4 Factors That Impact Adoption of Behavioral Health Integration

New research provides guidance for managing the adoption of behavioral health integration.

Four factors have a major impact on adoption of behavioral health integration at healthcare organizations, a recent research article says.

About 20% of U.S. adults have a clinically significant behavioral health condition. Prejudice against people with behavioral health conditions and shortages of behavioral health workers has limited effective treatment. Integrating behavioral health into medical care is a top strategy to address behavioral health conditions.

The recent research article was published by Annals of Internal Medicine and funded by the American Medical Association and The Commonwealth Fund. The study features interviews with 47 physician practice leaders and clinicians, 20 behavioral health integration experts, and five vendors.

The researchers found four factors impact the implementation of behavioral health integration initiatives.

1. Physician practice motivations for behavioral health integration

There are three motivations for behavioral health integration at physician practices, the research shows.

• Behavioral health integration can expand access to services when there are shortages of behavioral health clinicians. "One primary care physician explained that before implementing behavioral health integration, the practice was frequently unable to respond quickly to new behavioral health needs," the researchers wrote.
   
• Behavioral health integration can boost the responsiveness to behavioral health screening. "Some practices reported that, before behavioral health integration, nonbehavioral health clinicians felt unable to respond when behavioral health screens identified behavioral health needs. This sense of helplessness led some clinicians to screen inconsistently," the researchers wrote.
   
• Behavioral health integration can bolster a physician practice's reputation. "For example, a psychologist working for a mid-sized gastroenterology practice affiliated with an urban academic medical center explained that behavioral health integration was 'something cutting edge that sets [the practice] apart from other competing institutions in the area,'" the researchers wrote.

2. Crafting tailored approaches to behavioral health integration

Physician practices tend to tailor their behavioral health integration models in accordance with the practice's patient population needs, workflows, resources, and financial opportunities. Most of the practices in the study adopted a form of co-location—which features onsite behavioral health clinicians providing enhanced access within physician practices—because the co-location model can be a good fit with pre-existing practice workflows.

3. Behavioral health integration barriers

The research found three primary barriers to behavioral health integration.

• There are cultural differences between behavioral and nonbehavioral health clinicians. "Several interviewees reported that behavioral health clinicians, who may be accustomed to 50-minute patient visits and long-term patient relationships without substantial staff supervision responsibilities, could have challenges acculturating to medical clinics," the researchers wrote. Methods identified to bridge cultural divides include utilizing organizational champions and practice leaders to engage both behavioral and nonbehavioral health clinicians.
   
• There are barriers to flow of information. "Most participating practices reported that behavioral health records were shared infrequently with nonbehavioral health clinicians or were accessible only with special permission," the researchers wrote. Causes of poor information flow include electronic health record systems that are not designed for behavioral health integration and overly restrictive interpretations of laws and regulations such as the Health Insurance Portability and Accountability Act (HIPAA).
   
• There are billing challenges. "Several practices in our sample reported that billing for behavioral health integration could be complex, burdensome, and unfamiliar to behavioral health providers," the researchers wrote.

4. Impact of payment models

About one third of the practices examined in the study reported losing money on behavioral health services. The practices used a range of payment models:

• Internal organizational support that was not covered or fully covered by reimbursements received for behavioral health integration
   
• Grant funding to launch behavioral health integration
   
• Medicare fee-for-service billing codes
   
• Alternative payment models such as shared saving and capitation

"There was no one-size-fits-all payment model that practices used to support behavioral health integration," the researchers wrote.   

Promoting behavioral health integration

Leadership is crucial to overcome cultural barriers to behavioral health integration, says Patrice Harris, MD, MA, a practicing psychiatrist in the Atlanta area who stepped down as president of the American Medical Association on June 7.

"We have to start at the top, and we have to make sure there is a commitment on the part of the leadership of the organization to make it work. Then the leaders can bring together clinicians, administrators, and everyone working on all the teams to develop a plan of action," she says.

To foster the flow of information needed to achieve behavioral health integration success, staff members must have a firm grasp on the intricacies of HIPAA, Harris says. "You want to make sure everyone is on the same page regarding what is appropriate and what is not appropriate. In the service of their patients, clinicians can share information."

A team effort is required to address billing challenges, she says. "Usually, there are billing challenges regardless of the integration model. When you are having these conversations, you need to have your chief financial officer and billing team in the room. There are definitely workflow changes to process claims."

Behavioral health integration efforts can generate return on investment, but ROI should not be defined narrowly, Harris says. "We have seen financial returns, but we have to be candid—those financial returns do not always accrue immediately. That is why you have to think about patient outcomes and longer term returns on investment."