Sustaining Integrated Behavioral Health Services Pt. 2
This guide presents four steps for safety-net and other primary care providers to integrate behavioral health services and achieve sustainable integrated care models. Before embarking, review and discuss each step with your executive leadership and integrated care team members, including the referenced tools and resources. Contact the SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) to schedule a 1:1 technical assistance consultation to help support your integrated care planning.
Step 1 – Operational and Administrative Readiness
Assessing whether your organization is ready to integrate behavioral health services is a critical first step. Primary care and safety-net providers can use the following tools and resources to assess the organizational landscape, detect gaps, and identify resources and enhancements needed to support behavioral health integration in your organization.
In assessing operational and administrative readiness, consider the following questions:
- Are behavioral health services included in your mission statement?
- Is addressing behavioral health part of your strategic plan?
- Has your organization identified a model of integrated care to use?
- Are financial and billing practices aligned to support behavioral health integration?
- If partnering with a behavioral health organization, do you have contractual agreements or MOUs (memorandum of understanding) in place?
- Do your administrative policies (including, corporate mission statement, operating budget narrative, language in contracts, and MOUs) support integrating substance use and mental health services?
- Are board members and leadership informed about the need for behavioral health services and have they “bought-in” to integration?
Resources and tools to help support operational and administrative readiness
- Consider the questions and pathways described in the Quick Start Guide to Behavioral Health Integration to help identify the right path and the right mix for your provider organization to achieve integrated care goals.
- Utilize the Agency for Healthcare Research and Quality’s (AHRQ) Academy for Integration Behavioral Health and Primary Care Playbook. The Playbook is a guide to integrating behavioral health in primary care and other ambulatory care settings. While this guide is geared toward primary care settings, it can easily be adapted to other integrated environments.
- Review the Standard Framework for Levels of Integrated Healthcare, a six-level framework that can be used for planning integrated care goals.
- Use the Four Quadrant Model, a tool that describes levels of integration in terms of medical and behavioral health complexity and risk.
- Outline a plan for workflow that includes all relevant departments (e.g., intake, clinical services, facilities management, human resources).
- Complete assessment tools like the Integrated Care Practice Assessment Tool to identify your center’s readiness to implement behavioral health services.
- Complete the MAT Checklist to assess readiness to provide MAT (medication-assisted treatment).
- Understand the important confidentiality concerns unique to integrated care settings.
- Review the Contracts and MOUs section of the CIHS website for sample documents and related webinars.
Step 2 – Workforce Development
Core competencies, or skills necessary for working in an integrated care setting, are the building blocks of the integrated care workforce and essential to quality care delivery. It is important to grow the skills of your existing workforce in areas such as implementing evidence-based screening, interventions, and collaborative care planning. In assessing workforce development, consider the following questions:
- Is your workforce trained and appropriately licensed/certified to provide routine behavioral health services?
- Is there effective communication between primary care providers and behavioral health providers? Is there a team approach to care?
- Are primary care and behavioral health providers working together to develop treatment plans?
- Is your organization implementing MAT?
- Is your organization implementing routine screening, brief intervention, and referral to treatment services (SBIRT)?
- Do your electronic health record and policies support health information exchange across the organization?
Resources and tools to help support workforce development
- Access the Core Competencies for Integrated Behavioral Health and Primary Care to identify the core competencies for integrated care workforce in areas such as communication, collaboration and teamwork, and cultural competence.
- Review the Essential Elements of Effective Integrated Primary and Behavioral Health Care Teams to understand the essentials to developing a strong and successful integrated care team.
- Review the Building Capacity for Behavioral Health Services Within Primary Care and Medical Settings white paper that provides recommendations and guidance to provider teams working toward integrating behavioral health services.
- Access the screening, brief intervention, referral to treatment (SBIRT) resources to identify evidence-based screening tools and approaches to delivering effective brief interventions to address substance use concerns.
- Review sample job descriptions for the integrated care workforce to help develop your recruitment materials.
- Review the Tips for Promoting Peer Providers in Integrated Health.
- Identify ways your organization can benefit from National Health Service Corps Participation.
Step 3 – Clinical Practice Tools
Evaluating whether your organization’s clinical practices support high-functioning integrated teams and patient-centered practices is essential to providing comprehensive primary care and behavioral healthcare services.
In assessing clinical practices, consider the following questions:
- Is your organization screening for depression, anxiety, and other behavioral disorders using validated screening tools?
- Is team-based care where behavioral health and medical providers are equal partners central to your service delivery?
- Do you have shared information systems that facilitate coordination and communication across behavioral health and medical providers?
- Are there environmental or geographic considerations that may impact care (e.g., rural settings) and can they be addressed?
- Is your organization systematically reviewing behavioral health outcomes using registries and other tools?
- Does your organization have strong partnerships with specialty care providers and social service organizations within your community?
- Are individuals served by your organization presenting with health concerns that require uniquely designed treatments (e.g., HIV)?
- Does your service delivery model involve family members and caregivers in treatment planning?
Resources to help clinics select appropriate clinical screening tools:
- Access evidence-based screening tools for alcohol and other drugs, depression, trauma, and suicide to integrate them into routine services.
- Understand the necessary steps to overcoming barriers to expanding the use of MAT for substance use disorders by reviewing this white paper on lessons learned.
- Review existing tools that may apply to special populations, such as individuals living with HIV. HRSA and the Centers for Disease Control and Prevention (CDC) developed Integrated HIV Prevention and Care Plan Guidance in 2015.
- The Rural Health Information Hub offers evidence-based toolkits on developing integrated treatment programs specifically tailored to those living in rural communities.
- Learn how to implement Telebehavioral Health Services with this six module training series. Hear from experts on implementing telebehavioral health and on tools that are available to support providers.
- Access tools and resources to practice trauma-informed care.
Step 4 – Sustainability and Continuous Improvement
Once behavioral health services are fully integrated into service delivery at your organization, sustaining these services becomes the focus. Understanding how to get reimbursed adequately for behavioral health services, maintaining a strong and dedicated workforce, and assessing how to achieve improvements in health outcomes are critical to a lasting integrated care delivery model.
When planning for sustainability, consider the following questions:
- Have you established a team that is empowered to champion integration?
- Is your governing board engaged in and supportive of your integrated care planning?
- Are you billing and coding for all behavioral health services and/or contracting for these services?
- Have you utilized a core set of performance measures to benchmark against other organizations and determine where improvements need to be me made?
- Are you in value-based contracts that reward your organization for preventing unnecessary emergency department (ED) visits, re-hospitalizations, or decreasing the days of stay at hospitals?
- Are you using behavioral health data to influence policy and practice decisions?
- Are you using data to inform quality improvement, to incentive teams, and to demonstrate outcomes to key stakeholders?
- In presentations, are you highlighting the benefits you’ve seen from integrating care?
- What tools are being used for ongoing program evaluation?
Resources to support sustainability
- Review the Cost Assessment of Collaborative Healthcare Tool available from the Eugene S. Farley, Jr. Center.
- Review resources available from the Advancing Integrated Mental Health Solutions (AIMS) Center, such as the financial modeling workbook.
- Use the tool from CIHS to help build the business case for integrated care at https://www.integration.samhsa.gov/resource/the-business-case-for-the-integration-of-behavioral-health-and-primary-care.
- Review the Sustainability: Making Integrated Care Stick issue brief to learn more about key considerations such as leadership buy-in, stakeholder partnerships, and in-service trainings for staff to support ongoing integration efforts.
- Washington University in St. Louis has developed a Program Sustainability Assessment Tool that guides numerous types of groups through eight key assessment domains, including organizational capacity, program evaluation, and funding stability.
- Develop a working knowledge of state-level impact on integrated care, and how policy development may lead to changes in funding and practice. The 2016 report by the National Association of Community Health Centers is a good starting point.
- Review the Centers for Medicare & Medicaid Services (CMS) information on Medicaid programs’ payment for integrated care.
- Consider the infrastructure required for billing and impact of current payment methodologies on financial sustainability (for an in-depth review of Medicare payment for integrated health, see the Matthew J. Press, M.D., et al. article in The New England Journal of Medicine).
- Access a host of resources on lessons learned and best practices shared during Innovation Community discussions on topics such as implementing MAT services for tobacco cessation and enhancing depression screening.
Clients, health care teams, and researchers agree that integrating care promotes a whole-person approach to health with immediate and lasting benefits. Whether just starting to integrate behavioral health services or working to enhance services already in place, following these essential steps will enhance service delivery and provide the necessary tools to successfully integrate behavioral health services. The SAMHSA-HRSA Center for Integrated Health Solutions is available to help at each step through 1:1 or group training and technical assistance, as well as helpful online resources.