NYAPRS Note: A new report from United Hospital Fund and Dr. Henry Chung and Montefiore Medical Center offers a roadmap for primary care physicians to integrate behavioral health treatment into their overall care. It outlines eight key domains of integrated care that include including beneficiaries on multi-disciplinary teams, offering culturally informed supports to encourage improved self-care and linkages with community and social services. The report also suggests a framework that can help practices "map the investments they will need to make in time, training, workforce and resources” to integrate behavioral healthcare.
Advancing Integration of Behavioral Health into Primary Care: A Continuum-Based Framework
Author/Editor: Henry Chung, MD, Nina Rostanski, MPH, Hope Glassberg, MPA, and Harold Alan Pincus, MD
United Hospital Fund
Despite significant prevalence, behavioral health conditions frequently go undiagnosed and untreated. Primary care providers can play a significant role in both diagnosing and facilitating treatment of these conditions, making increasing capacity for treatment of behavioral health conditions in primary care settings a core strategy for improving access to and quality of care. Recognizing the importance of this approach, New York State has prioritized implementation of behavioral health integration models through both the Medicaid Delivery System Reform Incentive Payment (DSRIP) program and the emerging Advanced Primary Care (APC) model.
Although evidence-based integration models work well when implemented properly, there has been relatively little guidance on the underlying steps primary care practices can take to build toward more advanced models, including how smaller and medium-sized practices, in particular, can accomplish integration objectives given resource constraints.
Based on a targeted literature review and input from diverse stakeholders, the framework presented in this guide seeks to provide primary care practices, as well as DSRIP Performing Provider Systems (PPSs) and other organizing entities, with practical guidance on incremental steps to achieve and advance key elements of integrated care for all types of primary care practices.
An Evidence-Based Framework for Primary Care–Behavioral Health Integration
The framework presented in this guide is intended to help practices initiate and develop operational plans to achieve effective, evidence-based integration. The framework lays out on the vertical axis key components of integrated care across integration models, grouped into eight broad domains (see Appendix C).
These domains are:
- Case finding, screening, and referral to care;
- Use of a multi-disciplinary professional team—including patients—to provide care;
- Ongoing care management;
- Systematic quality improvement;
- Decision support for measurement-based, stepped care;
- Culturally adapted self-management support;
- Information tracking and exchange among providers;
- Linkages with community/social services.
Building upon existing literature and stakeholder input, the framework identifies preliminary, intermediate, and advanced representations of each component along the horizontal axis. The rows of the framework represent parallel paths toward integration that can be moved along at different speeds, following a series of incremental steps or guideposts.
Conveying a sense of movement and momentum, the framework’s continuum allows practices to place themselves along the pathway and identify their status within each domain, rather than rigidly anchoring practices to a specific level of integration across domains.
The eight domains of the framework allow practices to increase their capabilities in different aspects of integrated care at different rates, based on resources and practice structure.
Using the Framework
The framework, as outlined briefly below, provides a way for practices to organize themselves based on existing strengths while developing resources to advance their integration. Specifically, we recommend that practices initially use the framework to assess their current state of integration and develop future-state goals. Recognizing that there is latitude on how to advance specific integration components, the framework aims to provide a roadmap for practices to make investments in time, training, workforce, and resources that are necessary to improve the implementation of integration and patient care. However, a practice’s individual characteristics will influence its goals, making achieving the most advanced state of each domain and its components not necessarily the ultimate target for every practice.
A Checklist for Implementing Behavioral Health Integration
GETTING STARTED: MANAGING CHANGE
- Establish commitment from senior leadership and identify practice champions.
THE FRAMEWORK STEP BY STEP
- Assemble an appropriately staffed team to assess the current state of integration.
- Perform a self-assessment, using data to determine current status of practice in each of the components and subcomponents of the framework.
- Perform an environmental scan to identify potential external resources for facilitating integration efforts.
- Prioritize domains for change.
- Set specific, measurable, and achievable 3- to 12-month goals for each component of the framework.
- Assess existing and necessary resources for achievement of integration goals, including capital investments, personnel, and technology costs.
- Assess attainability of goals to ensure they are realistic and appropriate.
Observations and Conclusions
Through ongoing New York State initiatives, there are meaningful opportunities to change the way that behavioral health services are delivered in primary care; however, challenges remain. While this framework offers operational guidance for increasing integration of behavioral health care into primary care, there are external considerations not addressed here that will shape pathways to integration, including regulation, reimbursement, workforce, and other policy issues. Finally, the practice transformation described in this framework requires a fundamental change in practice culture, as both the primary care and behavioral health fields contend with significant workforce shortages in New York State and nationally.
This framework is a work in progress, with more work needed, in particular, on developing metrics that reflect achievement of the key components of integrated care, as well as on incentivizing movement toward increased integration. While discussions of various value based payment approaches are underway, it will be crucial for payers and policymakers to consider intermediate financial incentives to help practices support movement toward
increased integration; this framework may be useful in developing these incentives, in association with measurable performance criteria.
Through ongoing efforts, the authors intend to continue to refine the framework and assess its applicability and utility in the significant transformation underway in New York State.