Behavioral Health Integration Fact Sheet

This fact sheet was developed by the APA Office of Health and Health Care Financing's Integrated Primary Care Advisory Group.

The two most widely adopted models of care integration are the Primary Care Behavioral Health Model (PCBH) and the Collaborative Care Model (CoCM). The PCBH model is population based and includes a licensed behavioral health professional—such as a psychologist—who functions as a Behavioral Health Consultant (BHC) and is a core member of the primary care team. The BHC contributes to the implementation of practice-wide prevention and early identification and intervention strategies, as well as offers targeted treatment for behavioral health conditions, suboptimal health behaviors exacerbating physical health concerns, and chronic health conditions across the lifespan (i.e., pediatric, adult, and older adult populations). As a member of the primary care team, the behavioral health professional shares in the responsibility and liability of patient care. In contrast, the CoCM model, based on an adult chronic care management approach, involves psychiatric services that include psychopharmacological recommendations supplemented by brief psychoeducation or problem-solving skills training for a defined group of adult primary care patients diagnosed with chronic mental illness. Most commonly, the CoCM model is employed for patients with major depression. A team comprised of a primary care provider and a care manager (e.g., nurse, social worker) provides most of the direct care to patients. A consulting psychiatrist (often located off-site) does not see the patients or share patient care responsibility, but rather provides suggestions to the primary care provider regarding medication management and defers liability to those who have direct care of the patients.

APA believes in adopting evidence-based integrated behavioral health services, recognizing that a one-size-fits-all model will not work for all primary care settings. Instead, APA emphasizes that the primary care practice's needs, internal and community-based resources, practice-based goals, and, importantly, patient population be the drivers for determining the best approach to care. Ideally, each primary care clinic will have the option to choose the model or combination of models that will best address the behavioral health needs of its patient panel and that the services provided will be flexibly implemented over time based on patient and practice needs (Sunderji et al., 2020). Adopting integrated behavioral health approaches that support the uniqueness and needs of the specific patient population and primary care team appropriately will best address population health overall.

Effective integrated behavioral health providers come from a range of disciplines including psychology, psychiatry, social work, developmental-behavioral pediatrics, and nursing, as well as licensed mental health practitioners, patient navigators, and care coordinators. In fact, numerous health systems and primary care specialties successfully implement internal teams comprised of diverse behavioral health providing staff. These include Family Medicine, Internal Medicine, Pediatrics, Geriatrics, OBGYN, Federally Qualified Health, Community Health Centers/Teaching Health Centers, the Department of Defense, and Veterans Affairs.

For over a decade, efforts to improve the United States health care system have rested on the simultaneous pursuit of several aims, initially known as the Triple Aim of Health Care, and now recognized as the Quadruple Aim (Berwick et al., 2008; Bodenheimer & Sinsky, 2014; Institute for Health Care Improvement, 2007). The Quadruple Aim is a well-established, widely used framework consisting of four interrelated objectives:

• Best care, as measured by improving the patient’s experience of care including improved access to services;
• Improved outcomes, as measured by improving the health outcomes of the population;
• Reducing costs, as measured by reducing the expenditures of health care; and
• Provider well-being, as measured by improving clinician experience.

PCBH aligns with and delivers on the objectives of the Quadruple Aim. Improved provider experience bodes well for patient outcomes, eliminating overuse or misuse of treatment or diagnostic testing can lead to both reduced costs and improved patient health. The balanced pursuit of the Quadruple Aim is consistent with evolving health care business models.

PCBH improves the patient/family experience of care (satisfaction with care)

• Patient preference for PCBH services (Ogbeide et al., 2018)
• Improves access to mental health care (Hodgkinson et al., 2017; Pomerantz et al., 2010)
• Increases engagement and linkage to specialty mental health treatment when needed (Bohnert et al., 2016; Brawer et al., 2010; Wray et al., 2012; Zanjani et al., 2008)
• Increases antidepressant adherence (Szymanski et al., 2013)
• Reduces wait time for mental health services (Pomerantz et al., 2008; Pomerantz et al., 2010) and no-show rates (Pomerantz et al., 2010)
• Improves relationship between patient and provider (Corso et al., 2012)

PCBH improves patient outcomes (improves population health; Reiter & Bauman, 2016)

• Increases provider adherence to treatment guidelines and appropriate antidepressant prescribing (Brawer et al., 2010; Serrano & Monden, 2011)
• Decreases in level of patient distress found two years post integrated primary care intervention (Cigrang et al., 2007)
• Improvements in outcomes regardless of presentation severity (Bryan et al., 2012; Cigrang et al., 2007)
• Targeted interventions associated with broad improvements in symptom reduction, functioning, and well-being (Bridges et al., 2014, 2015; Bryan et al., 2009, 2012; Cigrang et al., 2007, 2011; Corso et al., 2012; Davis et al., 2008; Gomez et al., 2014; Goodie et al., 2009; McFeature & Pierce, 2012; Ray-Sannerud et al., 2012; Sadock et al., 2014; Wilfong et al., 2021)
• Improvements noted across multiple behavioral health presentations including depression, substance use, psychiatric comorbidities, and suicidal ideation (Bryan et al., 2008; Oslin et al., 2006; Pomerantz et al., 2008; Watts et al., 2007)
• Improved completion of anticipatory guidance in well child care (Buchholz & Talmi, 2012)
• Randomized controlled trial demonstrated that as compared to a control group (usual care), patients receiving PCBH services reported greater use of coping strategies, greater adherence to relapse prevention plans, and greater use of antidepressant medication with retention and satisfaction highest among patients who received PCBH services (Robinson et al., 2020)
• Medical providers consider BHCs to be valuable members of integrated health care, noting that BHCs contribute to improvement in providers’ abilities to provide care (Torrence et al., 2014)
• Integrated behavioral health services in adult primary care have been shown to result in clinically significant decreases in depressive and anxiety symptoms among patients with depressive and anxiety disorders (Bogucki et al., 2021a; Bogucki et al., 2021b; Reppeto et al., 2021; Sawchuk et al., 2018)
• Reduction in suicidal ideation after behavioral consultation visit (Reppeto et al., 2018)
• Integrated behavioral health programs were able to quickly adapt to the challenges posed by the COVID-19 pandemic, ensuring continued access to evidence-based mental health services for the primary care population (Bogucki et al., 2021c)

PCBH is cost-effective care (reduces cost of care; Reiter & Bauman, 2016)

• More appropriate prescribing by primary care providers (Cummings et al., 2009; Monson et al., 2012)
• Large reductions in specialty mental health referral rate (Cummings et al., 2009; Landoll et al., 2019; Monson et al., 2012; Serrano & Monden, 2011)
• Primary care providers see more patients, spend less time in visits, and collect more revenue on days when a behavioral health provider is present (Cummings et al., 2009; Gouge et al., 2016; Monson et al., 2012)
• Reduces mental health care costs (Landoll et al., 2019; Yu et al., 2017)
• Rates of preventable inpatient utilization decrease significantly (Lanoye et al., 2017)
• Reduced emergency department encounters (Reppeto et al., 2021)

PCBH improves provider experience of care (Reiter & Bauman, 2016)

• Helps medical providers offer care for patients with more complex needs (Funderburk et al., 2012; Torrence et al., 2014)
• Improvements in clinical outcomes result in more satisfied providers (Angantyr et al., 2015; Brawer et al., 2010; Serrano & Monden, 2011; Torrence et al., 2014)
• Team work creates a supportive practice environment (Audet et al., 2006; Funderburk et al., 2012; Westheimer et al., 2008)
• Helps mitigate burnout in primary care providers (Zubatsky et al., 2018)

Pediatric IPC

• Integrated behavioral health services in pediatric primary care offers a wide continuum of services ranging from prevention and health promotion activities (e.g., pregnancy-related depression, developmental and Healthy Steps consultations) to interventions around mental health concerns (e.g., mental health and psychopharmacology consultations; Talmi et al., 2016).
• Pediatric integrated care provides population-level care to more children, removes barriers to obtaining care and increases access to quality evidence-based treatments (Njoroge et al., 2016).
• PCBH services with pediatric patients are associated with savings in terms of medical cost-offset with one study finding a total monthly savings of $9,424 in reduced health care charges over the period after a behavioral health visit as compared to the period prior across patients who completed an episode of care (Dopp et al., 2018).

Women’s Primary Care/OBGYN

• The integration of behavioral health services into a perinatal program has been associated with a significant increase in screening of perinatal mood and anxiety disorders (Lomonaco-Haycraft et al., 2019).

IPC with Marginalized Populations

• Integrated behavioral health services have demonstrated effectiveness in improving outcomes among racially and ethnically diverse patient populations, including Latinos (Bridges et al., 2014; Flynn et al., 2020) and African Americans (Berge et al., 2017; Sadock et al., 2014).
• Low-income communities in particular have greater willingness to access mental health services if available in primary care than in specialty care (Ogbeide et al., 2018).

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