behavioral health integration · behavioral health primary care integration

For Better or for Worse: Honoring the Partnership in Behavioral Health and Primary Care Integration

“I now pronounce you…Integrated.”

The early days of the integrated healthcare relationship are typically idyllic, filled with smiles and hopes and dreams. Oh, if we could only maintain that blissful state forever…

Unfortunately relationships don’t maintain a static pattern but are interspersed with disruptions on occasion (or frequently). When these disturbances intervene, the blissful state is challenged.

These are the times that try administrators’ souls.

For a partnership to persevere the inevitable challenges, the basic foundation must be solid.  Just as skyscrapers are built with deep foundations that are not only solid but allow flexibility to prevent collapse when severe environmental or other hazardous conditions erupt, the integrated partnership requires a carefully developed, yet flexible foundation. With a firm core, the relationship has the elements in place to withstand challenges that are sure to occur. (Click here for more information on building a successful behavioral health – primary care partnership.)

Sustainability Planning

Sustainability plans are often synonymous with financial sustainability but will occasionally focus on health information technology in the planning as well. The partnership itself, however, is often overlooked in the sustainability plan. This is unfortunate because if the partnership fails, the plan is rendered moot. The actual partnership itself is taken for granted after the initial honeymoon phase. This is a grave mistake for true sustainability.

Consider this scenario:
Due to internal operational and fiscal needs, the behavioral health partner’s executive team has decided to reassign the integrated BH counselor who has been working in the primary care clinic for two years. The counselor will be replaced with another counselor who is more experienced and is credentialed in both mental health and substance use disorders. Seeing this rearrangement as a win-win, the behavioral health partner is shocked and confused when they hear that the primary care partner, in reaction to this news, is considering hiring their own counselor instead of accepting the replacement counselor. There are even rumors that they might pull out of the partnership.

What went wrong?

  1. The behavioral health partner failed to include the primary care partner in the discussion, thus failing to honor the relationship; the primary care partner felt disrespected.
  2. Rather than express concern to the behavioral health partner, the primary care partner took a reactionary approach instead.
  3. Unaware of behavioral health partner’s internal issues, the primary care partner assumed the worst.
  4. The behavioral health partner failed to understand the value of the individual to the team, not just for the service provided. Counselors are not interchangeable. The counselor was viewed as a valued member of the primary care team.
  5. The executive teams of the partners stopped communicating after the partnership was launched, resulting in a weakening of the committment by each partner.

The list could go on.

This partnership, though financially sound, has neglected to nurture the core relationship. As long as things were going smoothly, the partnership appeared to be successful. Unfortunately, a slight disruption to the routine has threatened the weak core of the partnership. In addition to the obvious lack of effective communication taking place in this dysfunctional relationship, there are other factors also present that are all too common in partnerships:

  • Lack of commitment
  • Lack of respect

Commitment and respect underscore the core requirements for longevity.


All partners must be committed to ensuring that integration efforts have the necessary tools for success. This includes the committment of time, not just financial and other resources. When the commitment is present, there is no concern over “fair weather friends” syndrome.

  • Are you prepared to make sacrifices necessary for success?
  • When the going gets tough are you still committed?


Basic respect is crucial. Your partner has many challenges and concerns that are unrelated to your partnership. Respecting that these are important to your partner whether or not you can fully recognize the impact goes a long way toward being a good partner. Taking the time to gain a better understanding is even better.

  • Do you have a thorough understanding of your partner’s business model?
  • Do you understand the challenges that your partner faces specific to the specialty such as regulatory, operational, clinical, etc.?

Why are these things important?

Understanding and honoring the things that are important to your partner organization strengthens the core of your relationship. Remember, the Golden Rule applies to behavioral health and primary care integration partnerships, too.


3 thoughts on “For Better or for Worse: Honoring the Partnership in Behavioral Health and Primary Care Integration

  1. Thanks Cheryl for your always thoughtful and thought provoking contributions to the wonderful world of Behavioral Health – Primary Care Integration. My particular “partnership” involves me (a licensed clinical psychologist) and a couple of clinical social workers working in (and for) a rural FQHC. The courtship began about three years ago when the FQHC administration realized (read “hoped”) that the competing demands on primary care providers’ time could be reduced (read “increase productivity”) by shunting difficult, time-consuming “mental” patients to counselors. The explicit motivation was fiscal and PCP job satisfaction with very little, if any, consideration given to behavioral healthcare treatment modalities and outcomes. Difficult, time-consuming “mental” patients in fact demand considerably more time and attention than is available in the average 15 minute clinic visit. In fact, I have pushed administration hard on the need for 50 minute therapy sessions in order to deal with the myriad of complex biopsychosocial problems these economically deprived people present with. And the push-back has been couched in terms of “it’s not financially sustainable.” As you said “The partnership itself, however, is often overlooked in the sustainability plan.” For behavioral healthcare to contribute clinical value to integration partnership, the FQHC (with its emphasis on treating medical conditions) must be “prepared to make sacrifices necessary for success.”

  2. Thank you for your kind words, John.
    I’m glad that you find value in my blog.
    Finding the right balance in integrated healthcare is not an easy task but one that can be accomplished with persistence and a little thinking outside the box. The fast pace of the primary care clinic often creates challenges for behavioral health service delivery. In a health home model, these individuals with more intensive needs might be better served in a behavioral health home.
    There are no easy answers but I am encouraged by the ongoing focus on behavioral health and primary care integration. We have made great progress and I feel certain that we will figure it out. It’s absolutely worth the effort.
    Thanks for reading!

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