behavioral health integration

Behavioral Health Integration 2013 in Review

2013 has been a very good year for Behavioral Health Integration Blog! Our popular Integrated Care Thought Leader Series began this year, providing insights into the minds of some of the most prominent thought leaders in integrated care, including Dr. Alexander “Sandy” Blount, Dr. Benjamin Druss, Larry Fricks, and Dr. Benjamin Miller. Stay tuned in 2014! We have several excellent integrated care thought leaders lined up, to provide their expert perspectives on whole health and integrating behavioral health and primary care for enhancing health outcomes, reducing healthcare costs, and improving access to healthcare.

The stats helper monkeys prepared a 2013 annual report for this blog.

Here’s an excerpt:

A New York City subway train holds 1,200 people. This blog was viewed about 4,800 times in 2013. If it were a NYC subway train, it would take about 4 trips to carry that many people.

Click here to see the complete report.

Affordable Care Act · behavioral health integration

Behavioral Health Homes

In the midst of talk of healthcare reform, it is apparent that the face of healthcare is undergoing numerous changes from the traditional delivery system. Accountable Care Organizations and other collaborative efforts are proving to be viable solutions for addressing the gaps within healthcare, providing a glimpse of its future structure. Efforts are underway across the nation (and internationally) to integrate behavioral health and primary services within the ACOs as well as between community behavioral health and primary care providers.

The Patient Protection and Affordable Care Act has created a health home option in Medicaid for treatment of chronic conditions. Thus, the concept of the health home was created, with incentives in place for a more holistic approach to healthcare in an attempt to improve quality of care, contain or reduce costs, and improve outcomes. With behavioral health conditions meeting the established criteria for chronic conditions, behavioral health homes are the ideal solution for meeting the needs of people with serious behavioral health disorders who have not traditionally accessed healthcare on an ongoing basis. While the majority of information circulating regarding healthcare integration is related to integrating behavioral health into a primary care setting, it’s a mistake to assume that primary care will absorb all behavioral health services. Specialty behavioral healthcare plays a distinct and important role within healthcare. Individuals with serious mental illnesses historically receive the majority of their services in community behavioral health settings. Many prefer to receive their primary care services within this setting as well for a variety of reasons. Primary care, in its typical current structure, would require significant modifications to take on the added line of business. Many organizations have successfully managed this, with Cherokee Health Systems leading the way for decades. However, primary care clinics that are not prepared nor inclined to follow this model may defer to the Behavioral Health Home.

What is a Behavioral Health Home?

First, let’s talk about what it is not. It is not a group home or nursing home. It is not a physical structure meant to house those in need of behavioral health services. The behavioral health home is a behavioral health organization that serves as a health home for people with mental health and substance use disorders.

Behavioral Health Homes for People with Mental Health and Substance Use Conditions prepared by Dr. Benjamin Druss and Dr. Laurie Alexander for the SAMHSA-HRSA Center for Integrated Health Solutions provides a thorough overview and guidance for establishing the behavioral health home. This document provides practical information for providers in their efforts to provide a more comprehensive delivery system to address the triple aim of healthcare. Behavioral Health Homes for People with Mental Health and Substance Use Conditions is an excellent resource and a must-read for providers in their efforts toward transitioning their organizations into a behavioral health home.

behavioral health integration · behavioral health primary care integration · collaborative care · healthcare integration · mental health · primary care behavioral health integration

Making the Behavioral Health – Primary Care Marriage Work

Every relationship follows a similar pattern. The early phase begins with the selection of a partner. The same holds true for the integrated behavioral health and primary care partnership. It may begin with running into each other at a meeting. Or perhaps while reading the latest report on the emerging trend of healthcare integration, Accountable Care Organizations, health homes, etc…

The VISION begins to form                         

The behavioral health and primary care clinics enter into the dating relationship when the leaders of each, who have mutual admiration for each other, begin to recognize the potential of doing business together. One leader calls the other, suggesting they get together for lunch. It’s only lunch, he rationalizes to himself, it doesn’t mean anything…there’s no harm just in talking…. One thing leads to another during the wooing and courting phase; soon the idea transitions and the outline of a plan begins to emerge. The two leaders have entered the early stages of the partnership. The Vision is being created, becoming a driving force for each. The two organizations soon find themselves having serious discussions about forming a partnership. How did THIS happen?? The proposal is followed with a flurry of planning. There are so many details! Attorneys are kept busy creating a business plan and reviewing financial and regulatory documents, planning for the wedding of two organizations. Decisions must be made of how the assets are to be shared. Finances are sorted, MOUs are signed, and the partnership is official. The marriage of behavioral health and primary care creates a unique entity that is far greater together than either had, or could have been, alone. The early stage of the partnership is filled with excitement as the Vision takes shape and becomes reality. The shared vision is driven by the passion to become what neither can achieve alone. The specialty behavioral health provider and the primary care provider have integrated, raising the bar of healthcare for people with behavioral health disorders.

This marriage of healthcare providers is based on a Vision shared by two of eliminating the health disparities of people who suffer from serious mental illness and substance use disorders.



In the early days of the partnership, the Honeymoon phase, there is a distinct tendency toward assuming that both partners are speaking the same language and are working toward the same goals. The excitement of the new endeavor and the synergy created initially helps to move things along at a rapid pace. When the behavioral health partner talks about workflow and scheduling appointments, there is little thought given to the fact that these two concepts have VERY different meanings for the primary care provider. It is important to have a thorough review of operations from both perspectives and to find a viable middle-ground that both partners find acceptable. Making open, frequent communication a priority from the onset will prevent problems later on.  This should include a thorough overview of each organization’s regulatory, financial, and operational processes as well as overall mission. Don’t assume that the two partners really understand how each other’s organization functions.

Problems within the Partnership

If the partners neglect to develop an open culture of communication on the front end, it is likely that miscommunication will develop. The Honeymoon phase is in jeopardy. The entrepreneurial partner fails to understand the ongoing delays from the partner with the extensive bureaucratic approval process that prevents a quick turnaround of virtually everything. As misunderstandings develop into disappointments and resentments, the previous harmony is disrupted. The Honeymoon is over. Internal conflicts must be addressed immediately with candor. This is a good time to have an open conversation about all the aforementioned points and develop a plan for ongoing, frequent communication. Concerns about the great divide over productivity targets, outcome measures, and caseloads must be openly discussed, among other important points of contention. By devoting the necessary focus on the importance of Communication, the partnership will successfully transition to the third key component for a successful behavioral health – primary care marriage, Compromise. The shared mission to reduce health disparities for the individuals served who suffer from comorbid behavioral health and medical conditions will persevere. However, failure to make this transition may very well land this promising partnership into divorce court.


I shall argue that strong men, conversely, know when to compromise and that all principles can be compromised to serve a greater principle. –Andrew Carnegie

It isn’t easy to bring a behavioral health organization and a primary care organization together for the creation of an integrated partnership, despite the reason–altruistic or otherwise. When partners fail to provide adequate attention to open and effective communication, the excitement of early marriage can wane; the relationship may become troubled, requiring mediation. When misunderstandings occur and tempers flare, it’s time for an intervention to get the partnership back on track.

Marital Counseling

As with any relationship, compromise is a necessary element in the behavioral health – primary care partnership. After the honeymoon phase, the partnership enters a crucial period in which its future is determined by the ability of the partners to negotiate the (sometimes rocky) path ahead. Differences between the two entities become more apparent as pressure mounts via the divergent audits, budgets, various regulatory requirements, etc. Furthermore, what are the partners to do when they encounter conflicting requirements? Marital counseling may be in order at this point. In other words, it’s time for the partners to take a time-out and take an honest and open appraisal. Developing shared solutions are important for strengthening the bond. The partners must approach all dilemmas together as a team. Each has a vested interest; negotiating solutions will strengthen that bond. Wise leaders recognize that trust is not automatically bestowed. Members of the teams need time and patience for trust to develop. By bringing together members from each team who share similar roles and encouraging ongoing, regular interaction, trust begins to develop within the partnership. Remember that trust cannot be rushed but will grow into a strong foundation  throughout the partnering organizations if nurtured. Empowering the team provides the opportunity for everyone to develop a sense of ownership for successful outcomes. Empowered employs who feel that they play an important role in the organization and who feel valued by management have a greater sense of commitment to the organization. Allow team members the ability to make decisions rather than having every movement scripted. When the receptionist is empowered to work-in an emergency patient without having to gain approval for every occurrence, amazing things begin to happen:  The receptionist feels like a valued member of the team, the patient benefits from the responsiveness, and the other members of the team benefit from the smooth workflow. In marriage, each partner has a responsibility for doing his/her part to ensure equilibrium. The same is true between andwithin the partnership.

Determine Expectations

Mentioning expectations at this point might seem unnecessary. After all, the behavioral health and primary care organization have formed the partnership for the distinct purpose of providing healthcare integration. It’s a very clear expectation and doesn’t require discussion. Or does it? Just as a couple contemplating marriage might wrongly assume that each has the same idea of what their marriage will be like (one partner daydreams about a trendy loft in the city while the other longs for a house with a massive lawn in the suburbs), the integrated healthcare partnership can fall into the same trap of flawed thinking. Don’t assume! The chances for happily ever after increase exponentially when time and effort are committed for open discussions about expectations for the partnership. Both partners must be willing to compromise on expectations when they are incongruent. And don’t forget:

People with serious mental illness are dying while we try to figure this out!


With individuals who suffer from serious mental illnesses dying 25 years prematurely on average, behavioral health and primary care have been mandated to address this health disparity. More effective protocols are in order and must be initiated immediately. This is a matter of life and death. The Behavioral Health and Primary Care Marriage is a viable solution.

Growing Old Together

Once the marriage has successfully navigated the first three essential components of a behavioral health – primary care marriage, VisionCommunication, and Compromise,  the final component builds and maintains the mature partnership for growing old together.

The Whole is Greater Than the Sum of Its Parts

The Behavioral Health – Primary Care Marriage, at its best, is an entity so much more than just two collaborating organizations. The synergistic effect of the partnering of two organizations has the ability to surpass what either can accomplish alone. The community behavioral health organization has expertise in treating complex behavioral health disorders but does not address the primary care needs of individuals. The primary care organization excels at treating a myriad of health conditions including mild behavioral health disorders but does not have the expertise to address serious mental illness or substance use disorders. The marriage of behavioral health and primary care serves as a means of connecting the head and the body; it may be thought of as the neck of healthcare. The neck allows the best of both worlds to work together in unison, becoming far greater than either can be alone.

Enhanced Outcomes through Blending of Resources

Measuring outcomes provides evidence of the value of the partnership. Through building on the expertise of each, the blended resources result in enhanced outcomes. For example, theUniversity of Washington’s IMPACT Evidence-based Depression Care has impressive results in improved outcomes with significant cost reduction through collaborative care. The marriage thrives with ongoing feedback, allowing for calibration to ensure that services are effective and financially sustainable. To provide a comprehensive overview, it is recommended that individual health outcome indicators, service outcome indicators, and outcomes data for decision making are included in the repertoire of data collected for analysis and sharing. Implement a system of collecting the indicators at the onset of the partnership. The indicators must be meaningful to both partners. The National Association of State Mental Health Program Directors has a very useful report for guiding the process, Measurement of Health Status for People with Serious Mental Illness.


Frequent, regular intervals of sharing results with the team establish a sense of accountability that builds the foundation for longevity. Both partners have responsibility to the partnership and to producing positive outcomes. By following the Four Key Components for a Successful Behavioral Health and Primary Care Marriage, the partnership will live happily ever after.