Sustaining Integrated Behavioral Health Services Pt. 1
Integrated care teams currently serve more than 25 million patients in the U.S. The key to successful integrated care is high-functioning multidisciplinary teams. Teams should be comprised of staff with the core professional competencies and personal qualities needed to deliver services in integrated care settings. To achieve this, organizations should develop strategies and utilize best practices to recruit, hire, train, and retain competent care providers who function well in a team environment. The capacity to function well in a team is an important skill for clinicians working in integrated care settings.
This brief guide provides managers (including primary care and behavioral health medical directors, team leads and supervisors) with information to assist them in developing integrated care teams with the necessary skills. Building on the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) resource on Core Competencies for Integrated Care, this document provides HRSA-funded safety-net providers suggested recruitment resources and interview questions to help develop an integrated care staff. Included are techniques to identify behavioral health clinicians with the right skills and qualities to work in integrated care settings as well as training resources to continue strengthening the integrated care team. Additional resources are provided to support establishing teams appropriate to the specific clinical environment.
Core Competencies for Integrated Care Teams
Along with aspects of a job description that are based on the organization's culture and preferences, core competencies can be directly inserted into job descriptions to help both hiring managers and applicants understand the requirements of the position. Applicants can be asked to provide examples of how their skills and experiences map to these competencies. A single set of core competencies should be used to assess both primary care and behavioral health members of the integrated care team. These core competencies reflect common strengths to foster integration between team members and avoid inter-professional divides between medical and behavioral health professionals.
To that end, the SAMHSA-HRSA CIHS established the following core competencies for integrated care team members:
- Interpersonal communication: The ability to establish rapport quickly and communicate effectively with patients, their family members, and other providers.
- Collaboration and teamwork: The ability to function effectively as a member of an inter-professional team that includes behavioral health and primary care providers, patients, and family members.
- Ability to screen and assess patients: The ability to conduct brief, evidence-based, and developmentally appropriate screening and to conduct or arrange for more detailed assessments when indicated.
- Care planning and care coordination: The ability to implement integrated care plans and use of coordination to ensure access to an array of linked services and information exchange among patients, family members, and providers.
- Ability to conduct targeted integrated health interventions: The ability to provide a range of brief, focused prevention, treatment, and recovery services as well as longer-term treatment and support for patients with persistent illnesses.
- Cultural competence and adaptation: The ability to provide services that are relevant to the culture of the patient and family.
- System-oriented practice: The ability to function effectively within the organizational and financial structures of the local system of healthcare.
- Practice-based learning and quality improvement: The ability to assess and continually improve the services delivered as an individual provider and as an inter-professional team.
- Ability to use information systems and informatics: The ability to use information technology flexibly to support and improve integrated healthcare, often requiring different models than traditional primary or behavioral healthcare.
Additional Considerations in Program Development
While assessing core competencies of existing and potential staff, safety-net providers should also review strategies for ensuring that there is an adequate staffing mix and clinic structure to meet staff and patient needs:
- How can teams effectively use inter-professional education and training to achieve improved patient care and shared language, culture, and processes across integrated care teams? To ensure a culturally-competent team, select candidates with a demonstrated interest and skill in culturally-informed care and an interest in sharing these talents with teammates.
- What is the best staffing mix to ensure your organization has an effective care team that possesses the core competencies? For example, to conduct efficient screening for substance use and address the competency of practice-based learning, consider partnering a pharmacist with the behavioral health clinician to help address medication compliance and complicated reconciliations. A diverse interdisciplinary staff can help fill-in individual provider gaps to create a wealth of well-rounded team competencies. Staff can provide trainings to increase shared knowledge and abilities (as appropriate within one’s scope of practice). CIHS provides free consultation and 1:1 technical assistance (TA) to help organizations determine staffing needs and answer many other questions that arise while starting an integrated program.
- What resources are needed for all clinical staff to be effective? Consider the importance of clinic design and space as well as electronic health records (EHR) and systems to facilitate shared treatment planning and workflows.
- It is also important to consider valuable staff positions beyond provider roles; these may include care coordinators to help refer when appropriate and coordinate higher levels of care; a scheduler to efficiently manage time and resources; and staff to deal with billing matters, such as insurance authorizations.
- Who are the integral partners to help meet workforce needs? It may be necessary to involve building partnerships with external clinics or providers to fill gaps, to consider telehealth interventions in rural areas, and to bring in other internal and external allies.
Interviewing and Recruiting Strategies for Integrated Care Teams
Team members must be skilled in core competencies as well as implementation of evidence-based practices, culturally-appropriate services delivery, and strong communication and teamwork skills. Team members must also bridge the divide that often exists between primary care and behavioral health, while collaborating with staff across the entire organization. Staff may also be expected to work with other care settings, such as hospitals, rehabilitation centers, and community-based organizations. When reviewing potential applicants for integrated care teams, hiring managers should look for a mix of experience and professional training to bridge divides between primary care and behavioral health disciplines. For example, clinicians with experience both in serious mental illness/acute crises and comorbid physical conditions such as chronic pain or diabetes will be particularly well-suited to integrated care. Additionally, it is quite helpful for staff to be familiar with treatment modalities relevant to the primary care setting (pain, insomnia, anxiety, etc.). Integrated teams comprised of and working with many types of disciplines and personalities must function in a mindful and relationship-oriented way that continuously bridges these professional gaps.
During interviews, hiring managers should ask behavioral questions that address the applicant’s ability to effectively communicate and coordinate care inter-professionally. Interview questions should be tailored to reflect the core competencies associated with the position. One interview strategy to consider is team-based interviewing, which can provide the opportunity to simulate a team environment for the candidate and to ask questions from different points of view on the core competencies of a candidate.
“I have learned that interviewing potential candidates with the team increases the understanding of the work environment for the interviewee and investment by the team members in the training and orientation of a new staff member.” Medical Director, Bronx, New York The following are sample interview questions that will help hiring managers learn about a behavioral health provider applicant’s strengths in working in a team-based environment.
- Describe a time when you worked as a member of a clinical team in service to patients, and describe how the team worked together. What role did you play? What was your most valuable contribution? What were the successes and areas for improvement in the team’s functioning?
- In what evidence-based treatment approaches are you well-versed? How do you navigate the various advantages and drawbacks of evidence-based therapies?
- What have been your greatest challenges in time management and prioritizing competing demands, and how do you manage them?
- Describe a time you consulted with another provider about helping a patient make a health behavior change. What techniques did you employ and what communication strategies did you use?
- If you had only 15 minutes with a patient who had marital difficulties and was referred to you for insomnia, what would you do?
- What consultation would you give a primary care provider about an obese patient with diabetes who is non-compliant with treatment?
- If you had to refer a patient to a specialist, what would be your steps and how would you ensure successful follow-through?
Resources for Successful Recruiting and Retention
Successful recruitment and retention of team members is important, as turnover can be challenging and often disruptive to service delivery. There are several important considerations that often impact recruitment and retention:
- Has your agency developed strategic partnerships for acquiring the brightest talent?
- Are salaries commensurate with local cost of living, and competitive enough to attract strong talent?
- Is there potential for advancement, and if not, what opportunities for growth exist to retain employees over time?
- Are you recruiting sufficient numbers of providers to provide services without overburdening staff?
- How are you showcasing your center’s offerings? Are you advertising and modeling diverse workplace initiatives, work-life balance, loan repayment programs, and other potentially unseen perks?
- If utilizing remote or telework staff, how are they kept engaged when not onsite?
- Have you built a relationship with local training centers and schools to draw early career talent? This may be aided by offering health professions education on site.
- Does your severance process include an exit survey to help identify opportunities for organizational improvement?
Acquiring great employees can be a significant hurdle, and keeping those skilled hires on board requires ongoing consideration of the factors that tend to enable staff to feel challenged, secure, and engaged. Form innovative partnerships with other organizations as a method of recruitment. Agencies should consider that internships and trainee opportunities, shadowing, and cross-agency placements are not only opportunities to shape the next generation of healthcare providers, but also invaluable opportunities for recruitment. Offering valuable incentives such as telework or remote positions can be a recruitment tool as they open positions to those outside typical geographic boundaries, and may save on relocation expenses. Virtual positions can also be a method for accommodating people with disabilities including mental illness. These flexible offerings should not, however, be extended at the cost of valuable services such as warm hand-offs and consultation. Consider important factors such as involving offsite employees in all meetings, using video conferencing when possible, and celebrating the achievements of off-site staffing the same way you might for on-site staff.
There are many resources to help managers recruit and retain quality, competent team members, including the Association of Clinicians for the Underserved that provides sample job descriptions, and the Success Through Achievement & Retention (STAR) program which provides tools for assessing retention rates. CIHS also offers curated job descriptions from integrated care sites that have successfully recruited a full range of staff.
Integrated Care Team Training Resources
One valuable tool to retain quality team members is providing ongoing training and support to foster clinical excellence and professional growth. Several toolkits and technical assistance resources provide free educational and knowledge building supports for clinical staff (see below). Incorporating these into strategic planning is an important step for staff retention.
- AIMS Center: The University of Washington’s Advancing Mental Health Solutions (AIMS) Center has free resources available for many evidence-based behavioral health treatments that can be incorporated into primary care settings.
- Zero Suicide Toolkit: The Zero Suicide toolkit is a comprehensive set of guidelines for implementing suicide prevention in an integrated care setting. Resources include guidelines on all aspects of implementation, including how to develop commitment from leaders of healthcare systems, training a competent and caring workforce, identifying and assessing suicide risk among patients, engaging individuals in collaborative safety planning, and evidence-based treatments.
- AHRQ Curriculum Tools: The Agency for Healthcare Research and Quality (AHRQ) includes evidence-based curricula on many integrated care models and interventions, such as the chronic care model and the shared decision-making model.
- The Behavioral Health Workforce Research Center is engaged in several projects designed to improve data collection, estimate workforce size and composition, and assess practice activities for all workers involved in prevention and/or treatment of mental health and substance use disorders. The Center’s focus spans three primary areas: developing the minimum data set for the behavioral health workforce, studying workforce characteristics and practice settings, and studying scopes of practice.
Building successful integrated care teams is an important step toward achieving optimal care models, and requires that hiring managers use thoughtful recruitment, training, and retention strategies. Retention is improved when the core competencies facilitate integrated care planning, staff training and skill-building.
The SAMHSA-HRSA Center for Integrated Health Solutions offers a wide variety of trainings and technical assistance for leadership, administrative, support staff and providers who wish to integrate behavioral health and primary care. Contact us at Integration@TheNationalCouncil.org.
- United States Health Center Fact Sheet. (March 2017). National Association of Community Health Centers, Bethesda, MD. Retrieved from http://www.nachc.org/wp-content/uploads/2017/03/US17.pdf.
- Primary and Behavioral Health Integration: Guiding Principles for Workforce Development. SAMHSA-HRSA Center for Integrated Health Solutions, Washington, DC. Retrieved from https://www.integration.samhsa.gov/resource/primary-and-behavioral-health-integration-guiding-principles-for-workforce-development-cihs.
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- Hoge, M.A., Morris, J.A., Laraia, M., Pomerantz A., & Farley, T. (January 2014). Core Competencies for Integrated Behavioral Health and Primary Care. SAMHSA - HRSA Center for Integrated Health Solutions, Washington, DC. Retrieved from https://www.integration.samhsa.gov/workforce/Integration_Competencies_Final.pdf.
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- Workforce Series: Rural Behavioral Health. National Rural Health Association, Washington, DC. https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/WorkforceRuralBehavHealth.pdf.aspx?lang=en-US
- About the NHSC. National Health Service Corps, Rockville, MD. https:/www.nhsc.hrsa.gov/corpsexperience/aboutus/index.html
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- Maternal and Child Health Workforce Training. HRSA Maternal & Child Health/U.S. DHHS, North Bethesda, MD. Retrieved from https://mchb.hrsa.gov/maternal-child-health-initiatives/workforce-training.