Sharing a Playbook: Integrated Care in Community Health Centers in the United States

Objectives. We investigated basic measures used to assess collaboration between colocated providers and to gauge the extent to which health centers practice integrated care.Methods. We used the Assessment of Behavioral Health Services survey and the 2010 Uniform Data System to explore the elements of integrated care for behavioral health conditions. We used multivariable regression models to examine the correlates of integrated care.Results. More than 85% of health centers provided mental health services in 2010, and almost half offered substance use treatment. Health centers commonly reported shared access to information among behavioral health and medical providers and joint care planning. A higher degree of integrated care involving joint case conferences was less common. Health centers without electronic health records and those with lower percentages of total staff composed of behavioral health workers were less likely to provide integrated care.Conclusions. A 2-pronged strategy involving financial incentives and technical assistance to spread best practices might increase integrated care, particularly among health centers that are not maximizing the potential of electronic health records and health centers with low behavioral health staffing levels.The treatment of behavioral health conditions is a key component of quality care.1 Behavioral health encompasses mental health and substance use disorders as well as health behaviors.2 Improving access to screening and treatment services for mental health and substance use disorders is critical to the success of wider efforts to improve the health care system to pursue the triple aim3 of better health, better care, and lower per-person costs.4,5 However, medical and behavioral health care providers have historically practiced in isolation, with little communication or coordination. The need to better integrate behavioral and medical care is especially pronounced for underserved patients; according to the Institute of Medicine, “[t]he single greatest flaw of the mental health safety net is its nearly total disconnection from the core [general medical] safety net.”6^(p189)Mental health and substance use disorder services are frequently provided in primary care settings; in fact, many patients with behavioral health disorders never receive care in a specialty behavioral health setting.7,8 Community health centers are key portals of access to medical and behavioral health services in underserved communities.9 Community health centers are also called “federally qualified health centers” or “health centers.” We used data from federally qualified health centers that received grant funding in 2010 under Section 330 of the Public Health Services Act through the Bureau of Primary Care at the Health Resources and Services Administration of the US Department of Health and Human Services. Because many health center patients face additional access barriers—40% of health center patients were uninsured in 2010—treatment initiation and engagement might be improved if on-site behavioral health services are available where patients access medical care and links to social services.10 The “warm handoff” to a behavioral health provider can create trust, because colocation with medical services can destigmatize behavioral health treatment. Patients already visit health centers for medical and other types of services, so accessing behavioral health services on-site at the health center is likely to be convenient.11 In addition, colocating primary care and behavioral health services is a strategy to mitigate barriers to accessing care related to cultural beliefs among patients.12Health centers are required to provide mental health and substance use disorder services on-site or by referral. Most health centers have on-site behavioral health specialists, particularly larger health centers, those located in urban areas, in the Northeast and West, in local areas with greater availability of behavioral health specialists, and in states that allow Medicaid same-day billing for medical and behavioral health services.13,14 Health center capacity is expanding under the Affordable Care Act (Patient Protection and Affordable Care Act, Pub L No. 111-148, 124 Stat. 855 [March 2010]) to increase access to care for underserved patients and communities.15 Improving access to behavioral health services at health centers is currently a priority; more than 1 in 3 health centers received funding to expand behavioral health capacity in 2014 of more than $105 million.16Building on the foundation of colocated behavioral health specialists and primary care providers, health centers are exploring how to integrate behavioral health services into primary care.17,18 A commonly used continuum specifies 3 basic levels of orchestration between behavioral health and medical care: coordinated from 2 separate locations, colocated in a shared space, or integrated.10,19 The definition is still evolving, but integrated care is distinguished by colocated, team-based care and, optimally, a shared care plan with both behavioral health and medical elements.10,20–23Integrated care typically refers to providing behavioral health services in the primary care setting, whereas the closely related terms “coordination” and “collaboration” are used to describe shared access to information, communication, and consultation between medical and behavioral health providers, regardless of whether the services are colocated.24,25 We examined the processes used by primary care and behavioral health clinicians in health centers to conduct evidence-based activities to improve integration: colocating medical and behavioral health services, shared access to information in patient records, joint case conferences, and joint care planning.26It is important to note that colocating medical and behavioral health services does not necessarily lead to communication and collaboration; sustained technical assistance might be needed to support providers as they make the necessary changes to cultures, structures, and processes to allow more interdisciplinary communication and collaboration.27,28 Barriers to integrated care include a lack of consensus regarding team members’ roles29,30 and interprofessional conflict stemming from differing cultural norms and mental models of practice.31 The siloed and fragmented reimbursement landscape is another factor, particularly because reimbursement is often fee for service on the basis of the volume of patient encounters; funding streams that cover provider-to-provider communication might be necessary to support integrated care.32^,33Prohibitions on same-day billing for medical and behavioral health services are another roadblock.13,34 Additional financial barriers include staffing costs and health information technology (IT) implementation costs.35 There are many other issues related to health IT, including usability issues of care coordination and registry functions, limited interoperability hindering health information exchange, and additional privacy protections for information on substance use disorders.20,36–39We explored some basic measures that can be used to assess collaboration between colocated providers and to gauge the extent to which a health center is practicing integrated care. We asked 2 main questions. First, to what extent is integrated care occurring for health center patients with behavioral health conditions? Second, which health center characteristics are associated with practicing integrated care? We hypothesized that larger health centers, those with electronic health records (EHRs), and those with higher percentages of total staffing composed of behavioral health specialists might be more likely to provide integrated care.Our study makes a unique contribution to the literature by presenting nationally representative data on the elements of integrated care for patients with behavioral health conditions in health centers. The findings on contextual and health center characteristics associated with practicing integrated care in health centers might guide policies designed to reduce unmet needs for behavioral health treatment services among underserved patients.