Care Delivery Transformation Framework
Integrated Behavioral Health

Because mental and physical health are intertwined, one approach to transforming care delivery is integrating behavioral and physical health care. Integrated care is the systemic coordination of physical and behavioral health services across the care continuum. Care moves bidirectionally, and behavioral health professionals can be embedded into a medical practice, or a medical professional can be integrated into a behavioral health system.¹ Key components of this can look like:²

• Co-location — working within the same facility or practice.
• Team-based care — operating as one interdisciplinary care team.
• Patient-centered care — a single treatment plan that accounts for both mental and physical health.
• Care management — regular screenings to identify, track, and treat mental and physical health concerns.

Delivering integrated care is critical to treating the whole patient and drives at least five positive impacts:³

• Improved patient outcomes. Almost 70% of patients with behavioral health disorders have a medical co-morbidity, and almost 30% of adults with a medical condition — many of which are chronic — have a behavioral health condition.⁴ Integrated care delivery is associated with improvements in symptoms, functioning and well-being, as well as improved management of chronic conditions, decreased hospitalizations and improved quality of life.
• Reduced total cost of care. A significant portion of acute hospital care and emergency department (ED) visits are related to a co-morbid behavioral health condition or disorder. Medical costs for treating patients with chronic medical and co-morbid mental health/substance use disorder (MH/SUD) conditions are two to three times higher on average compared to the costs for beneficiaries who don’t have co-morbid MH/ SUD conditions.⁵ As detailed below, there is an opportunity for large cost savings through integrated health services.
• Increased access to behavioral health services. With 160 million people living in a Health Resources and Services Administration-designated Mental Health Professional Shortage Area, co-locating, embedding or providing access to behavioral health clinicians, sometimes via telehealth, in a primary care physician’s office can improve timely access to behavioral health care. Increased access can also lead to reduced disparities in health outcomes and stigma. Many clinicians’ experience illustrates that “incorporating mental health into primary care removes cultural barriers and stigma.”⁶
• Enhanced patient satisfaction. Embedding behavioral health services into a practice patients are familiar with can bring many benefits. These include the ease of “one-stop shopping,” reducing stigma and having the opportunity for in-person “warm” hand-offs between clinicians.
• Improved workforce productivity and satisfaction. The University of Michigan’s Behavioral Health Workforce Research Center found that integrated care can have a positive impact on the workforce by increasing employee productivity, boosting employee satisfaction, stabilizing primary care physicians’ workload and making it easier to refer patients to other specialties where they might lack expertise.⁷

Payment Models

Driven by the positive effects of integrated behavioral health, government agencies have developed several approaches to expand coverage and make care more affordable and efficient.

• Collaborative Care Model (CoCM) billing codes allow providers to bill for behavioral health services in primary care settings.
• Behavioral Health Integration billing codes provide payment for planning services for individuals with behavioral health disorders.
• Medicare covers select groups of behavioral health practitioners, including licensed clinical social workers, marriage and family therapists, and mental health counselors.
• 1115 Demonstration Waivers under Medicaid promote integrated behavioral health services. For example, the Innovation in Behavioral Health model is currently running in three states.
• Safety Planning Intervention and Follow-up Contacts Interventions codes provide billing options for crisis settings and EDs for patients with suicidality or at risk for intentional suicide by overdose.
• Principle illness navigation, Transitional Care Management and Chronic Pain Management and Treatment offer opportunities for practitioners other than medical doctors to provide holistic care management, though not specific to behavioral health services.

Implementation Considerations

The Care Delivery Transformation Framework incorporates several operational infrastructure elements and foundational principles that, when strategically aligned, can support hospital and health system leaders as they design, implement or scale integrated behavioral health across primary care, specialty care, emergency and inpatient settings. Below are some strategic considerations to keep in mind when integrating behavioral and physical health:

Workforce

• Stakeholder Engagement. Involve key stakeholders (e.g., leadership, clinicians, administration, IT and quality teams) in the design and implementation of integrated behavioral care models. Integrated care models may vary based on the care setting and the unique attributes of the hospital and community.
• Clinical and Operational Champions. Identifying champions who are familiar with leading organizational change can bridge clinical and operational teams, reinforce new workflows and normalize a culture of team-based care.
• Training. Thorough training for all clinical staff, existing and new, is critical. This type of screening should include, as appropriate for each team member:
  • Identification. How and when to use evidence-based screening tools.
  • Response. When to deliver brief interventions or refer to specialty care.
  • Communication. How to use person-centered, stigmareducing language.
  • Brief interventions. Distinguish how brief interventions differ from traditional therapy for treatment of both substance use disorders and mental health disorders. For example, the SAMHSA TIP Sheet 34 offers brief interventions for substance use disorder, and motivational interviewing is an evidence-based brief intervention option for patients with mental health disorders.
• Co-location. Co-locating members of the medical and behavioral health teams can increase accessibility, support hand-offs and facilitate collaboration.⁹

Person-centered

• Whole-person Care. Interdisciplinary care teams work together to support the physical, emotional, social and environmental factors that can influence the patient’s health; coordinate their interventions; and involve the patient and family in defining goals and treatment priorities.
• Stigma Education. Train staff to use language that is respectful and supports patients seeking behavioral health care.

Community-based Partnerships

• Leverage Centers and Clinics. Community Mental Health Centers, Certified Community Behavioral Health Clinics, Federally Qualified Health Centers and Rural Health Clinics can be included as community partners to help integrate behavioral health care and bolster areas such as the workforce.
• Non-medical Drivers of Health. Explore partnerships with community-based organizations to support patients’ needs for housing, food, employment and transportation.

Policies and Procedures

• Selection. IBH models can be customized to meet an organization’s needs and preferences. Organizations should assess patient needs, staffing capacity and infrastructure readiness when choosing between models. The Purchaser Business Group on Health has a robust guide on selecting an integration model, comparing the CoCM and Primary Care Behavioral Health (PCBH) Model. Questions to answer include:
  • What are the needs of the site and patient populations? Who are the stakeholders?
  • Which model seems most appropriate for the needs of patients and staff? Why?
    • CoCM
      • Can we commit to a psychiatric consultant? Can we adhere to using a patient registry?
    • PCBH
      • Can we hire licensed behavioral health clinicians? Can we provide physical space in the office to support collaboration?
• Screening and Referral Pathways. Implement standardized, evidence-based screening procedures (e.g., PHQ- 9 and GAD) to identify behavioral health concerns. When needed, conduct a comprehensive evaluation, discuss treatment options and refer to the appropriate level of care.

Accessible and Affordable Care

• Leverage Technology. Telehealth strategies such as e-consults, therapy, medication management and remote screening can expand access to behavioral health services, mitigate workforce shortages and support integrated care teams.
• Affordable Care. Implementing intervention earlier in the patient journey as part of primary care or as standard practice in acute hospital settings can reduce length of stay and ED visits, ultimately lowering the cost of care. In one study, adults enrolled in an integrated health care system had lower rates of acute care utilization and lower payments received by the delivery system.10

Conclusion

When organizations treat behavioral and physical health together, patients receive whole-person care that can result in lower overall cost and reduced stigma. Integrated care can also strengthen the health care workforce, as providers may experience greater satisfaction when delivering high-quality, patient-centered care.

AHA Resources

Explore additional AHA resources that focus on integrated behavioral health care:

Care Delivery Transformation Framework

• Infographic. Visual representation of transformational care delivery models across clinical and community settings and how they are linked together.
• Discussion Guide. Foster conversations with hospital leaders and their teams to identify opportunities to transform care delivery.
• Issue Brief. Dig deeper into the framework with the issue brief.

Integrating Physical and Behavioral Health: The Time is Now

The AHA’s vision is of a just society of healthy communities, where all individuals reach their highest potential for health. Integration of physical and behavioral health services can help us move closer to achieving the vision. Download this issue brief to learn more.

Physical & Behavioral Health Integration Resources

This site offers evidence-informed examples of hospitals and health systems successfully integrating behavioral and physical health services, as well as research and thought leadership on the impacts of integrated care.

People Matter, Words Matter

The AHA, together with behavioral health and language experts from member hospitals and partner organizations, released a series of posters to help your employees adopt patient-centered, respectful language. Please consider downloading, printing and sharing each poster with your team members, and encourage them to use this language both in front of patients and when talking to colleagues. People matter and the words we use to describe them or the disorders they have matter, as well.

Citations

1. https://www.aha.org/system/files/media/file/2019/12/value-initiative-issue-brief-integrated-behavioral-health-high-value-care.pdf
2. https://www.thenationalcouncil.org/wp-content/uploads/2020/01/CIHS_Framework_Final_charts.pdf  
3. https://www.aha.org/system/files/media/file/2023/09/AHA-BH-Integration-TimeisNow-whitepaper-september-2023.pdf
4. http://ibhpartners.org/wp-content/uploads/2015/12/co-occurring-disorders-Druss.pdf  
5. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Professional-Topics/Integrated-Care/Milliman-Report-Economic-Impact-Integrated-Implications-Psychiatry.pdf   
6. https://www.chenmed.com/blog/value-based-primary-care-offers-model-how-successfully-integrate-mental-health
7. https://dn710005.ca.archive.org/0/items/fa-2-p-3-team-based-care-case-studies-full-report/FA2P3_Team-based-Care-Case-Studies_Full-Report.pdf
8. https://www.chiefhealthcareexecutive.com/view/rady-children-s-finds-success-in-reducing-mental-health-visits-to-emergency-department
9. https://pubmed.ncbi.nlm.nih.gov/39884862/
10. https://jamanetwork.com/journals/jama/fullarticle/2545685 

Download the Integrated Behavioral Health Issue Brief