the results being inconsistent between practices, and (c) the lack of psychometric data [20].

Despite these many efforts to substantiate models and measures of IBH, primary care organizations continue to struggle with implementation [21,22]. These organizations are looking for practical and actionable definitions of clear IBH processes and structures that will help them improve mental and behavioral health outcomes in their practices, without being confined to rigid model definitions. This would allow them to developmentally tackle smaller improvements that may set the stage for deeper integration as they are able to garner and apply resources.

Defining a clear set of IBH processes and structures that drive key patient outcomes, based on Donabedian’s model of quality care [23], can aid in serving practice transformation efforts and allow for improved research and evaluation to speed implementation. Therefore, we aimed to evaluate a set of core processes and structures of IBH across IBH models, an IBH Cross-Model Framework, based on a mixed-methods approach.

METHODS

A mixed-methods approach was used to qualitatively and quantitatively evaluate a consensus-defined framework of IBH core processes and structures in primary care. The consensus-based framework was developed by a small group of nine domain experts participating as investigators (i.e., including several co-authors) in a large pragmatic trial, Integrated Behavioral Health in Primary Care (IBH-PC) funded by the Patient-Centered Outcomes Research Institute (PCORI), who drafted the first version and subsequently refined it for evaluation with input from 31 experts, staff, and stakeholders from the IBH-PC study at an annual study meeting, guided by Starfield’s “4 C’s” Primary Care Model [24]. The framework drew from several well documented models [3–5,11,25] and was evaluated using three types of evaluation: (a) an on-line survey of national domain experts, policy makers, and patient and caregiver stakeholders, (b) a gap analysis with two well-established metrics of IBH, and (c) a real-world usability test. National domain experts were solicited from within the IBH-PC study investigators and from experts in well-published IBH models such as Collaborative Care and PCBH.

Sixty-one national domain experts, policy makers, and patient and caregiver stakeholders were identified as leaders and stakeholders in the field of IBH. Participants were identified from the IBH-PC study investigators and stakeholders, national domain experts representing well documented IBH models (i.e., the expert published substantially in well-established IBH model or led a large organization known for disseminating IBH, such as the Veterans Administration or Department of Defense), and MN Health Collaborative leadership. Participants were solicited via email to participate in a 68-question survey and the Institutional Review Board determined this research was exempt from the federal human subjects regulations, including the requirement for IRB approval and continued review. Participants were asked to rate the level of importance of each principle and associated process and structure, the feasibility of measuring each process and structure, and the feasibility of using the electronic health record (EHR) to measure them. Questions on the survey included: (a) [process/structure] is important to IBH (scale ranged on a 5-point scale from “strongly agree” to “strongly disagree”), (b) [process/structure] is feasible to measure in every day practice (scale ranged on a 5-point scale from “strongly agree” to “strongly disagree”), and (c) [process/structure] can be measured in the electronic health record (options included “yes” or “no”).

The gap analysis aimed to identify missing core processes and structures in the framework. Five members of the research team performed crosswalks for each process and structure in the framework with the Practice Integration Profile (PIP) [3] and the NCQA PCMH and Distinction in Behavioral Health Integration (BHI) criteria [18]. Crosswalks were performed in each direction (i.e., matches to the framework and gaps of items not matching from the PIP and PCMH/BHI criteria) and at least two members cross-walked each item. Raters defined “strong” matches as near complete overlap, “weak” matches as some overlap, but a clear missing part to the match, and “no” match as having no overlap with any items. All discrepancies were discussed to reach unanimous consensus across three research team members.

The real-world usability test was conducted in collaboration with the Minnesota’s MN Health Collaborative, given they were engaged in a state-wide effort to improve IBH across 15 organizations serving approximately 70% of citizens in Minnesota. They were convened by the ICSI, the Institute for Clinical Systems Improvement, an independent nonprofit whose mission includes finding solutions to healthcare’s toughest challenges through collaboration. The MN Health Collaborative IBH workgroup leadership was given a working draft of the framework, asked for input on improvements prior to conducting the evaluation survey, and then given a final framework draft to disseminate throughout their collaborative. They were then asked to describe their experience with the final framework and detail how it was used in their state-wide effort.

RESULTS

IBH Cross-Model Framework—evaluation survey results

The IBH Cross-Model Framework included a final set of five principles, mapped to 25 clinic processes, and nine clinic structures needed to support the processes (see Tables 2–7 for definitions). The 25 IBH processes mapped to six core principles, which were defined as: Principle (1), Patient-centric Care—“Ensure patient is well engaged with the entire care team, understands the various roles for themselves and their providers, and is supported and guided to manage their lives, health, and treatment”; Principle (2), Treatment to Target—“Ensure clear goals and measures are defined to guide and track care”; Principle (3), Use Evidence-based Behavioral Treatments—“Ensure the best evidence-based care is used across medical and mental/behavioral care”; Principle (4), Conduct Efficient Team Care—“Ensure integrated behavioral healthcare is efficient and comprehensive, supported by appropriate policies and procedures”; and Principle (5), Population Based Care—“Ensure limited services reach the most patients while targeting the patients most in need.” Each process within a principle included a short description and a definition that describes the process in functional terms (see Tables 2–6). The nine core structures were defined as clinic structures needed to support the 25 IBH processes and also included a short description and clear definition for each structure (see Table 7).

Table 2 |.

Principle 1—“Patient-centric Care” related processes, evaluation ratings, and crosswalk to PIP and NCQA measures

#	Process Short Description	Process Definition	Important (% agreeda)	Feasible to Measure (% agreeda)	Measurable in the EHR (% yes)	PIP	PCMH/BH
1	Orient patient to integrated care culture	IBH team knows their roles and responsibilities on the integrated behavioral health team; they orient patient to integrated care team (e.g., explains to patient what the roles of each IBH team member are, standardized brief role descriptions for each IBH team member; scope of care, common clinic activities, documentation standards, coordinated team (both IBH as well as rest of primary care team) based clinic behaviors desired)	86%	48%	30%	*	*
2	Patient participates in making decisions related to care plan and treatment	IBH team get feedback from the patient about the care plan to make sure the patient is well engaged, in agreement with the plan, and that they use shared decision making (e.g., standardized protocol based on best current evidence, that lists specific questions/ concerns and documentation for each team member to be used to ensure patient is engaged in care plan decisions, shared care plan is documented)	93%	66%	54%	**	**
3	Promote patient autonomy	IBH team targets giving and supporting autonomy of the patient as they move through treatment (e.g., self-management plan in individual care plans)	93%	52%	48%	X	**
4	Patient reports changes in health, symptoms, function over time	Patient fills out appropriate metrics prior to and during IBH team treatment engagement, tailored to the patient addressing what drove the engagement in IBH and keeps the care team informed of progress and changes with health and function (e.g., behavioral health and function screeners and symptom measures); encouraged to use a primary care appropriate measure that has a global as well as specific subscale (e.g., anxiety, depression, insomnia, relationship, life function) that could be given to every patient on every appointment	93%	90%	85%	*	**

^aRespondents rated the question as either “agree” or “strongly agree.

^*weak match,

^**strong match; X did not match.

Table 7 |.

Core structures for integrated behavioral health

#	Structure Short Description	Structure Definition	Important (% agreeda)	Feasible to Measure (% agreeda)	PIP	PCMH/BH
1	Financial billing strategies that net sustainability of staff and providers on the IBH team	The clinic has effective fiscal strategies for sustaining IBH provider and staff time	100%	56%	X	X
2	Administrative support and supervision for IBH team	The clinic provides administrative support and supervision to all IBH providers and staff as needed (e.g., clinical supervision for nurses, mid-level providers providing behavioral interventions and medication adherence support)	92%	52%	X	X
3	Routine examination of provider and clinic outcomes for quality improvement	The clinic regularly (e.g., quarterly) reviews provider and clinic level outcomes to improve care as needed (e.g., via quality improvement initiatives)	88%	80%	X	**
4	Interoperable EHR access for all of the IBH team	IBH team providers share access across the electronic health record systems in the practice	100%	84%	**	**
5	IBH team has available and appropriate space	IBH team providers have reasonable and appropriate work space allocated within the practice that supports productive work space and collaboration	100%	72%	**	*
6	Behavioral health provider (BHP) available to the clinic	IBH includes a qualified behavioral health provider (BHP) licensed / trained to provide evidence based behavioral interventions	92%	84%	X	**
7	BHP team has protected time to do outreach and follow-ups as needed	BHP team has protected time to review and manage the caseload, conduct outreach and follow-ups as needed (e.g., identifying cases at risk, triage to the right level of care / intensify treatment, do outreach)	96%	52%	X	*
8	BHP team has accountability for access and outcomes	Patient panels are monitored for timely access to care and outcomes are evaluated to drive care improvements	96%	68%	*	*
9	Tracking system for panel management	Clinic tools (e.g., registry, real time reports) are in place to support identifying, tracking, and monitoring IBH related cases	92%	76%	**	X

^aRespondents rated the question as either “agree” or “strongly agree.

^*weak match;

^**strong match; X did not match.

Table 6 |.

Principle 5—“Population Based Care” related processes, evaluation ratings, and crosswalk to PIP and NCQA measures

#	Process Short Description	Process Definition	Important (% agreeda)	Feasible to Measure (% agreeda)	Measurable in the EHR (% yes)	PIP	PCMH/BH
1	Use BHP resources for patients most in need	Focus use of BHP services to address the behavioral health care needs across the spectrum of primary care patients, including prevention, early at risk, and complex and high risk patients who could benefit most from combination of behavioral health and medical services (i.e., the practice selects target populations for care and defines strategies to identify and engagement); including engagement of disadvantaged and disparity affected populations	88%	32%	55%	*	**
2	Use appropriate assessment of key indicators to triage patients to behavioral health resources	The clinic uses a deliberate process to triage priority patients into IBH team based care (e.g., clinic uses defined care paths and screening strategies for engaging patients in behavioral health services)	92%	52%	53%	**	*

^aRespondents rated the question as either “agree” or “strongly agree.

^*weak match;

^**strong match.

The response rate to the survey was 48% (N = 29), with 25 participants answering 100% of the questionnaire. Overall, participants uniformly rated each process and structure as important to IBH. Rating percentages of importance of each process and structure ranged from 84% to 100%, with 11 (32%) of the total 34 processes and structures rated as important by 100% of respondents, and 29 (85%) of the 34 processes and structures rated as important by 90% or more of respondents.

Participants had variable ratings on feasibility of measurement of the 34 processes and structures. Rating percentages ranged from 28% to 90% and ratings ranged widely across processes and structures. Participants identified several areas as difficult to measure within each of the five principles and some of the structures. In particular, processes that were rated as more difficult to measure included: (a) evidence-based care or more nuanced interactions with patients or the team and (b) financial strategies for sustainability as well as structures that support IBH teams.

Participants also had variable ratings on how well the EHR could be leveraged to measure processes of IBH. Rating percentages ranged from 11% to 100% in favor of “yes.” Trust among the team, workflow, and orienting the patient to IBH were ranked among the lowest as measurable in the EHR, whereas brief visits, screeners, and assessment, and consultation with psychiatry were ranked highest (see Tables 2–7).

Mapping between IBH Cross-Model Framework, PIP, and NCQA

The IBH Cross-Model Framework overall mapped well to items from the PIP and NCQA PCMH and BHI items, with 91% (31/34 processes and structures) matching to at least one item in the PIP or NCQA criteria, and the majority (64%) of the items mapping strongly. The PIP mapped 100% (30/30 items) to the framework and the framework mapped 70% (24/34 items) to the PIP, with 41% (14/34 items) mapping strongly. Namely, 20 of the framework items (16 processes and four structures) were not strongly represented in the PIP. The NCQA PCMH and BHI criteria mapped 54% (64/118 criteria) to the framework and the framework mapped 82% (18/34 items) to PCMH and BHI criteria, with 50% (17/34 items) mapping strongly. The NCQA BHI criteria included two items from the BHI specific criteria that did not match, namely, an item addressing training (i.e., “BH 02: Provides resources and training for the care team to enhance its capacity to address the behavioral health needs of patients”) and an item addressing safe prescribing (i.e., “BH 10: Reviews controlled substance database when prescribing relevant medications”). The NCQA PCMH categories included items that did not match the framework, namely, from the Team-Based Care and Practice Organization (TC), Care Coordination and Care Transfers (CC), Knowing and Managing Your Patients (KM), Patient-Centered Access and Continuity (AC), and Performance Measurement and Quality Improvement (QI) categories. Some of the PCMH criteria were not IBH-specific and therefore would not be expected to match. However, several criteria that did not match, that were relevant to IBH, addressed areas such as handling of disparities, health information exchanges, engagement in clinic governance by patients/caregivers/families, assessment of diversity, language needs, reviewing of controlled substance registries, community engagement, achievement of performance metrics, and more detailed quality improvement processes.

IBH Cross-Model Framework pilot test with Minnesota Health Collaborative

The MN Health Collaborative IBH working group determined that they needed to define a common language and narrative of what was meant by fully integrated behavioral health. A search of current IBH models resulted in the identification of our working draft of the framework. They then completed an internal “Discovery Deep Dive” of the working draft of the framework components, assisted with refining the draft with an emphasis on the need for both processes and structures to be clearly defined, and took the final IBH Cross-Model Framework to their workgroup. They determined that the final framework allowed for needed organizational adaptation of a common language as well as identifying core elements of success.

Health systems within the MN Health Collaborative uniformly adopted the IBH Cross-Model Framework as a shared community standard for advancing IBH in primary care. These partnering organizations individually selected one or two components of the framework to focus their improvement efforts, based on feedback from surveys of their primary care providers. Components selected varied from organization to organization. To understand future depth of adoption and level of spread, they planned to conduct periodic site self-assessment surveys. They reported that the IBH Cross-Model Framework provided a shared community definition and standard for IBH, which allowed shared learning and accelerated changes in a coordinated fashion across the Collaborative.

CONCLUSION

The IBH Cross-Model Framework demonstrated good acceptability overall. It filled a crucial gap for the MN Health Collaborative, by providing their healthcare organization partners a clearly defined IBH target to guide their change initiative. National experts and stakeholders agreed that components of the framework reflected IBH well, it mapped to a high proportion of existing metrics of IBH, and it was adopted as a community standard in a state-wide effort to improve IBH across health organizations that touch 70% of the state. The IBH Cross-Model Framework may provide useful definitions of clear processes and structures in line with Donabedian’s model of quality care in an easy to consume format for practices aiming to improve IBH.

IBH in primary care may help address several areas of complex stressors in primary care, which include provider satisfaction issues, suicide, and insurmountable financial and system stressors [26–29]. Primary care providers are driven to see high volumes of patients to maintain revenue and financial stability, limiting their ability to address thorough whole person care. Although IBH is not a universal solution for all these issues, its promising evidence base demonstrates that it may both improve patient care and reduce costs across healthcare systems [10]. Providing key gaps to dissemination like this clearly defined definitions of processes and structures associated with IBH may help dissemination efforts both within research and real-world contexts.

Feasible and reliable measurement of clinic processes and structures of IBH is of value to policy makers who are driving payment reform in healthcare. The National Committee for Quality Assurance (NCQA) now offers NCQA Distinction in Behavioral Health Integration for NCQA-recognized Patient Centered Medical Homes [30]. Based on the survey results, the majority of the processes and 100% of the structures were rated as feasible to be measured, and most of those processes were rated as measurable within the EHR. These ratings suggest that the EHR may provide a means to feasibly and reliably measure many features of IBH within primary care clinics, addressing an important gap in executing policy and payment reform. However, the majority of participants also rated 38% (nine out of 29) of the processes to be infeasible to measure, inferring that comprehensively measuring IBH feasibly and reliably within clinics may be difficult. The EHR therefore provides a promising venue to conduct reliable measurement of IBH processes, but future efforts should also problem solve methods to measure IBH outside the EHR.

The framework was grounded in existing IBH models and could be improved and expanded to include several aspects that current evidence–based models do not overtly address such as population disparities and diversity, substance use and safer prescribing of controlled substances, and community engagement. Our survey sample size was also limited and we may not have captured all relevant perspectives. Future development of frameworks that define processes and structures will need to keep pace with emerging evidence in new areas.

The IBH Cross-Model Framework offers a concrete set of processes and structures of integrated behavioral health in primary care, crossing models of integrated behavioral health and diverse primary care practice settings. This framework is designed to fill a definitional gap that may be of utility to both research and real world contexts aiming to improve IBH. The framework may also provide utility in the development of future measures of IBH in primary care, particularly measurements driven by data captured in routine care within electronic health records.

Table 3 |.

Principle 2—“Treatment to Target” related processes, evaluation ratings, and crosswalk to PIP and NCQA measures

#	Process Short Description	Process Definition	Important (% agreeda)	Feasible to Measure (% agreeda)	Measurable in the EHR (% yes)	PIP	PCMH/BH
1	Provide care focused on improving overall health and quality of life	IBH team makes sure to target patient centered goals that address overall health, function, and quality of life related outcomes (e.g., employment, family conflicts, spiritual health, etc.)	96%	68%	74%	*	X
2	Provide stepped care with intensity based on outcome data	IBH team monitors patient outcome data (including patient reported outcomes measured at baseline and follow-up) for improvement, if improvement is not occurring (e.g., measure scores are not improving), then steps up care (e.g., intensifies treatment course, refers to specialists, refers to outside mental health provider if needed care is beyond the scope of primary care (e.g., psychiatric hospitalization needed) and adjusts treatment plan)	96%	84%	82%	X	**
3	Focus on small changes through patient-centric goal setting or priorities, emphasizing function	IBH team sets achievable goals (e.g., using SMART format) with patients, documented in the care plan to ensure success at assessing and monitoring small changes, working towards larger goals, with emphasis on improving or maintaining function	96%	72%	60%	**	**
4	Conduct accurate assessment	IBH team conducts appropriate assessments (e.g., screeners administered, assessment interviews tease out appropriate differential diagnoses) of medical (e.g., assessment of physical drivers affecting mood and function like anemia, thyroid function, sleep apnea, etc.) and psychosocial issues (e.g., psychiatric diagnoses, social stressors/needs, trauma and developmental history, substance use, etc.) to guide care	92%	88%	83%	*	*
5	Address barriers when goals are not being met	IBH team actively investigates and works together to resolve any barriers to care (e.g., deliberately assess and address cultural and logistical barriers to care, patient-provider relationship issues that may limit engagement in care)	100%	56%	45%	X	**
6	Define desired outcomes of care	Based on medical and psychosocial issues and patient’s goals/preferences, the IBH team sets measurable targets (symptoms/function within a given time frame) for care	92%	76%	82%	*	*
7	Measure desired outcomes of care - continuous monitoring (use a tracking system)	IBH team uses a tracking system (e.g., electronic health record system, registry, spreadsheet) to: measure outcomes regularly (e.g., at each visit as appropriate), support clinical decision making over time (e.g., measures tracking triggers stepping up care as patients are noted as not improving), and support management of their patient panel (e.g., doing outreach to patients who are not showing for care, removing patients regularly to ensure caseloads have population reach in the clinic)	100%	68%	76%	**	*
8	Conduct patient caseload management	IBH team does outreach regularly to patients on their panel (including phone and letters if necessary) who have not shown for care regularly (e.g., missed two or more consecutive appointments); IBH team helps coordinate care within the clinic (e.g., regular communication between behavioral health and primary care providers to ensure care plans are both in synergy with patient goals and feasible for patients) and with referrals inside and outside of the clinic; IBH team uses systematic tracking (e.g., weekly caseload review to identify patients who are not improving or falling through the cracks to proactively step up care) to inform clinical decision making overtime	96%	68%	71%	**	*

^aRespondents rated the question as either “agree” or “strongly agree.

^*weak match,

^**strong match; X did not match.

Table 4 |.

Principle 3—“Use Evidence-based Behavioral Treatments” related processes, evaluation ratings, and crosswalk to PIP and NCQA measures

#Process Short Description	Process Definition	Important (% agreeda)	Feasible to Measure (% agreeda)	Measurable in the EHR (% yes)	PIP	PCMH/BH
1Deliver care that maximizes evidence based treatment	Health conditions are treated with a combination of all available evidence based treatments (e.g., behavioral, pharmacological, surgical, etc.) in a coordinated fashion (i.e., coordinate behavioral interventions with medication treatments, care plan is developed and updated regularly) - routine consideration of behavioral health treatments in context of other treatments within the context of patient preference	100%	52%	67%	*	**
2Provide evidence-based behavioral treatments that are reinforced across the team	IBH team provides evidence-based behavioral health interventions (e.g., behavioral activation, questioning unhelpful thinking, problem solving, communication skills training, relaxation training, health behavior change for obesity, physical activity, insomnia, tobacco use, substance misuse, chronic pain, etc.) by licensure/training, tailored case management (e.g., housing applications, community resource linkages, etc.), and coordinates psychotropic medications and physical medicine across the team, integrating psychiatric consultation as needed; IBH providers use appropriate interventions to common primary care issues (e.g., diabetes, obesity, chronic pain, tobacco use, chronic conditions, substance misuse, insomnia, depression, anxiety, personal conflict, etc.); IBH providers help patients learn strategies to minimize symptoms and improve function that can be used by the patient outside of the primary care clinic (e.g., skills for self-management strategies that address health and quality of life improvements, engaging family and support as appropriate); IBH providers support medication adherence and relapse prevention planning	92%	28%	50%	**	**
3Provide psychoeducation: Team provides education to the patient about the benefits and details of relevant behavioral health interventions	IBH providers share evidence concerning core elements of treatment (e.g., brief behavioral strategies that can address chronic pain, depression, lifestyle change, etc.) to achieve behavioral health related outcomes; this includes cross-sharing information with the patient and between disciplines of providers	92%	48%	72%	X	**

^aRespondents rated the question as either “agree” or “strongly agree.

^*weak match;

^**strong match; X did not match.

Table 5 |.

Principle 4—“Conduct Efficient Team Care” related processes evaluation ratings, and crosswalk to PIP and NCQA measures

#	Process Short Description	Process Definition	Important (% agreeda)	Feasible to Measure (% agreeda)	Measurable in the EHR (% yes)	PIP	PCMH/BH
1	Establish and maintain clear team roles and workflow	Define and support the roles and responsibilities of the IBH team in the practice (e.g., establish policies and procedures, define and implement triage strategies to IBH teams)	100%	56%	26%	X	X
2	Conduct brief visits as appropriate	IBH providers see patients as needed, keeping treatment focused if possible (e.g., 1–6, 15–30 minute appointments for the majority of patients), and refers out for more intensive treatment (e.g., Cognitive Processing Therapy for PTSD to a specialty outpatient psychologist, community mental health) if focused treatment does not produce the expected results	84%	80%	100%	**	**
3	Maintain strong team communication	IBH team uses clear and consistent communication (e.g., team meetings/huddles, EHR charting, etc.), particularly related to psychosocial issues across the team to facilitate care coordination (note that clear communication does not necessarily ensure care coordination, but is a foundational component needed if it is going to be done well and consistently)	100%	56%	48%	**	**
4	Develop mutual trust among team	IBH team identify and respond to problems in teamwork and collaboration (e.g., address team frustrations), and further develop team functions (e.g., clarify triage and coordination practices as teams mature) to help improve bonds and development of shared goals and tasks with patients	100%	36%	11%	*	X
5	Use a common medical/behavioral language	IBH team uses descriptions of care and shared language that help patients engage each providers’ role and care (e.g., brief descriptions of different providers roles with no jargon)	100%	36%	32%	X	*
6	Perform routine suicide/homicide risk assessment, management, and referrals	IBH team uses consistent steps and strategies (e.g., by following established policies and procedures) to assess, manage, and refer patients to higher level of care at risk for suicide/homicide (i.e., any serious risk to self or others) as indicated by level of evidence based standards of risk	96%	88%	95%	**	**
7	Provide fast and easy access to behavioral health providers	Patients are seen quickly and easily, ideally at the point of primary care when a psychosocial issue is identified (e.g., same day appointments prior to or after the patient is seen by a primary care provider or within 24–48 hours per patient desire and availability), and follows up with the IBH team as needed in a timely fashion based on symptom and function severity and patient desire (e.g., as quickly as possible, typically within a week or two, based on the patient’s availability and the urgency of the care)	100%	84%	85%	**	**
8	Provide patient access and integrated care team consultation to psychiatry	Use psychiatric consultation and care as needed (e.g., consultation on new or non-improving patients with mental health issues) for psychotropic medication care recommendations, differential diagnoses, and treatment for co-morbid psychiatric issues	84%	72%	94%	**	*

^aRespondents rated the question as either “agree” or “strongly agree.

^*weak match;

^**strong match; X did not match.

Implications.

Practice:

The integrated behavioral health (IBH) Cross-Model Framework can be used to create targets for practice improvement efforts that are aimed at improving care through integrated behavioral health in primary care clinics.

Policy:

Policymakers can use the IBH Cross-Model Framework to help incentivize and reimburse primary care clinics who are trying to use and sustain integrated behavioral health.

Research:

Future research should be aimed at identifying which elements of primary care integrated behavioral health are associated with the best patient outcomes.