Integrated Behavioral & Primary Care
Integrating behavioral health into primary care practice brings mental health and/or substance abuse screenings and treatments into a primary care setting. These efforts can include coordination between primary care providers, case managers or behavioral health consultants, and mental health specialists (e.g., psychiatrists), and often require training and redefinition or realignment of staff roles (SAMHSA-HRSA Integrate, CG-Mental health). Telehealth tools such as electronic health records (EHRs), text messaging, mobile applications (apps), and online therapies may be used to support integration (Raney 2017). Mental health conditions and substance abuse issues often occur with other chronic medical conditions; patients with severe conditions are referred to specialty care (SAMHSA-HRSA Integrate).
Expected Beneficial Outcomes (Rated)
Improved mental health
Increased adherence to treatment
Improved quality of life
Increased patient engagement
Increased patient satisfaction
Other Potential Beneficial Outcomes
Reduced drug and alcohol use
Evidence of Effectiveness
There is strong evidence that integrating behavioral health into primary care practice improves mental health (Asarnow 2015, Cully 2017, ICER-Tice 2015, Cochrane-Bower 2011*), especially depression symptoms (ICER-Tice 2015, CG-Mental health, Butler 2011*, Gilbody 2006a*). Integrating care also increases patients’ adherence to treatment (Kolko 2014, Thota 2012*), improves their quality of life (Thota 2012*), and increases patient satisfaction (ICER-Tice 2015, Kolko 2014) and engagement with health care providers (Wissow 2013).
Integrating depression screening and treatment into primary care has been shown to improve depression symptoms for adolescent, adult, and elderly patients (CG-Mental health, AHRQ-Butler 2008). Such care appears effective in various settings, including practices with limited resources and practices in rural and urban areas (CG-Mental health, Berger-Jenkins 2012*, Serrano 2011). Integrated care improves youth mental health outcomes, including depression and substance use, more than usual care (Asarnow 2015). Integrated care in pediatric practices increases initiation and completion of treatment, improves behavior problems, and reduces hyperactivity and parental stress (Kolko 2014). Experts suggest that increasing incentives to integrate primary care and behavioral health care may improve children’s health (Asarnow 2015).
Collaborative care approaches that use case managers to organize and integrate behavioral and primary care improve response to treatment, increase remission and recovery from symptoms, and increase satisfaction with care among patients with depression in the short- and long-term (CG-Mental health, Gilbody 2006a*). Coordination which includes regular and planned psychiatrist supervision of case managers has been shown to be more effective than efforts with unplanned supervision (Gilbody 2006a*). Collaboration and communication between medical and behavioral health providers have also been shown to increase the success and sustainability of integration efforts (Muse 2017*).
Integrated care has been shown to reduce depression and anxiety for veterans with heart failure and chronic obstructive pulmonary disease (COPD), and can improve health-related quality of life for veterans with COPD in the short-term (Cully 2017). For patients suffering from chronic pain and substance abuse disorders in addition to depression, multiple interventions in primary care settings (e.g., motivational interviewing and cognitive behavioral therapy) may improve mental health and reduce drug and alcohol use more effectively than a single intervention (Haibach 2014*).
Universal mental health screening during pediatric appointments can increase parent, youth, and primary care providers willingness to discuss mental health concerns. Framing screening as universal, confidential, and designed to improve communication may further support patient and family engagement (Wissow 2013). A Bronx-based study of a pediatric behavioral health integration program suggests programs that use pediatric psychologists and psychiatrists to integrate care can increase referral rates to pediatric mental health practitioners and increase primary care provider comfort managing school-age and adolescent attention-deficit hyperactivity disorder-related behaviors (ADHD) more than clinics that use social workers to integrate behavioral health (German 2017). Experts suggest that psychologists who integrate behavioral health into pediatric primary care use principles of culturally adapted care to meet the needs of racial and ethnic minority youth (Arora 2017*).
Economic studies indicate that integrating behavioral health and primary care to treat depression is associated with greater costs and better health outcomes than traditional care models. Overall, studies have shown integrated care to be cost-effective in terms of quality-adjusted life-years (QALYs) saved (CG-Mental health). Integrated care may reduce costs and medical utilization in rural areas (Peterson 2017*).
Impact on Disparities
Likely to decrease disparities
The Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral Health and Primary Care (AHRQ Academy) includes resources, research, and tools to support integrated care (AHRQ-Integrate). The Substance Abuse and Mental Health Services Administration (SAMHSA) includes numerous resources from federal agencies and national organizations on integrating behavioral health and primary care (SAMHSA-Children MH). The Primary Care Team LEAP is another example of an organization that offers guidance on how to integrate behavioral health into primary care through co-location or collaborative agreements (PCT-LEAP).
There are several models to integrate behavioral health into primary care practice. The AIMS Center at the University of Washington, for example, uses a Collaborative Care model based on five core principles: patient-centered team care, population-based care, measurement-based treatment to target, evidence-based care, and accountable care (AIMS-Collaborative care). The Institute for Clinical Systems Improvement’s Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program uses these same components for patients with depression (ICSI-DIAMOND).
AHRQ-Integrate - Agency for Healthcare Research and Quality (AHRQ). The Academy: Integrating behavioral health and primary care.
AIMS-Collaborative care - Collaborative Care. Advancing Integrated Mental Health Solutions (AIMS). The University of Washington.
ICSI-DIAMOND - DIAMOND for depression. Institute for Clinical Systems Improvement (ICSI).
SAMHSA-HRSA Integrate - SAMHSA-HRSA Center for Integrated Health Solutions. Integrate behavioral health into primary care.
WIPHL - Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL).
PCT-LEAP - The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP). Behavioral health integration. Princeton: Robert Wood Johnson Foundation (RWJF).
SNMHI-BHI - Safety Net Medical Home Initiative (SNMHI). Organized, evidence-based care: Behavioral health integration (BHI). Sponsored by The Commonwealth Fund, Qualis Health and the MacColl Center for Health Care Innovation at the Group Health Research Institute.
SAMHSA-Children MH - Substance Abuse and Mental Health Services Administration (SAMHSA). Children’s mental health (MH): Behavioral health care integration resources.