Simply locating a behavioral health program in the same facility as primary care services won’t accomplish integrated care. While physical proximity is vitally important, integration must take place on many levels – physical, financial, clinical, administrative, and attitudinal –– to achieve a true coordinated, multidisciplinary approach.
It’s a good idea for community health agencies contemplating or initiating an integrated behavioral program to first look at where on a continuum their agency currently falls: LEVELS OF INTEGRATED BEHAVIORAL HEALTH CARE.
An effective tool for readiness self-evaluation has been developed by Keith Miles et al. in "Conceptualizing and Measuring Dimensions of Integration in Service Models Delivering Mental Health Care to Primary Care Patients" below. The assessment instrument measures the level of integration along five basic dimensions: communication; physical proximity of primary and mental health care; temporal proximity of primary and mental care; integration of mental health expertise/services; and integration with respect to the degree of stigma. Click the title to access this measurement instrument.
by Keith M. Miles, MPA, Karen W. Linkins, PhD, Hongtu Chen, PhD, Cynthia Zubritsky, PhD, JoAnn Kirchner, MD, Eugenie H. Coakley, MA, MPH, Louise Quijano, PhD , and Stephen J. Bartels, MD, MS, 2007.
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Dr. Jurgen Unutzer, a leader in the IMPACT depression treatment model and research, posed several fundamental questions clinics needed to ask themselves to prepare for implementation of the model. These questions apply equally to clinics contemplating all types of integrated behavioral care programs:
- How will clients be identified?
- Who will prescribe antidepressants?
- Who will provide counseling/psychotherapy?
- Who will provide mental health back-up?
- Who will track clinical outcomes and how?
- How will treatment changes be initiated?
- How will team members communicate?
- What is the overall implementation strategy?
- Who will lead/coordinate the effort?
- What kind of provider/staff training is needed?
- What structural/program changes are needed?
- What are anticipated barriers and challenges?
- How will we measure success?
- How can the model be sustained?
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Several other instruments are available to both enable clinics to self-assess how prepared they are to undertake integrated care and to point them to specific areas that they need consider. Dale Jarvis, at the behest of the National Council, prepared "High Level Provider Assessment". Case Western Reserve developed the "Integrated Treatment Tool to Evaluate the Integration of Primary and Behavioral Health Care" and the AIMS Center developed the "Patient-Centered Integrated Behavioral Care Principles and Tasks" in consultation with national experts. Besides measuring readiness, the self-assessment survey can serve to direct and focus clinics embarking on integrated care. AIMS also created a team building checklist to help clinics identify and assign specific tasks associated with integrated care.
To assure that our grantees fell all across the spectrum of integrated behavioral care, IBHP developed an Integration Level Survey, a brief checklist grant applicants completed to provide an indication of how closely behavioral services were aligned with general health care at their primary clinics.
FOR MORE READINESS AND ASSESSMENT TOOLS, GO TO "LEVELS OF INTEGRATED BEHAVIORAL HEALTH CARE" AND "OTHER DIMENSIONS OF INTEGRATION" IN THE "WHAT" SECTION OF THIS WEBSITE.
Using the anchors provided in options 16 through 20 below, assign the point score from 0-20 which best describes the array of MH services and expertise available within the primary care setting in the model used to deliver MH care to primary care patients (It is not necessary to select the number associated with any one anchor... just the most appropriate number from 0-20).
Very Low Low Moderate High Very High
0---/---/---/---/---5--/---/---/---/---10--/---/---/---/---15--/---/---/---/---20
Very Low – No specialty MH expertise is available within the PC clinic; standard MH pharmacological interventions may be provided by the PCP on occasion; patients with anything more than minor MH problems are always referred to off-site specialty MH care for the expertise or services needed.
0 Points
Low – Very limited specialty MH expertise is available within the PC clinic; standard MH pharmacological interventions are usually provided by the PCP; patients with modestly complex MH problems are almost always referred to off-site specialty MH care for the expertise or services needed.
5 points
Moderate – Some limited MH expertise is available within the PC clinic, with a trained MH counselor or psychiatrist available for consultation by phone but not in the clinic; standard pharmacological intervention and some short-term counseling for routine MH disorders are provided by the PCP; patients with moderately complex problems are usually referred to off-site specialty MH care for the expertise or services needed.
10 Points
High – Basic MH expertise is available within the PC clinic with a trained MH counselor or psychiatrist on site for face-to-face consultation or/and MH treatment; all pharmacological and many counseling services for MH disorders are available within the PC clinic setting; only patients with complex problems or treatment resistance are usually referred to specialty MH care.
15 Points
Very High – A wide range of specialty MH expertise is available within the PC clinic setting; almost all basic types of MH services are provided within the PC setting by fully qualified MH clinicians; patients with all kinds of MH disorders can be treated at the PC setting, with minimal need to use outside specialty MH expertise or services.
20 Points
Availability of MH Expertise/Service Score (0-20) (Put on Score Sheet): _____
Using the anchors provided in options 21 through 25 below, assign the point score from 0-20 which best describes the extent to which primary care services and MH services are integrated with respect to the elimination of stigma associated with attending a setting for MH services. (It is not necessary to select the number associated with any one anchor... just the best number from 0-20)
Very Low Low Moderate High Very High
0---/---/---/---/---5--/---/---/---/---10--/---/---/---/---15--/---/---/---/---20
Very Low - Wherever located, the MH office or program is known by name and signage, and is referred to by the PCP staff as a separate designated setting for those requiring MH or SA assistance ( i.e. the "Mental Health Office", "Psychiatry Service or Dept.", the "Psych team", the "SA Counselor" "the MH Outpatient Clinic"). Medical and MH staff make no attempt to treat it as other than a separate program for those in need of MH services.
0 Points
Low - Wherever located, the MH office or program may have a name and signage only indirectly related to MH treatment (“Behavioral services”, “Health Counseling”, “EAP Program”), but Medical and MH staff make little attempt to avoid referring to it or treating it as a separate program for those in need of MH services.
5 Points
Moderate - Wherever located, the MH office or program has a distinct separate name and signage but it is not directly related to MH treatment (“Integrated Care Office”, “Collaborative Care Office”). Medical and MH staff do make some attempts to avoid referring to it or treating it as a separate program for those in need of MH services.
10 Points
High - Wherever located, minimal distinction is made, in terms of signage, clinic names, or in the PC staff's references, between the PC setting and the MH setting. Medical and MH staff make real attempts to avoid referring to it or treating it as a separate program for those in need of MH services.
15 Points
Very High - Wherever located, no distinction is made, in terms of signage, clinic names, or in the PC staff's references, between the PC and the MH setting, and Medical and MH staff always avoid referring to it or treating it as a separate program for those in need of MH services.
20 Points
Elimination of Stigma Score (0-20): ____
