Expand patient care and improve practice efficiency

Behavioral Health Integration into Ambulatory Practice

  • Elizabeth Drake, MD University of Michigan
  • Marcia Valenstein, MD, MS University of Michigan
CME Credits: 0.5
Behavioral Health Integration into Ambulatory Practice

How will this module help me embed behavioral health
in my practice?

  1. Five steps to implement your new model
  2. Answers to commonly asked questions
  3. Examples of practices that have successfully implemented an integrated behavioral health model

CME accreditation information 

Increasing administrative responsibilities—due to regulatory pressures and evolving payment and care delivery models—reduce the amount of time physicians spend delivering direct patient care. Embedding behavioral health within primary care or select secondary care practices expands the services a patient can receive. By bringing medical and psychosocial services together with primary care, the team is better able to meet both the mental and general health needs of the patient.

Behavioral health integration into ambulatory practice
Release Date: October 2015
End Date: October 2019

Objectives

At the end of this activity, participants will be able to:

  1. Assess current processes and resources to determine the behavioral health model that will work best for the practice and its patients.
  2. Describe how to integrate complementary team-based care roles.
  3. Determine how to incorporate behavioral health services into team-based primary care.
  4. Identify metrics to track and monitor the embedded behavioral health model over time.

Target Audience

This activity is designed to meet the educational needs of practicing physicians.

Statement of Need

The integration of behavioral health professionals into the primary care team provides a more effective and efficient mechanism to address patient behavioral and mental health needs. Embedding behavioral health within primary care expands the services a patient can receive during their regular primary care appointments. By bringing medical and psychosocial services together, the team is better able to conveniently and consistently meet both the general and mental health needs of their patients.

Statement of Competency

This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Accreditation Statement

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The American Medical Association designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claiming Your CME Credit

To claim AMA PRA Category 1 Credit™, you must 1) view the module content in its entirety, 2) successfully complete the quiz answering 4 out of 5 questions correctly and 3) complete the evaluation.

Planning Committee

  • Alejandro Aparicio, MD, Director, Medical Education Programs, AMA
  • Rita LePard, CME Program Committee, AMA
  • Anita Miriyala, Graduate Intern, Professional Satisfaction and Practice Sustainability, AMA
  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA
  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
  • Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

Author(s)

  • Elizabeth Drake, MD, General Internist, University of Michigan
  • Marcia Valenstein, MD, MS, Professor, Department of Psychiatry, University of Michigan Medical School and Senior Research Scientist, Department of Veterans Affairs, University of Michigan

Faculty

  • Arshiya A. Baig, MD, MPH, Assistant Professor of Medicine, University of Chicago
  • Sonal Saraswat Gupta, MD, FACP, Internal Medicine, Heritage Medical Associates
  • John C. Fortney, PhD, Professor and Director, Division of Population Health, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington
  • Jeffrey M. Pyne, MD, Central Arkansas Veterans Healthcare System
  • Andrew Schutzbank, MD, MPH, Vice President, Clinical Development, Iora Health
  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA
  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
  • Marc Avery, MD, Clinical Professor, Associate Director for Clinical Services, AIMS Center University of Washington

About the Professional Satisfaction, Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement

The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

Media Types

This activity is available to learners through Internet and Print.

Hardware/software Requirements

Adobe Flash 9.0.115 or above
Audio speakers or headphones
Screen resolution of 800X600 or higher
MS Internet Explorer 8.0 or higher, Firefox, Opera, Safari, etc.
Adobe Reader 5.0 or higher

References

  1. University of Washington, Psychiatry & Behavioral Sciences, Division of Integrated Care & Public Health. Advancing Integrated Mental Health Solutions (AIMS) Center. Collaborative Care Staffing Ratios. http://aims.uw.edu/resource-library/collaborative-care-staffing-ratios. Accessed August 10, 2015.
  2. University of Washington, Psychiatry & Behavioral Sciences, Division of Integrated Care & Public Health. Advancing Integrated Mental Health Solutions (AIMS) Center. Education & Training. https://aims.uw.edu/program-area/education-training. Accessed August 10, 2015.
  3. Vanderbilt University School of Nursing. Health Coaching Certificate Program http://www.nursing.vanderbilt.edu/certificate/health_coaching.html. Accessed August 10, 2015.
  4. Duke Integrative Medicine. Integrative Health Coach Training. https://www.dukeintegrativemedicine.org/integrative-health-coach-training/. Accessed August 10, 2015.
  5. National Society of Health Coaches. http://www.nshcoa.com/. Accessed August 10, 2015.
  6. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10:CD006525.
  7. Cochrane. Collaborative care for people with depression and anxiety. http://www.cochrane.org/CD006525/DEPRESSN_collaborative-care-for-people-with-depression-and-anxiety. Accessed August 10, 2015.
  8. University of Washington, Psychiatry & Behavioral Sciences, Division of Integrated Care & Public Health. Advancing Integrated Mental Health Solutions (AIMS) Center. Collaborative Care Case Study: Behavioral Health Integration Program. http://aims.uw.edu/collaborative-care-case-study-behavioral-health-integration-program. Accessed August 10, 2015.
  9. University of Washington, Psychiatry & Behavioral Sciences, Division of Integrated Care & Public Health. Advancing Integrated Mental Health Solutions (AIMS) Center. Impact Training. http://aims.uw.edu/resource-library/impact-training. Accessed August 10, 2015.
  10. Unützer J, Chan YF, Hafer E, et al. Quality improvement with pay-for-performance incentives in integrated behavioral health care. Am J Public Health. 2012;102(6):e41-e45.
  11. Smith TE, Erlich MD, Sederer LI. Integrated care: integrating general medical and behavioral health care: the New York State perspective. Psychiatr Serv. 2013;64(9):828-831.
  12. Substance Abuse and Mental Health Services Administration (SAMHSA)-Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions. Behavioral Health in Primary Care. Integrating behavioral health into primary care. http://www.integration.samhsa.gov/integrated-care-models/behavioral-health-in-primary-care. Accessed August 10, 2015.
  13. SAMHSA-HRSA Center for Integrated Health Solutions. Patient Health Questionnaire (PHQ-9). http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf. Accessed August 10, 2015.
  14. SAMHSA-HRSA Center for Integrated Health Solutions. Generalized Anxiety Disorder 7-item (GAD-7) Scale. http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf. Accessed August 10, 2015.
  15. SAMHSA-HRSA Center for Integrated Health Solutions. Stable Resource Toolkit: AUDIT-C. http://www.integration.samhsa.gov/images/res/tool_auditc.pdf. Accessed August 10, 2015.
  16. U.S. Department of Health and Human Services. National Institutes of Health. PROMIS. http://www.nihpromis.org/default#2. Accessed August 26, 2015.

Introduction

What does it mean to integrate behavioral health into ambulatory practice?

Many medical conditions are greatly affected by patients’ behavioral choices and mental health issues. Physician-led primary care teams often must address many common mental health disorders, such as depression, anxiety and substance abuse. In addition, behavioral and lifestyle issues, such as smoking, lack of exercise and poor sleep, impact many aspects of health. By bringing medical and behavioral health services together within primary care, the team is better able to meet both the mental and general health needs of the patient.

Practice transformation through organizational development introduction

Five steps for integrating a behavioral health model into ambulatory care

  1. Assess current needs and resources
  2. Design a team-based care model
  3. Train members of the primary care team
  4. Implement the team-based behavioral health model
  5. Monitor and improve processes
  1. 1

    Assess current needs and resources

    Physician-led primary care teams are in a position to effectively screen patients for a range of behavioral health issues and to systematically follow up on treatment response. These issues could include mild to moderate depression or anxiety. The practice team should review the ways in which behavioral health issues are currently being identified and followed. Defining existing behavioral treatment resources will allow a practice to accurately identify any additional resources that might be needed, such as an embedded behavioral health specialist. Determine the practice needs for behavioral health resources based on your patient population. Caring for a large population of patients with mild or moderate depression or anxiety may warrant the development of a model with a set of resources that is different than that used for patients with chronic disease who need behavior and lifestyle support. Through this exercise, your practice will determine whether, for example, training a nurse to become a behavioral health care manager or hiring a social worker to become the practice’s behavioral health specialist will work best based on your patient population’s needs.

Integrate behavioral health into ambulatory practice for your patients #STEPSforward

  • Which patients would benefit most from an integrated behavioral health model?

    This model is most appropriate for patients with mild to moderate depression and anxiety. The resources allocated to support the model within the primary care practice can also be impactful for patients who have behavioral or educational needs based on a lifestyle-altering condition, such as obesity, diabetes or hypertension. The model is not meant to meet the needs of patients who have acute suicidal ideation or unstable psychosis. These patients should be under the direct care of a psychiatrist.

  • How many patients with behavioral health needs do I need to have to warrant embedding a behavioral health specialist?

    The ideal staffing ratio depends on the model of care that is used and the patient population. The University of Washington Advancing Integrated Mental Health Solutions (AIMS) Center has created a matrix of staffing ratios for diverse clinic settings with recommendations about the use of full-time equivalent (FTE) care managers and psychiatric consultants based on the size and needs of the patient population. It also includes the suggested case load for each care manager within the model. Tools like this matrix can help your practice determine the resources required to support your patients.

  1. 2

    Design a team-based care model

    In an embedded behavioral health model, team members will often have complementary roles in providing care to patients with mental health conditions. Frequently, the integrated behavioral health care team will include the patient, the primary care physician (PCP), a behavioralist and a consulting psychiatrist. The behavioralist may be a behavioral health case manager (often a social worker or nurse), a medical assistant (MA) or lay person trained to do lifestyle counseling or a clinical psychologist. In most models, the clinical psychologist is involved on a consultative basis. The physician-led team works together with shared goals, treatment plans, workflows and, ideally, in at least a partially co-located space to increase team member communication and collaboration. The PCP and/or psychiatrist supervise the hands-on work of the behavioralist and collaborate in frequent patient panel reviews with the team to identify patient needs and opportunities for intervention. In more remote areas or smaller practices, the behavioralist or psychiatrist may consult via telemedicine; this may be a more cost-effective and feasible approach to offering behavioral health services.

  • What should our model look like?

    Models vary depending on patient needs and practice capabilities. While this module describes the optimal model for providing basic mental health care, some practices may expand their model to offer a broader panel of behavioral health services. Some models include a lay person behavioralist who has been trained in lifestyle counseling for weight loss, exercise and smoking cessation. This person would function as an advanced health coach, and the position could be filled by a high-performer who already works in the practice and has an interest in additional training. Another practice model may involve a nurse or social worker who provides lifestyle counseling and addresses anxiety, depression, sleep disturbances and social-service needs. Additionally, most models involve a psychiatrist who is available to consult in-person or virtually with the behavioralist and/or PCP on the management of patients with more complex psychiatric problems. Of these options, you may find that one model or a hybrid will work best for your practice.

  • What is a warm hand-off and how does it improve care?

    A warm hand-off gives the PCP, MA or nurse the opportunity to directly hand off the patient to their behavioralist. During a conversation with the patient during rooming, for example, the MA may find that the patient needs a more in-depth assessment by a behavioralist. Paging the behavioralist directly to the room and involving the patient in the transition of care to that person increases their credibility and the patient’s trust in them. It also eliminates the need for the patient to schedule a follow-up appointment with a behavioralist, which is an additional step that may not be taken by patients.

  • Could the behavioralist be shared among multiple physician-led teams in a practice?

    Yes. A behavioralist could support multiple clinicians within a practice. It is possible that s/he could support multiple clinics, though a warm hand-off of care is ideal and is more often possible if the behavioralist is available on site. The practice can try to anticipate which patients will require assistance from a behavioralist and request their presence while the patient is still in the clinic. This will ensure that the warm hand-off occurs seamlessly, thereby decreasing wait time for the patient, PCP and behavioralist.

  1. 3

    Train members of the primary care team

    In training the physician-led team to appropriately integrate behavioral health into patient care, there are several critical elements that should be covered.

    1. A
      Know how and when to give mental health assessments.

    The team members who will be rooming patients and conducting pre-visit planning should be trained in how to give mental health screens using a PHQ-2 or PHQ-9. On a pre-visit questionnaire, there may be a question that is a “trigger” for a more in-depth mental health assessment, such as “Have you felt down, depressed or hopeless or lost interest in doing things lately?”

Train members of the primary care team
    1. B
      Recognize triggers for involving behavioral health.

    Events such as a death in the family, job loss, a recent cancer diagnosis (for the patient, a partner or friend), domestic abuse or a history of depression or some other psychiatric condition should trigger a behavioral health assessment and, potentially, a behavioral health referral. For a patient who possesses one or more of these triggers, the practice may decide that they want the behavioralist to be proactively involved in the patient’s care.

    1. C
      Understand the behavioral health referral process.

    When a patient does require a behavioral health intervention, make sure the team knows what pathway to follow. Should the patient be assessed that day? Do they need a full consult with a psychiatrist? Create processes and protocols for staff to recognize when the behavioralist should become involved. Also, ensure that the staff knows which aspects of patient follow-up are their responsibility and which belong to the behavioralist. This should be determined based on shared practice protocols.

  1. 4

    Implement the team-based behavioral health model

    In a physician-led team-based behavioral health model, the entire team—the PCP, behavioralist, nurses, MAs and the consulting psychiatrist—will work together to provide collaborative care to patients.

    • The MA or nurse assesses the patient for mental health needs by listening for triggers and reviewing any screening questions on the pre-visit questionnaire.
    • The PCP implements screening and monitoring tools for mental health disorders, makes the diagnosis, initiates treatment and manages medications.
    • The behavioralist (e.g., nurse, care manager or social worker) monitors depression symptom severity, treatment adherence and side effects and reports these results to the PCP. Depending on training and skill level, the behavioralist can also provide motivational interviewing, problem solving therapy, behavioral activation and/or grief support.
    • A consulting psychiatrist can assist with review of the panel of patients with behavioral health issues and/or answer the PCP's questions about diagnosis and medication management in more complex situations or as needed.
  1. 5

    Monitor and improve processes

    After the new model has been implemented, the team has the opportunity to continually refine and improve the process. Identifying metrics to track prior to implementation will help the team stay focused and monitor improvement over time. Include these metrics on the practice dashboard or scorecard, and consider them as part of the practice’s most important quality metrics. Examples could include the following:

    • Increased referrals to behavioralist
    • Increased percentage of patients on antidepressants seen by behavioralist
    • Increased use of the following forms:
    • Improved medication adherence
    • Decreased depression scores
    • Fewer emergency department visits
    • Fewer readmissions

    Continuous training, reminders and development opportunities for the team members, including the behavioralist, nurses and MAs, will help them continue to develop their skillsets and more fully integrate their behavioral health knowledge into their daily interactions with patients.

    Finally, to keep the focus on improvement, keep the behavioral health team on the agenda at team meetings. This will give the team the opportunity to continuously explore ways to collectively make the process better, increase communication and keep everyone focused on providing the best care to patients.

  • What patient outcomes should we expect to see?

    From a patient perspective, success will correlate with decreased symptoms as reflected in improved scores on symptom-based scales or improved functioning. Population health data will reflect decreased symptoms, improved functional status and enhanced well-being and quality of life for patients. The success of the program will also be reflected in the satisfaction of the health care team members as they provide their patients with quality care in a timely, integrated fashion. PROMIS provides tools to help your practice identify how to measure the important indicators that you choose to evaluate.

  • Can you give examples of patients who received care from an integrated behavioral health team?

    Patient 1: Anna is a 52-year-old female who has a history of depression and who has been stable on fluoxetine daily for many years. At the patient’s yearly physical, the MA administers a PHQ-9 screen that identifies increasing mood symptoms, and the MA alerts the physician. The patient confides in her physician that she and her husband have recently separated in the setting of infidelity. Over several months, her PCP titrates her fluoxetine upwards to 40 mg daily and ultimately adds Wellbutrin XL for augmentation, but no improvement is seen and the patient reports experiencing unwanted side effects. She is referred to the behavioral health care manager for brief psychotherapy over six weeks. Through a routine panel management meeting, her case is reviewed with the embedded psychiatrist who recommends a transition to Effexor. Her PCP implements this plan with the support of the behavioralist. The patient is reevaluated in six weeks and is found to have significant improvement in her symptoms.

    Patient 2: Rhoda is a 39-year-old female who has had stable depression for five years on bupropion. She is enrolled in a depression population registry through her PCP’s office. The behavioralist calls her every three months and administers a PHQ-9 over the phone. The patient consistently scores less than 4 (favorable) until the most recent call, when she scores 17 (indicative of residual depressive symptoms). The behavioralist learns of the recent unexpected death of the patient’s child. He schedules an urgent appointment with her PCP who diagnoses the patient with recurrent depression and prescribes trazadone and sertraline. The case manager provides grief counseling and also refers her to a grief support group. Over time, the patient reaches her treatment goals.

Conclusion

Embedding behavioral health within primary care or select secondary care practices expands the services a patient can receive in their primary care clinic. It is convenient for the patient (one-stop shopping). In addition, many medical conditions are greatly impacted by patients’ behavioral choices and mental health issues. By bringing medical and psychosocial services together within primary care, the team is better able to meet both the mental and general health needs of the patient.

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References

  1. University of Washington, Psychiatry & Behavioral Sciences, Division of Integrated Care & Public Health. Advancing Integrated Mental Health Solutions (AIMS) Center. Collaborative Care Staffing Ratios. http://aims.uw.edu/resource-library/collaborative-care-staffing-ratios. Accessed August 10, 2015.
  2. University of Washington, Psychiatry & Behavioral Sciences, Division of Integrated Care & Public Health. Advancing Integrated Mental Health Solutions (AIMS) Center. Education & Training. https://aims.uw.edu/program-area/education-training. Accessed August 10, 2015.
  3. Vanderbilt University School of Nursing. Health Coaching Certificate Program http://www.nursing.vanderbilt.edu/certificate/health_coaching.html. Accessed August 10, 2015.
  4. Duke Integrative Medicine. Integrative Health Coach Training. https://www.dukeintegrativemedicine.org/integrative-health-coach-training/. Accessed August 10, 2015.
  5. National Society of Health Coaches. http://www.nshcoa.com/. Accessed August 10, 2015.
  6. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10:CD006525.
  7. Cochrane. Collaborative care for people with depression and anxiety. http://www.cochrane.org/CD006525/DEPRESSN_collaborative-care-for-people-with-depression-and-anxiety. Accessed August 10, 2015.
  8. University of Washington, Psychiatry & Behavioral Sciences, Division of Integrated Care & Public Health. Advancing Integrated Mental Health Solutions (AIMS) Center. Collaborative Care Case Study: Behavioral Health Integration Program. http://aims.uw.edu/collaborative-care-case-study-behavioral-health-integration-program. Accessed August 10, 2015.
  9. University of Washington, Psychiatry & Behavioral Sciences, Division of Integrated Care & Public Health. Advancing Integrated Mental Health Solutions (AIMS) Center. Impact Training. http://aims.uw.edu/resource-library/impact-training. Accessed August 10, 2015.
  10. Unützer J, Chan YF, Hafer E, et al. Quality improvement with pay-for-performance incentives in integrated behavioral health care. Am J Public Health. 2012;102(6):e41-e45.
  11. Smith TE, Erlich MD, Sederer LI. Integrated care: integrating general medical and behavioral health care: the New York State perspective. Psychiatr Serv. 2013;64(9):828-831.
  12. Substance Abuse and Mental Health Services Administration (SAMHSA)-Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions. Behavioral Health in Primary Care. Integrating behavioral health into primary care. http://www.integration.samhsa.gov/integrated-care-models/behavioral-health-in-primary-care. Accessed August 10, 2015.
  13. SAMHSA-HRSA Center for Integrated Health Solutions. Patient Health Questionnaire (PHQ-9). http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf. Accessed August 10, 2015.
  14. SAMHSA-HRSA Center for Integrated Health Solutions. Generalized Anxiety Disorder 7-item (GAD-7) Scale. http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf. Accessed August 10, 2015.
  15. SAMHSA-HRSA Center for Integrated Health Solutions. Stable Resource Toolkit: AUDIT-C. http://www.integration.samhsa.gov/images/res/tool_auditc.pdf. Accessed August 10, 2015.
  16. U.S. Department of Health and Human Services. National Institutes of Health. PROMIS. http://www.nihpromis.org/default#2. Accessed August 26, 2015.

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