MODELS OF INTEGRATED BEHAVIORAL HEALTH CARE
We at the Integrated Behavioral Health Project (IBHP) have found that integrated models differ in a number of essential components and along a number of dimensions, among them:
- Use of a screening tool to identify mental health problems. Popular among clinics is the PHQ-9 which identifies and measures depression.
Presence of “warm hand-offs”. Physicians appreciate having behavioral staff immediately available for their clients and a personal introduction by the physician often results the transfer clients' trust to the counselor. However, the current absence of same-day funding in some states has put a damper on this procedure.
- Physical proximity of behavioral staff with medical staff. Most integrated clinics have counselors working alongside the medical providers to enhance collaboration.
- Financial integration. Often grant requirements and other funding streams will dictate the type and course of treatment.
- Use of outcome measures to assess effectiveness. The PHQ-9 is often used not only as a screener but as way to track changes over time. Other clinics use more global measures like the Duke Health Profile.
- Case conferencing between primary and behavioral staff. A few smaller clinics have the luxury of meeting to discuss individual cases regularly, but most confine their conjoint meetings to administrative matters or cross-training. Discussions of individual clients are usually conducted ad hoc on the fly “curb-side” consultation is the rule.
- Use of psychiatrists as service providers or consultants. Retaining a psychiatrist is especially problematic in smaller and/or rural clinics. Some clinics go without psychiatric services; others make use of a “circuit-rider” or access such services via telecommunications.
- Degree of case management. Most clinics are not reimbursed for care/case management and thus, though the need is great, the services are modest.
- Length of therapy. Most clinics have a cap of eight or less therapeutic sessions unless there are special circumstances, with each session lasting 15-30 minutes on average. [For more info, go to Clinical Approaches]
- Therapeutic orientation. Most integrated programs offer behaviorally and cognitively-oriented treatment. The emphasis on the clients' identification of problems and the encouragement for the clients taking an active role to resolve them meshes nicely with the self-help and client empowerment movement. [For more info, go to Clinical Approaches]
- Severity of mental disorders the clinic is willing to treat.
- Physician familiarity with and willingness to prescribe psychotropic medication.
- Involvement of primary care physicians in behavioral care.
- Consolidation/separation of client's record.
- Group or individual self-management sessions designed to help patients' compliance with medical treatment regimen.
- Provision of cross-education: mental health training for primary care providers and medical training for behavioral staff.
- Conjoint consultation.
- “Ownership” and supervision of the behavioral staff.
- Level of involvement of behavioral staff with medical issues. Some behavioral staff are actively engaged in pain management, smoking cessation, dietary issues and other psycho-medical areas. Most are, to some extent, involved in motivating the client to adhere to the medical treatment regimen.
- Relationship with local mental health department and ease of referrals to that system. A common problem expressed by clinics, especially those in rural areas, is the lack of access to the mental health system. The degree of access often dictates the severity level of the clinic?'s clientele.
- Comprehensiveness of feedback provided to the primary care physician by behavioral staff.
- Collaboration with colleges/universities to provide training for students. Some clinics have arrangements to proctor Marriage, Family and
- Child Counselor students or social work graduate students on site.
- Participation in collaboratives. Some clinics are involved in either the Depression or the Diabetes Collaborative, which require both screening and progress measures.
- Presence of a substance abuse program. While many clinics treat substance abuse, there is frequently no separate program for it; rather, it is treated as one of the identified problems to be addressed.
Partners in Health: Primary Care / County Mental Health Collaboration Tool Kit, created by this website host, IBHP, explores models of interaction between these two systems of care. Milbank Memorial Foundation's "Evolving Models of Behavioral Health in Primary Care" gives examples of integration within primary care clinics.
Integrated models can also be drawn up using a number of different dimensions – staffing, organizational framing, population treated, system of care structure and other variables. Below are some commonly accepted model frameworks:
The well-known and widely adopted Four-Quadrant Model is conceptual system-wide framework developed by Barbara Mauer that serves as a guideline for assigning treatment responsibility between the specialty mental health agencies and primary care clinics. The model divides the general treatment population into four groupings based on their behavioral and physical health risks and status, then suggests system elements to address the needs of each particular subpopulation. A discussion of the Four-Quadrant Model and its implications for a countywide or statewide system of care is found in the National Association of State Mental Health Program Director’s “Integrating Behavioral Health And Primary Care Services: Opportunities and Challenges for State Mental Health Authorities.”
The individual quadrants in this conceptual design are as follows:
Quadrant I: Low Behavioral and Physical Complexity/Risk – served in primary care with behavioral health staff on site.
Quadrant II: High Behavioral Health, Low Physical Health Complexity/Risk – served in a specialty behavioral health system that coordinates with the primary care provider, or in more advanced integrated systems, that provides primary care services within the behavioral health setting.
Quadrant III: Low Behavioral, high physical health complexity/risk – served in the primary care/medical specialty system with behavioral staff on site in primary or medical specialty care, coordinating with all medical care providers including disease care managers.
Quadrant IV: High behavioral, high physical health complexity/risk – served in both the specialty behavioral health and primary care/medical specialty systems.
(excerpted from “Integrating Behavioral Health and Primary Care Services: Opportunities and Challenges for State Mental Health Authorities by Barbara Mauer, 2005)
One way to look at an integrated model is to determine the relationship between the behavioral and primary care staff and the responsibility for the behavioral program. The following are some different approaches:
- The specialty mental health system outstations behavioral professionals to work at primary care sites.
- Behavioral staff are hired, trained and supervised by the primary care clinics.
- The primary care clinics “purchase” or contract for behavioral services with the county/state or with private organizations. These services can be in the form of:
-permanent full-time or part-time staff stationed at the clinics;
-telemedicine consultation or direct services originating off-site;
-“circuit-riding” professionals servicing a number of clinics within a particular geographic location.
- Health clinics outstation health workers at mental health sites to conduct screening and routine check-ups.
- Primary care clinics and specialty mental health jointly share costs or grant funding for behavioral services.
- Primary care and specialty mental health providers have a “quid pro quo” arrangement whereby each swaps professional services to the other's treatment population.
- Colleges or universities supply student behavioral health staff as part of their training programs.
Primary care clinics sometimes limit the target population for their integrated behavioral program. The model thus flows from the defined treatment population. Some examples are:
- Targeting the general client population: Behavioral consultants consider everyone in the primary care population eligible for behavioral services. This “wide net” approach, the one most primary clinics use, endeavors to reach as many appropriate clients as possible, but leaves more in-depth services specialized mental health agencies.
- Targeting specific mental disorders: Behavioral consultants screen for and treat only disorders specified in a set protocol.
- Targeting specific levels of disorder severity: The program has “front door” criteria for entry into the program, i.e., a severity and/or impairment threshold, as usually determined by a screening tool.
- Targeting specific physical disorders: Mental health consultants deal with the behavioral components of specific chronic disorders like diabetes or high blood pressure, working with clients on diet, life style changes, medication adherence, and providing training and education about the disorder and how to cope.
- Targeting specific age group: Behavioral consultants screen for and treat only a specified age group, such as minors or seniors.
- Targeting co-morbidity: Behavioral consultants provide enhanced services for a defined group of persons with a co-occurring mental and physical disorder, such as diabetes and depression. Because of its relatively common occurrence and frequent association with physical diseases, depression is often the targeted behavioral component.
- Targeting high utilizers: Behavioral consultants outreach those identified as frequent visit clients and/or those associated with high costs.
Providing only training and education to primary care doctors: The mental health specialists only provide educational support
Providing only consultation to primary care doctors: The mental health specialists provide support to the primary care professional staff rather than delivering direct client treatment
Providing direct counseling/therapy to clients referred by primary care doctors.