Keywords

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. 1.

    Citing and using a published consensus functional definition as a general basis.

  2. 2.

    Using a broad range of handy, concise, and entirely compatible definitions for particular audiences and purposes

  3. 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):

Table 2.1 AHRQ two-sentence “what is it” definition
Full size table

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”:

Table 2.2 AHRQ two-sentence definition augmented with “how” and “supported by” functions
Full size table

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?”

Table 2.3 AHRQ definition with many of its clarifying sub-points
Full size table

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.

Table 2.4 Compatible answers to “what is it” for different audiences and purposes
Full size table

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 .

Table 2.5 Common operating models of behavioral health integration
Full size table

Models are a package of design choices. Here are some important things to remember about “models”:

  1. 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. 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. 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. 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. 1.

    A stepped care protocol

  2. 2.

    A registry for all DIAMOND patients

  3. 3.

    A care manager working with primary care clinicians, patients, consulting psychiatrist

  4. 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.

Table 2.6 A worksheet for balancing fidelity with local tailoring for integrated behavioral healthcare
Full size table

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. 1.

    What is integrated behavioral health in general (a published, professionally grounded definition—the general case)?

  2. 2.

    What does that mean for me here? (Handy context-specific answers to the “what is it” question for various audiences and occasions)

  3. 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.