Primary Care Behavioral Health Integration Model

The primary care behavioral health integration model is an approach that brings medical and mental health services together into one setting. This model focuses on improving health and overall quality of life through collaboration, holistic care, and integration of services at multiple levels. Integration of services can occur in multiple settings, including clinics, hospitals, and mobile medical units.

The Substance Abuse and Mental Health Services Administration's National Center for Integrated Health Solutions developed a Standard Framework for Levels of Integrated Healthcare that describes six levels of integration with primary care. The framework follows a continuum within three categories — coordinated, co-located, and integrated — with two levels in each category. Level 1 is Minimal Collaboration, where mental health and primary care providers work in separate buildings and have infrequent communication, and Level 6 is Full Collaboration, in which providers operate as one team and patients view the system as one single entity.

Within the primary care behavioral health integration model, evidence-based models for integrating care include:

The Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model, also known as the Collaborative Care Model, is a collaborative approach that connects a depression care manager (DCM), a primary care provider, and a psychiatrist. This team works together to create treatment plans and provide care for patients with common mental health conditions such as depression. The IMPACT model uses a stepped-care approach to provide the most effective, yet least resource-intensive, treatment to meet the patient's needs. Research has shown that patients receiving care through this model experience significant improvement in mental health compared to patients receiving traditional primary care.
The expanded Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, or Behavioral Screening and Intervention (BSI), is an evidence-based public health model that integrates mental health screening, brief intervention, and referral to treatment into the primary care setting. Although historically used by primary care providers to deliver early intervention and treatment to people with substance use disorders, SBIRT can also be used as a universal screening tool for a wide range of behavioral health concerns.

Examples of Rural Programs that Integrate Behavioral and Primary Care

Cherokee Health Systems serves several rural communities in Tennessee and is a national leader in primary care behavioral health integration. Cherokee embeds behavioral health consultants, typically psychologists or clinical social workers, in primary care teams. Primary care providers screen all patients for mood disorders and substance abuse and co-manage those who screen positive with behavioral health consultants. The primary care and behavioral health staff can also connect patients to a psychiatrist, often via telephone or telehealth. All care team members are connected through shared electronic health records. Cherokee Health Systems offers trainings for program planners through their Integrated Care Training Academy.
Due to the increased need for mental health services in Marquette County, Michigan, the Upper Great Lakes (UGL) Family Health Center introduced Cross-Walk, an integrated primary care and behavioral health program. The program trains primary care staff, care managers, and providers in motivational interviewing and behavioral health screening methods. Together, they collaboratively design behavioral health treatment plans. This model also involves collaboration from dental care providers to ensure comprehensive patient care.
Rural Health Innovations (RHI) initiated the Minnesota Integrative Behavioral Health Program to address the growing need for mental health services in Critical Access Hospitals. This program facilitated collaboration among healthcare providers, hospitals, and community services through strategy sessions to discuss evidence-based practices for successful behavioral health integration. This program emphasizes community collaboration, education, and use of evaluation as part of primary care behavioral health integration.

Implementation Considerations

The primary care behavioral health integration model can address stigma associated with seeking mental health services. When mental health professionals are located within the same facility as primary care professionals, it becomes less apparent that patients are seeking mental health treatment. Integrating behavioral care helps maintain the patient's privacy and minimizes the potential for negative judgment from community members, family, or friends. Rural integrated clinics may consider how best to advertise their services to explain that they provide both primary and behavioral healthcare to all patients.

Rural and low-income areas experience significant workforce shortages in mental healthcare, which is a barrier to accessing care. Patient referrals to healthcare providers located outside of the community can reduce the chances of follow-up and continuity of care. By integrating mental health services into primary care facilities, rural clinics can improve access to mental health services that are integral to overall wellness. The primary care behavioral health integration model can allow for a warm and sometimes immediate handoff to mental health providers if they share the same facility.

When implementing integrated care, programs should establish infrastructure for health information exchange to support communication among all providers involved in a patient's care. For example, the Health Care Partners Foundation developed a dual-provider assessment tool that enables both providers to assess a patient's medical and mental health needs together and compiles the results into one transition summary.

Staffing can be a significant challenge for rural clinics looking to start a behavioral health integration program. Strategies for addressing this barrier include working with behavioral health students and having staff work at multiple practice locations. For example, after starting its behavioral health integration program, Kirby Medical Center created an internship program for students at University of Illinois' Master of Social Work program to alleviate sustainability and staffing concerns. The J.C. Blair Memorial Hospital (now Penn Highlands Huntingdon) had limited availability of clinical staff but remained committed to maintaining access to care. Their integrated care staff respond to various practice locations and offer social work and care coordination support.

For more information on primary care behavioral health integration, including considerations for implementation, visit our Rural Services Integration Toolkit and the Integration of Mental Health Services in Primary Care Settings page in our Rural Prevention and Treatment of Substance Use Disorders Toolkit.

Program Clearinghouse Examples

Resources to Learn More

Achieving Behavioral Health Care Integration in Rural America
Document
Provides policy recommendations for expanding integrated primary care and behavioral healthcare in rural America with a focus on utilizing Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) in the process.
Organization(s): Bipartisan Policy Center
Date: 5/2023

Integrating Behavioral Health and Primary Care
Website
Shares resources, including guidebooks, websites, and journal articles supporting the integration of behavioral health into primary care services.
Organization(s): Agency for Healthcare Research and Quality

Primary Care Integration in Rural Areas: A Community-Focused Approach
Document
Proposes strategies for increasing access to integrated behavioral healthcare while considering cultural and contextual factors that are unique to rural communities.
Author(s): Selby-Nelson, E. M., Bradley, J. M., Schiefer, R. A., & Hoover-Thompson, A.
Citation: Families, Systems, & Health, 36(4), 528-534
Date: 2018

SBIRT: Now More Than Ever
Video/Multimedia
Discusses the importance of behavioral screening and intervention, and collaborative care in rural areas.
Organization(s): Great Lakes Mental Health Technology Transfer Center
Date: 6/2020