Primary Care Behavioral Health Model
Integrating behavioral health into primary care settings is a common services integration model. Separate
physical and behavioral health systems can lead to fragmented care delivery, poor health outcomes, higher
healthcare costs, and duplication of services. Behavioral health integration can increase access to behavioral
services for rural residents, reduce the stigma associated with seeking these services, and maximize resources.
The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services
Administration (HRSA) have developed a
framework for levels of integrated healthcare. The framework describes three main categories of care
behavioral health and primary care practitioners:
Coordinated Care: Coordinated care includes minimal collaboration or basic collaboration at
a distance. In this model, primary care and behavioral health providers communicate about shared patients,
but maintain separate facilities and systems.
Co-Located Care: Co-located care includes basic collaboration onsite, or close
collaboration with some systems integration. Behavioral health and primary care providers in a co-located
practice may share the same facility, but not necessarily the same practice space. For example, in one rural
community, a primary care practice is located in the same facility as the county’s mental health agency.
Primary care providers walk their patients over to the agency and introduce them to a clinical social
Integrated Care: Integrated care involves close collaboration in a partly integrated
practice or full collaboration in a transformed/merged practice. In this model, providers jointly plan and
execute goals, develop integrated care plans, co-manage patients, and maintain shared schedules. Integrated
practices use a systematic clinical approach to identify patients who are in need of behavioral health
services and engage both providers and patients in shared-decision making.
SAMHSA and HRSA have extensive
resources for practices seeking to integrate primary and behavioral health services. The
SAMHSA-HRSA Center for Integrated
Health Solutions offers a
start guide to behavioral health integration for safety-net primary care providers, a
framework for levels of integrated care, strategies for developing a
and establishing partnerships,
and tools to facilitate billing and financing
behavioral health integration.
Many rural communities are seeking to integrate primary care and substance abuse treatment in order to address
growing rates of opioid use in rural areas. The Rural Prevention
and Treatment of Substance Use Disorders Toolkit provides additional information about integration of mental
health services in primary care settings.
Examples of Rural Programs that Integrate Behavioral and Primary Care
A rural Federally Qualified Health Center (FQHC) in Virginia is co-located with the Behavioral
Health Services of the Shenandoah Valley Medical System, which offers consultations via a Primary
Behavioral Health (PBH) service. The FQHC administers yearly behavioral health screenings to all patients.
The primary care practitioner reviews the screenings and refers patients with qualifying scores to the PBH
provider for an on-the-spot consultation. If the patient requires ongoing treatment, the PBH provider
registers the patient with the behavioral health services department, which provides follow-up care in the
same building. Primary care and behavioral health providers can communicate about shared patients through
notes in a shared electronic health record.
Cherokee Health Systems, which serves several rural
communities in Tennessee, is a national leader in primary care behavioral health integration. Cherokee
embeds behavioral health consultants, who are commonly psychologists or clinical social workers, in primary
care teams. Primary care providers provide screenings for mood disorders and substance abuse to all patients
and co-manage those who screen positive with the behavioral health consultants. The primary care and
behavioral health staff also have access to a psychiatrist, often via the telephone or telehealth. All
members of the care team, including the psychiatrist, are connected through shared electronic health
records. Cherokee Health Systems offers trainings for program planners through their Integrated
Care Training Academy.
The Sierra Family Medical Clinic, located in rural Nevada
County, California received funding from a Tides Foundation Integrated Behavioral Health Program Grant to
develop video case studies that demonstrate warm hand-offs between a primary care and behavioral health
provider in a range of situations. The series includes an introduction, and covers topics such as depression with anxiety, bipolar
disorder, and pain
management, among others.
Considerations for Implementation
A key challenge to integrating behavioral health into primary care is the stigma associated with behavioral
health problems and with seeking help for these issues. The Rural Health Information Hub Rural Mental Health Topic Guide describes factors that may influence
stigma, which include a lack of understanding of mental illness and prejudice towards people with behavioral
health problems. The Rural Health Information Hub Rural Prevention and Treatment of Substance Use Disorders
Toolkit also discusses the stigma as a barrier to accessing
treatment for substance use disorders.
Rural residents may avoid seeking care because they perceive that they will have
a lack of privacy or anonymity in small and close-knit communities. To address this barrier, one rural clinic
redesigned the entrance of their clinic and their waiting room to emphasize that they provide integrated
services for all patients. In this clinic, all patients enter the same space and undergo the same intake
procedures, regardless of their special needs.
Rural program planners need to determine the level of behavioral health integration that is appropriate for
their community. While integrating behavioral health services can help maximize the use of scarce rural
healthcare resources, specialized behavioral health providers such as psychiatrists are still less
to practice in rural areas. In areas with significant health provider shortages, rural program planners
may consider implementing access to behavioral health services via telemedicine. For example,
two nursing homes in rural New York and Vermont partnered
with the University of Vermont to provide telepsychiatry services to residents. Additional considerations for
implementing a telemedicine intervention are described in the
Technology and Telemedicine Model.
Practices that are integrating behavioral health services should structure the workflow of providers to allow
time for warm hand-offs between primary care and behavioral health staff. This involves making a face-to-face
introduction to the behavioral health provider, which can help transfer the trust from provider to provider.
Program planners may also need to develop a formal communication and supervisory structure to monitor
collaboration between behavioral health and primary care staff. Cross-training may be necessary in order to
ensure that team members understand both their own roles and responsibilities and the intersection between
primary care and behavioral health. Additional considerations for training staff are described in Module 3: Training.
Though consultations, warm hand-offs, conferences, team meetings, and case management can be critical to the
success of an integrated care practice, these activities take time and are often not billable. The SAMHSA-HRSA
Center for Integrated Health Solutions offers billing
and financial information and resources.
Resources to Learn More
Integrating Behavioral and Physical Health Care in the
Real World: Early Lessons from Advancing Care Together
Describes the results of a mixed-methods study that assessed and compared how multiple practices were
integrating care. The article describes the study methods, practice-level changes, integration challenges, and
strategies for addressing those challenges.
Author(s): Davis, M., Balasubramanian, B., Waller, E., Miller, B., Green, L., & Cohen, D.
Citation: Journal of the American Board of Family Medicine, 26(5), 588-602
Behavioral Health Programs and Promising Practices
This report is a summary and analysis of rural behavioral health programs. Descriptions of programs are provided
along with highlights of promising practices.
Organizations(s): Health Resources and Services Administration
Rural Mental Health
This topic guide from the Rural Health Information Hub focuses on mental health in rural areas and helps health
and human services providers in their efforts to develop, maintain, and expand mental health services in rural
Organization(s): Rural Health Information Hub
Suicide Prevention Toolkit for Rural Primary Care. A
Primer for Primary Care Providers
This toolkit offers tools and resources for rural primary care providers who are seeking to implement suicide
prevention and treatment practices. It includes assessment guidelines, safety plans, billing tips, sample
protocols, and more.
Author(s): Dehay, T., Litts, D., McFaul, M., Smith, C., & West, M.
Organization(s): Western Interstate Commission for Higher Education (WICHE) and Suicide Prevention Resource