Abstract
This chapter defines integrated care using as its foundation a carefully vetted, published definition that is widely sanctioned. More importantly, it explains this official definition and translates it into compatible language both for use within your practice and also for audiences beyond your practice who will have different needs to know what you are doing. The chapter connects this definition to different models of integrated care. It culminates with providing a worksheet to determine how your local approach to integrating behavioral health sustains the essential features of integrated care while customizing it to what your patients need and what can be done under your circumstances.
Access provided by Autonomous University of Puebla. Download chapter PDF
Similar content being viewed by others
Keywords
- Primary care
- Behavioral health
- Integration
- Primary Care Behavioral Health model
- Collaborative Care Model
Preamble
Behavioral health integration can initially mean many things to many people; the concept and its implementation can become a source of confusion for physicians and innovation teams. Clinics can reduce initial ambiguity or confusion with a good enough shared view of what behavioral health integration looks like in action—based on national definitions tailored to the local situation. As a result, clinic leaders and implementers will be much clearer about required functions they need to implement. And their patients will be clearer on what they can expect from integrated behavioral health, once implemented. CJP
Introduction
Behavioral health integration can mean many things to many people. This chapter aims to provide physicians (and their teams) with accurate and practical ways to answer a question they will be asked over and over by different people at different times for different purposes:
“What is integrated behavioral health anyway?”
This aim is accomplished by helping a physician champion, other clinicians, and practice team members be comfortable in:
-
1.
Citing and using a published consensus functional definition as a general basis.
-
2.
Using a broad range of handy, concise, and entirely compatible definitions for particular audiences and purposes
-
3.
Being able to move from a general definition to a realistically tailored local implementation
A physician champion or innovation team can retain responsiveness to published literature and definitions while proceeding realistically in his or her own real world and the people in it. While doing this could sound like a recipe for “mush” or “anything goes,” this chapter offers systematic thinking on how to tailor your local work to general requirements and focus basic definitions to fit the situation at hand. This is to preserve the clinician’s need to remain professionally responsible while being practical “in the moment and on the ground”—communicating well and briefly to anyone who asks.
think about different compatible definitions for different purposes.
Part of working with definitions and being a systematic good communicator is being comfortable with a wide range of different, but compatible and accurate answers to “what is integrated behavioral health,” not just one “best” definition. What all these definitions should have in common is being concise—which means (1) expressing all the important information and (2) in few words. This implies a balance between “brief” and “detailed enough.”
In your communications as a clinician or leader in your clinic, you will constantly be balancing “all the important information” and “in few words.” The balance you strike depends on who you are talking to and their purposes—what aspects they are interested in and how many “pixels” in the picture they need to see right then. A rule of thumb is to create short handy definitions with distillations of key elements from the full-blown definitions. In that way, you are not introducing a different “picture,” just taking pixels out of the original picture—and you can add them back selectively as needed for different purposes while keeping the essence the same.
As you will see in Sect. 2.1, the published consensus definition (from the United States Agency for Healthcare Research and Quality, AHRQ ) contains as much or more information or “pixels” that you could ever want. But it is designed so that it can be progressively streamlined or “compressed”—down to two sentences if needed. As you will see in Sect. 2.2, simply expanding or compressing a general published definition likely does not meet all your needs to answer “what is it” as asked by different people with different purposes. For this purpose, you will need a range of concise answers focused on what that person wants to know.
Use the Published AHRQ Consensus Definition as an Expandable Basis for Conversation
Published agreement exists through AHRQ [1] on what high-level functions are required to count as genuine integrated behavioral health—what it looks like in action. This is an extended consensus definition created by a panel of well-known leaders and implementers in the field. It is an excellent reference, “north star,” and professional resource, even though far too detailed for most everyday conversation.
First, the two-sentence “what is it” definition (Table 2.1):
Note the broad scope of what is meant by “behavioral health” in the second sentence, far broader than diagnosable mental illnesses and conditions.
For a little more detail, use the “how” part of the definition. If you use the two-sentence definition but ask, “how do you do it,” Table 2.2 shows the required functions of integrated behavioral health. This adds a few more “pixels”:
This definition includes not only a clinical “how,” but an organizational “supported by”—because the clinical methods cannot be built or sustained without these organizational supporting functions well enough in place.
This enhancement to the two-sentence definition may be quite enough for most conversations. But at other times, you will hear, “Please be specific about what is involved.” Table 2.3 shows the AHRQ definition expanded with many of its clarifying sub-points. That many “pixels” are likely required for conversations about implementation—“what do I have to build exactly?”
The published AHRQ definition includes much more than you see in Table 2.3, should you need it, e.g., elements of a shared integrated behavioral healthcare plan and elements of systematic follow-up and adjustment of treatment. It has a table of contents with links, with more detail than you probably ever want to know.
The AHRQ definition is not the only useful resource. For example, the SAMHSA-HRSA “Standard Framework for Levels of Integrated Healthcare” has a structure you can adapt in the same way—starting with a one- or two-sentence definition and adding specifics or “pixels” to the picture as needed [2].
But there is more to having a broad repertoire of handy answers to “what is it” than compressing or expanding the AHRQ or other published definitions. You will likely need handy definitions for the needs and concerns of particular audiences and purposes.
Have a Range of Handy Answers to “What Is It” for Particular Audiences and Purposes
A clinician or other practice leader will be asked the “what is integrated behavioral health” question in all kinds of situations by all kinds of people with different purposes and different need for detail. So you will want a range of different, but entirely compatible answers or “definitions” tailored to different people and purposes. Having concise and contextually appropriate answers to “what is integrated behavioral health” can be regarded as a leader function that is open to all—as described in Chap. 5.
Table 2.4 offers examples of equivalent definitions or answers for different persons commonly encountered in the primary care environment . Because these persons have different purposes in asking the question, the answers are different, but equally accurate and almost equivalent. The content within all these sample responses can be found within the AHRQ definition, but is translated for use by the person and purpose at hand.
These are only examples. You can tailor your own responses that could be given between floor 1 and 2 on an elevator. But they could be followed with “Would you like to know more about that?” This would open the path for another layer of information for anyone interested—such as in Tables 2.1, 2.2, and 2.3 showing the AHRQ definition.
Be Able to Move from General Definitions to Your Own Locally Tailored Implementation
The AHRQ definitions of Tables 2.1, 2.2, and 2.3 or person-specific examples in Table 2.4 do not try to prescribe a specific granular implementation for your practice . There is too much to take into account locally to make any universal detailed prescription realistic. Just as a great definition of “airliner” does not include the mechanical drawings for any specific airplane, the functional definition of integrated behavioral health does not include exactly what to implement in your own clinic. Yet the need remains for a specific implementation that works for your purposes.
Some implementers employ a “model of integration ” to help tie general definition to specific implementation. A “model” is simply one of the currently recognized ways to operationalize the functions required in a general definition. Operating models are different means to the same or similar ends, but represent different distinguishable ways to “skin the cat” in different settings. Hence conversations about “what is integrated behavioral health” sometimes include the question, “What models of integration are out there and should I use one of them?”
It is worth pausing here to briefly describe common “models” that people may have heard about. Read Table 2.5 as a general guide, knowing that the terminology and specifics within these models are variable, evolving, and entail considerable overlap. For example, the first two models in the table (Primary Care Behavioral Health and Collaborative Care Model) are sometimes featured independently as anchoring models and sometimes are combined in actual implementations. In academic settings such as family medicine residencies , one or both may be combined with the “residency behavioral science education” model .
Models are a package of design choices. Here are some important things to remember about “models”:
-
1.
Models are shorthand for particular approaches to accomplishing the same core functions—a pattern of design choices. For example, the Collaborative Care Model archetypically features a primary care physician, care manager, and consulting psychiatrist collaborating using a registry for “treatment to target” for one or more conditions.
-
2.
Models often emerge from different research or practice cultures. For example, the Primary Care Behavioral Health model emerges from clinical practice culture, typically aimed at a wide variety of patient conditions and situations (“all comers”). The Collaborative Care Model emerged from a research culture (originally on late-life depression) and has gradually been extended to multiple conditions.
-
3.
Different models may be chosen based on practicalities—what or who is available to do the work, and what operational or information systems are available. For example, the Collaborative Care Model might be difficult to implement in an area with no psychiatrists, or none willing to work as consultants to primary care providers.
-
4.
All “models” are a means, not an end. They must accomplish the same basic functions of the AHRQ definition or equivalent general definitions. There is little point in arguing about “which flavor of integrated care” is best [3]. Each model has its own origins and properties, but they tend to mix and converge over time. Keep your eye on the defining functions of integrated behavioral health and “models” as a means to achieving them.
fidelity to a model or definition also requires realistic local tailoring, whether designing an implementation using a model of integration as a pattern, or working directly from the general definitions, to work…
…in your own practice,
…with what you can gather around you at the time you begin,
…at the pace you can move,
…with your own target starter populations and purposes, and
…with the resources and tolerance for change around you.
Implementing integrated behavioral health on a meaningful scale requires a definition or model to be scaled up (a pattern to be followed) and local tailoring (making it work well in local reality). There is value in both, and tension between “standardization” and “anything goes” does not go away. These are the characteristics of “polarities” requiring that you strike a balance between them [16,17,18,19,20,21,22,23].
Balance means preserving the general case while creating a local special case; the essence of the definition and what within it needs to be locally adapted. And do not leave that balance to the imagination. Actual implementation requires a shared understanding at a practical level of detail on what requires fidelity and what is locally tailored. Let us consider two examples of local tailoring to a specific model of integration.
Example 1
The DIAMOND Initiative was a Minnesota statewide initiative for care of depression following the Collaborative Care Model (CCM) , with a care manager and consulting psychiatrist working with primary care providersFootnote 1 [12, 17, 22, 24]. Especially because it had to be scaled up to 75 practices statewide, it was essential to be clear what components were essential—the core features—and what aspects of those components the practices had to do or decide for themselves. DIAMOND required fidelity to four components:
-
1.
A stepped care protocol
-
2.
A registry for all DIAMOND patients
-
3.
A care manager working with primary care clinicians, patients, consulting psychiatrist
-
4.
A consulting psychiatrist
These were all required to participate in DIAMOND. Clinic training materials included highly specific definition of those four components plus specifically what the clinics would need to build or adapt to their own situations.Footnote 2 Here are a few examples of what every practice did:
-
Tracked a certain set of data, but the type of medical record or tracking system was up to the practice.
-
Had a dedicated care manager trained by the project, but the discipline was up to the practice, e.g., nurse, social worker, behavioral health clinician, medical assistant.
-
Received a care management fee, but each practice negotiated its own rate with payers.
The required functions and what was to be locally decided were made explicit at the outset to minimize confusion across the 75 practices and to prevent both “cookie cutter” prescriptions that would exclude many practices, and so much diffusion of the intervention by “local tailoring” such that “anything goes.”
Example 2
Local tailoring can be done directly to a functional definition of integrated care without an intervening model. The AHRQ “lexicon” definition of integrated behavioral health does not entail or recommend a “model” such as CCM or PCBH. Table 2.6 shows a worksheet that can be used by your practice to help your implementation team be clear about what your clinic(s) can and must decide or do for yourselves given your local situation. Of course, this worksheet still does not actually tell you what you are going to do. But the “local tailoring” column asks the questions for which you will need answers. You can fill in those specific answers—which would begin to sketch out your own “special case” of integrated behavioral health.
Conclusion
This chapter has been a long answer to the question, “What is integrated behavioral health?” All practice leaders and implementers may need to answer this in one or more of the three ways outlined here:
-
1.
What is integrated behavioral health in general (a published, professionally grounded definition—the general case)?
-
2.
What does that mean for me here? (Handy context-specific answers to the “what is it” question for various audiences and occasions)
-
3.
How specifically will we make it work with who we are here? (The locally tailored implementation that you will be creating in your own clinic.)
With these three ways to answer “what is it,” your team can retain responsiveness to published literature and definitions while proceeding realistically in your real-world situation with the people in it; preserving the need to remain professionally responsible, and be practical about implementing things in the local context, and communicating well and briefly to anyone who asks.
Notes
- 1.
The DIAMOND Initiative (Depression Improvement Across Minnesota, Offering a New Direction) was a cooperative effort of 75 practices from small and large provider groups, supported by a financial model from all four major health plans and the Minnesota Dept. of Human Services, and facilitated by the Institute for Clinical Systems Improvement, a regional quality improvement organization.
- 2.
DIAMOND fidelity/local tailoring examples were extracted by the author from training materials supplied to all practices.
References
Peek CJ and the National Integration Academy Council (2013). Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. http://integrationacademy.ahrq.gov/lexicon.
Standard Framework for Levels of Integrated Healthcare. Center for Integrated Health Solutions, SAMHSA-HRSA. http://www.integration.samhsa.gov/resource/standard-framework-for-levels-of-integrated-healthcare
Unützer J. Which Flavor of Integrated Care? Psychiatric News. 2014;49(20)
References for PCBH model
Reiter JT, Dobmeyer AC, Hunter CL. The primary care behavioral health (PCBH) model: an overview and operational definition. J Clin Psychol Med Settings. 2018 Feb;26:109. https://doi.org/10.1007/s10880-017-9531-x.
Vogel ME, Kanzler KE, Aikens JE, Goodie JL. Integration of behavioral health and primary care: current knowledge and future directions.J. Behav Med. 2017;40(1):69–84. https://doi.org/10.1007/s10865-016-9798-7.
Beehler GP, Lilienthal KR, Possemato K, Johnson EM, King PR, Shepardson RL, et al. Narrative review of provider behavior in primary care behavioral, vol. 35. How Process Data Can Inform Quality Improvement. Fam Syst Health: Health; 2017. p. 257. https://doi.org/10.1037/fsh0000263.
Funderburk J, Dobmeyer A, Hunter C, Walsh C. Provider practices in the Primary Care Behavioral Health (PCBH) model: an initial examination in the Veterans Health Administration and United States Air Force. Families, Sytems, & Health. 2013;31(4):341–53. https://doi.org/10.1037/a0032770.
References for CCM model
The University of Washington AIMS Center. https://aims.uw.edu/collaborative-care
Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noël PH, Lin EH, Areán PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C. Collabrative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–45.
Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611–20. https://doi.org/10.1056/NEJMoa1003955.
Bauer AM, Azzone V, Goldman HH, Alexander L, Unutzer J, Coleman-Beattie B, Frank RG. Implementation of collaborative depression management at community-based primary care clinics: an evaluation. Psychiatr Serv. 2011;62(9):1047–53. https://doi.org/10.1176/appi.ps.62.9.104710.1176/ps.62.9.pss6209_1047.
Solberg LI, et al. The DIAMOND initiative: implementing collaborative care for depression in 75 primary care clinics. Implementation Science. 2013;8:135.
References on integration of primary care in mental health settings (“reverse integration”)
Maragakis A, Siddharthan R, RachBeisel J, Snipes C. Creating a ‘reverse’ integrated primary and mental healthcare clinic for those with serious mental illness. Prim Health Care Res Dev. 2016 Sep;17(5):421–7. https://doi.org/10.1017/S1463423615000523.
Gerrity, M., Zoller E. et al. Milbank memorial fund. Integrating primary care into behavioral health settings: What works for individuals with serious mental illness. 2014. https://www.integration.samhsa.gov/integrated-care-models/Integrating-Primary-Care-Report.pdf
Reference to medical family therapy
McDaniel S, Doherty W, Hepworth J. Medical Family Therapy and Integrated Care (second edition). Washington, DC: American Psychological Association; 2014.
Barry Johnson (1992). Polarity management: identifying and managing unsolvable problems. HRD Press. See also www.polaritymanagement.com.
Literature relevant to fidelity and local tailoring:
Crain AL, et al. Designing and implementing research on a statewide quality improvement initiative: The DIAMOND study and initiative. Med Care. 2013;51(9):e58–66.
Fleuren M, et al. Multiple determinants of innovation adoption. Int J of Quality Health Care 16:107–23.
Callahan CM, et al. Implementing dementia care models in primary care settings: The Aging Brain Care Medical Home. Aging Ment Health. 2011;15(1):5–12.
Kitson AL, et al. Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implementation Science 2008;3:1. https://doi.org/10.1186/1748-5908-3-1
Stroebel CK, et al. How complexity science can inform a reflective process for improvement in primary care practices. Jt Comm J Qual Patient Saf. 2005;3198:438–46.
Solberg LI, et al. Partnership research: a practical trial design for evaluation of a natural experiment to improve depression care. Med Care. 2010;48(7):576–82.
Crabtree BF, Miller WL, Stange KC. Understanding practice from the ground up. J Fam Pract. 2001;50(10):881–7.
DIAMOND
Solberg LI, et al. A stepped wedge evaluation of an initiative to spread the collaborative care model for depression in primary care. Ann Fam Med. 2015;13:412–20.
Resources
In addition to providing definitions and frameworks, these two organizations provide a package of resources for integrated behavioral health:
The AHRQ Academy for Integration of Behavioral Health and Primary Care: https://integrationacademy.ahrq.gov
The Substance Abuse and Mental Health Services Administration—Health Resources and Services Administration (SAMHSA-HRSA)’s Center for Integrated Health Solutions: https://www.integration.samhsa.gov
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Peek, C.J. (2019). What Is Integrated Behavioral Health?. In: Gold, S., Green, L. (eds) Integrated Behavioral Health in Primary Care. Springer, Cham. https://doi.org/10.1007/978-3-319-98587-9_2
Download citation
DOI: https://doi.org/10.1007/978-3-319-98587-9_2
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-98586-2
Online ISBN: 978-3-319-98587-9
eBook Packages: MedicineMedicine (R0)