Advancing Integrated Behavioral Health Care In Texas And Maine: Lessons From The Field

“We don’t even speak the same language,” a primary care provider explained during an Integrated Behavioral Health/Primary Care team meeting. “So, it’s not surprising it took us a lot longer to learn how to work together than we anticipated.” A substantial lesson for those working to integrate care is the complexity of it and the time needed to deal with the professional cultural differences encountered when primary care and behavioral health providers begin working together.

Foundations from two states offer this lesson and other tips they learned while engaged in transforming health care systems to provide integrated care since 2006. Because the transformation to deliver integrated care is systemic, these lessons are layered to reflect different levels of change: policy-level changes, organizational changes, and clinical practice changes.

In 2006, foundations in Texas and Maine began supporting integrated behavioral health and primary care by convening of stakeholders, strategic planning, implementation of service delivery initiatives, grant making, policy work, and learning communities. (Such communities bring cross-site organizations together to build capacity and expertise in integrated care through shared learning opportunities.)

The Hogg Foundation for Mental Health funded integrated care through a three-year grant program to bring the Collaborative Care model to clinics in Texas. It also funded a comprehensive integrated care resource guide, statewide learning communities, and a statewide conference. It partnered with the US Department of Health and Human Services (HHS) Office of Minority Health to generate two major reports (a consensus report and a funders’ report) and a comprehensive literature review—all exploring integrated care as a strategy to eliminate health disparities.

The foundation was instrumental in establishing the Integration of Health and Behavioral Health Services Workgroup in 2009 with the Texas Health and Human Services Commission to promote health care integration in Texas, as directed by the Texas Legislature.

In 2012, the foundation awarded eleven grants and recently made additional grants to three community health centers to embed peer support in the delivery of integrated care.

The Maine Health Access Foundation (MeHAF) invested $14 million in Maine in a twelve-year integrated care initiative that included forty-two grant projects involving more than 150 partnering organizations. Three rounds of grants were awarded for clinical practice and systemic transformation. Systems transformation grants generated changes in systems to support integrated care, such as having Maine be the first state to require integrated care as a core element of the Patient-Centered Medical Home pilots. More recently, five Behavioral Health Homes grants were awarded. MeHAF also supported evaluation, a robust learning community, technical assistance and coaching through contracts, inclusion of behavioral health records in the statewide electronic health record system, and a five-year public policy development effort. The policy committee successfully advocated for changes in regulations, reimbursement, workforce training, and electronic record systems to promote integrated care.

Consequently, integrated care is a core requirement not only in Maine’s Patient-Centered Medical Homes, but also in its Health Homes, Behavioral Health Homes, and State Innovation Model. As a result of these initiatives, more than 46 percent of Maine’s primary care practices provide some level of integrated care.

During the efforts to integrate care in Maine and Texas, several key lessons emerged.

Lessons Learned: What Is Needed for Integrated Care

For Policy

• Use an adaptive change approach to reflect the complexity of integrated care, rather than considering implementation as simply replicating practice models.
• Because of the complexity, funders and policy makers need to make long-term commitments and support ongoing champions of integrated care.
• Start-up funds are essential to pay for nonbillable administrative and clinical personnel time for cross-training, merging professional cultures, changing work flows and protocols, adopting new reimbursement coding and documentation, conducting data and quality of care analysis, and navigating licensing and other regulations.
• Advocating for licensing and regulatory language to align with integrated care practice is necessary in most states. The Hogg Foundation for Mental Health and MeHAF both supported convening statewide groups of stakeholders to create a collective voice to promote integrated care policy changes.
• Ongoing fee-for-service reimbursements and global payment models are essential to sustaining integrated care, and both need to include payment for administrative costs, care management, and coordination across systems.
• Having a shared interoperable electronic health record (EHR) at statewide or regional levels enhances integrated care practice.
• Establishing robust learning communities and site visits accelerates spread of integrated care through peer-to-peer learning and shared advocacy work.

For Organizations

• Administrative and clinical leadership commitment is essential to integrated care implementation success. This includes communicating to all staff that integrated care is a priority and allocating sufficient resources for implementation, including staff time. Involving providers in planning will create more buy-in.
• Hiring behavioral health specialists who are flexible with professional norms, who can adapt to the primary care site, and who can “market” their services to other providers and patients is perhaps the factor most critical to the success of integrated care implementation. (The term behavioral health specialists includes all types of professionals licensed to practice in behavioral health—for example, licensed social workers, counselors, psychiatrists, psychologists, and substance abuse counselors.)
• Providing medical and behavioral health providers and staff with shared EHR and data records enhances administrative and practice tracking (such as provider referrals to the behavioral health specialist) and quality improvement. Data showing patient health gains add to the perceived value of integrated care.
• Cross-training should be incorporated into regular meetings, new employee training, and staff trainings to minimize disruption of clinical operations. Integrated care indicators should be included in staff performance reviews.

For Clinical Practice

• Champions of integrated care and a nonhierarchical, team-based approach to care are conducive to integrated care practice.
• The behavioral health specialist should be included in all clinical operations, such as morning “huddles,” case reviews, and routine provider meetings. The behavioral health specialist’s work station should be placed within the primary care work pods to enhance communication and “warm hand-offs”—the warm hand-off is an integrated care technique in which the primary care provider directly introduces the patient to the behavioral health specialist during the patient’s medical visit. The behavioral health specialist’s work schedule should align with that of other providers.
• Medical and behavioral health specialist providers should share an EHR and work from one care plan that guides the patient’s medical and behavioral health care.
• Time should be built in to develop trust, common language, and common operations among the medical and behavioral professionals.
• Universal screening for behavioral health conditions (such as the PHQ-9 screen for depression) should be built into the patient interactions and results included in the patient’s health record.
• Care management and coordination with community services are primary components of successful integrated care. Using licensed social workers facilitates community connections that support patient health, such as transportation to health care appointments. Global payment structures or work-flow savings, generated by more efficient work flows of integrated care, can pay for care management.

Conclusion

Texas and Maine are among the many states in which foundations have supported the establishment and spread of integrated care through grants, augmented with learning communities, policy advocacy, and evaluation. The evaluations related to initiatives that promote integrated care already reveal critical elements that facilitate successful integrated care and will develop more refined lessons as integrated care becomes the standard of care across America. Sharing lessons learned across states can accelerate the spread of integrated care until it becomes the standard of care.

Related Resources

Cohen, Deborah. Addressing Behavioral Health Integration with Payment Reform. Health Affairs Blog, April 20, 2015.

Linkins, Karen W.; Frost, Lynda E.; Hayes Boober, Becky; and Brya, Jennifer J. (2013) “Moving from Partnership to Collective Accountability and Sustainable Change: Applying a Systems-Change Model to Foundations’ Evolving Roles,” Foundation Review, volume 5, issue 2.