Primary Care Behavioral Health Model

Integrating behavioral health into primary care settings is a common services integration model. Separate physical and behavioral health systems can lead to fragmented care delivery, poor health outcomes, higher healthcare costs, and duplication of services. Behavioral health integration can increase access to behavioral health services for rural residents, reduce the stigma associated with seeking these services, and maximize resources.

The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) have developed a standard framework for levels of integrated healthcare. The framework describes three main categories of care between behavioral health and primary care practitioners:

Coordinated Care: Coordinated care includes minimal collaboration or basic collaboration at a distance. In this model, primary care and behavioral health providers communicate about shared patients, but maintain separate facilities and systems.
Co-Located Care: Co-located care includes basic collaboration onsite, or close collaboration with some systems integration. Behavioral health and primary care providers in a co-located practice may share the same facility, but not necessarily the same practice space. For example, in one rural community, a primary care practice is located in the same facility as the county's mental health agency. Primary care providers walk their patients over to the agency and introduce them to a clinical social worker.
Integrated Care: Integrated care involves close collaboration in a partly integrated practice or full collaboration in a transformed/merged practice. In this model, providers jointly plan and execute goals, develop integrated care plans, co-manage patients, and maintain shared schedules. Integrated practices use a systematic clinical approach to identify patients who are in need of behavioral health services and engage both providers and patients in shared-decision making.

SAMHSA and HRSA have extensive resources for practices seeking to integrate primary and behavioral health services. The SAMHSA-HRSA Center for Integrated Health Solutions offers a quick start guide to behavioral health integration for safety-net primary care providers, a standard framework for levels of integrated care, strategies for developing a workforce and establishing partnerships, and tools to facilitate billing and financing behavioral health integration.

Many rural communities are seeking to integrate primary care and substance abuse treatment in order to address growing rates of opioid use in rural areas. The Rural Prevention and Treatment of Substance Use Disorders Toolkit provides additional information about integration of mental health services in primary care settings.

Examples of Rural Programs that Integrate Behavioral and Primary Care

A rural Federally Qualified Health Center (FQHC) in Virginia is co-located with the Behavioral Health Services of the Shenandoah Valley Medical System, which offers consultations via a Primary Behavioral Health (PBH) service. The FQHC administers yearly behavioral health screenings to all patients. The primary care practitioner reviews the screenings and refers patients with qualifying scores to the PBH provider for an on-the-spot consultation. If the patient requires ongoing treatment, the PBH provider registers the patient with the behavioral health services department, which provides follow-up care in the same building. Primary care and behavioral health providers can communicate about shared patients through notes in a shared electronic health record.
Cherokee Health Systems, which serves several rural communities in Tennessee, is a national leader in primary care behavioral health integration. Cherokee embeds behavioral health consultants, who are commonly psychologists or clinical social workers, in primary care teams. Primary care providers provide screenings for mood disorders and substance abuse to all patients and co-manage those who screen positive with the behavioral health consultants. The primary care and behavioral health staff also have access to a psychiatrist, often via the telephone or telehealth. All members of the care team, including the psychiatrist, are connected through shared electronic health records. Cherokee Health Systems offers trainings for program planners through their Integrated Care Training Academy.
The Sierra Family Medical Clinic, located in rural Nevada County, California received funding from a Tides Foundation Integrated Behavioral Health Program Grant to develop video case studies that demonstrate warm hand-offs between a primary care and behavioral health provider in a range of situations. The series includes an introduction, and covers topics such as depression with anxiety, bipolar disorder, and pain management, among others.

Considerations for Implementation

A key challenge to integrating behavioral health into primary care is the stigma associated with behavioral health problems and with seeking help for these issues. The Rural Health Information Hub Rural Mental Health Topic Guide describes factors that may influence stigma, which include a lack of understanding of mental illness and prejudice towards people with behavioral health problems. The Rural Health Information Hub Rural Prevention and Treatment of Substance Use Disorders Toolkit also discusses the stigma as a barrier to accessing treatment for substance use disorders.

Rural residents may avoid seeking care because they perceive that they will have a lack of privacy or anonymity in small and close-knit communities. To address this barrier, one rural clinic redesigned the entrance of their clinic and their waiting room to emphasize that they provide integrated services for all patients. In this clinic, all patients enter the same space and undergo the same intake procedures, regardless of their special needs.

Rural program planners need to determine the level of behavioral health integration that is appropriate for their community. While integrating behavioral health services can help maximize the use of scarce rural healthcare resources, specialized behavioral health providers such as psychiatrists are still less likely to practice in rural areas. In areas with significant health provider shortages, rural program planners may consider implementing access to behavioral health services via telemedicine. For example, two nursing homes in rural New York and Vermont partnered with the University of Vermont to provide telepsychiatry services to residents. Additional considerations for implementing a telemedicine intervention are described in the Technology and Telemedicine Model.

Practices that are integrating behavioral health services should structure the workflow of providers to allow time for warm hand-offs between primary care and behavioral health staff. This involves making a face-to-face introduction to the behavioral health provider, which can help transfer the trust from provider to provider.

Program planners may also need to develop a formal communication and supervisory structure to monitor collaboration between behavioral health and primary care staff. Cross-training may be necessary in order to ensure that team members understand both their own roles and responsibilities and the intersection between primary care and behavioral health. Additional considerations for training staff are described in Module 3: Training.

Though consultations, warm hand-offs, conferences, team meetings, and case management can be critical to the success of an integrated care practice, these activities take time and are often not billable. The SAMHSA-HRSA Center for Integrated Health Solutions offers billing and financial information and resources.

Resources to Learn More

Integrating Behavioral and Physical Health Care in the Real World: Early Lessons from Advancing Care Together
Document
Describes the results of a mixed-methods study that assessed and compared how multiple practices were integrating care. The article describes the study methods, practice-level changes, integration challenges, and strategies for addressing those challenges.
Author(s): Davis, M., Balasubramanian, B., Waller, E., Miller, B., Green, L., & Cohen, D.
Citation: Journal of the American Board of Family Medicine, 26(5), 588-602
Date: 9/2013

Rural Behavioral Health Programs and Promising Practices
Document
This report is a summary and analysis of rural behavioral health programs. Descriptions of programs are provided along with highlights of promising practices.
Organizations(s): Health Resources and Services Administration
Date: 6/2011

Rural Mental Health
Website
This topic guide from the Rural Health Information Hub focuses on mental health in rural areas and helps health and human services providers in their efforts to develop, maintain, and expand mental health services in rural communities.
Organization(s): Rural Health Information Hub

Suicide Prevention Toolkit for Rural Primary Care. A Primer for Primary Care Providers
Document
This toolkit offers tools and resources for rural primary care providers who are seeking to implement suicide prevention and treatment practices. It includes assessment guidelines, safety plans, billing tips, sample protocols, and more.
Author(s): Dehay, T., Litts, D., McFaul, M., Smith, C., & West, M.
Organization(s): Western Interstate Commission for Higher Education (WICHE) and Suicide Prevention Resource Center (SPRC)
Date: 2009