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 health 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 standard framework for levels of integrated healthcare. The framework describes three main categories of care between 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 worker.
• 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.

The Mental Health in Rural Communities Toolkit offers considerations for integrating behavioral health into primary care in rural communities. The Rural Prevention and Treatment of Substance Use Disorders Toolkit provides additional information about integration of behavioral health services in primary care settings. The Rural Mental Health Topic Guide describes factors that may affect successful integration of behavioral health, such as stigma.

Considerations for Implementation

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 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 likely to practice in rural areas. In areas with significant health provider shortages, rural program planners may consider implementing access to behavioral health services via telehealth. 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 Telehealth Model.

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 4: Implementation Considerations.