Behavioral Health Integration Capacity Assessment (BHICA) - Introduction

Purpose

The purpose of the Behavioral Health Integration Capacity Assessment (BHICA) is to assist behavioral health organizations in evaluating their ability to implement integrated care. We define integrated care as “the care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families[1], using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic health conditions), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”[2] The BHICA allows behavioral health organizations to evaluate their processes related to three approaches to integrated care: develop and coordinate formal or informal relationships with primary care providers, co-locate care, or build primary care capacity in-house. It also allows organizations to assess their existing operational and cultural infrastructure to support greater integration.

After completing the assessment, behavioral health organizations will be better positioned to:

  • Consider potential approaches to integration to better serve their population;
  • Understand how the current infrastructure of their organization could support greater integration;
  • Assess the organization’s strengths and challenges in undertaking different approaches to integration; and
  • Set and prioritize goals for the organization’s integration efforts.

Audience

The audience for the BHICA is behavioral health organizations that are actively planning how to implement or facilitate greater integration of primary care and behavioral health care and want to identify an appropriate approach for their organization. Organizations that have already selected an approach, but want to identify opportunities to improve, will also benefit from this self-assessment. Organizations that have not yet decided whether to pursue integration and want to understand the benefits of an integrated approach may find other tools and resources more useful than the self-assessment. Please see Appendix A for additional resources.

While the focus of this self-assessment is on behavioral health providers, much of the information presented will likely be useful to other types of organizations, as many of the lessons (e.g., culture change, financial barriers) are relevant regardless of context.

How Can We Best Meet An Individual’s Health Needs?

Behavioral health and primary care services are typically delivered by different providers in separate settings, often with little coordination. Substance abuse treatment, particularly for opiate dependence, may be even more segregated. For multiple reasons, this fragmented delivery of care can be particularly problematic for individuals seen in community behavioral health organizations. [3],[4] Individuals with mental illness or substance use disorders are at greater risk for complex physical health problems and have heightened morbidity and mortality compared with those without behavioral health issues and concerns.[5],[6] The side effects of psychiatric medications can produce adverse health outcomes, such as metabolic disorder and weight gain. At the same time, the mental illness or substance use disorder itself may interfere with an individual’s ability to receive and participate in appropriate care. Individuals with mental illness or substance use disorders may face barriers in accessing medical care and may feel more comfortable receiving care in a behavioral health setting, but most behavioral health clinics do not provide primary care services.

The Aspirational Model: Fully Integrated Care

Fully integrated care would seamlessly manage each individual’s behavioral health and primary care together. An individual would walk into the organization and be cared for by a behavioral health clinician who has already been in touch with the individual’s primary care provider. Physical health needs that affect behavioral health would be identified during the initial behavioral health visit, and a joint care plan would be developed. Simultaneously, the individual’s behavioral health needs would be communicated to the primary care provider, enabling two-way communication about the individual’s holistic health. All needed consents and information sharing would be in place to allow for seamless information sharing. This approach, with warm hand-offs and integrated services, would be optimal for managing the care of individuals with complex behavioral health needs.

Current models of care delivery are not always well-suited to address the health needs of individuals with mental illness or substance abuse diagnoses. While full integration for individuals may be an aspirational goal, organizations can take steps towards addressing individuals’ myriad health needs in a coordinated and team-based way.

Three Approaches To Integration

The Agency for Healthcare Research and Quality (AHRQ) lexicon[7] outlines three basic integration approaches designed to improve care delivery processes and outcomes:

  1. Coordinate care
  2. Co-locate
  3. Build primary care capability in-house

Regardless of the approach, achieving integration will take time, require building relationships, and require modifying administrative and operational functions.  The approach that best fits an organization will depend on its available resources and goals. The approaches outlined in the BHICA are not mutually exclusive implementation strategies. Rather, they represent different ways in which organizations can bring primary care services into their organization. Organizations may select components from different approaches based on what works best for them.

Coordinate Care

Behavioral health organizations regularly collaborate and consult with other providers to address the health needs of their population through better coordinated care. To accomplish this, organizations may build formal relationships through contracts with primary care providers or build informal networks of primary care and specialty providers. Organizations share as much data and information between providers as possible, consistent with federal or state information-sharing laws. Organizations may build relationships with community organizations that address the health, wellness, or social needs of individuals in their practice (e.g., YMCA, peer support centers, low-income housing advocates).

Co-Locate

Behavioral health organizations may also integrate care by being on the same site or campus with a primary care provider such as a federally qualified health center. In this approach, organizations provide team-based care with referrals between behavioral and primary care providers and, when possible, warm hand-offs—direct introductions to the other provider at the time of the individual’s visit. Organizations share as much data and information between providers as possible, consistent with federal and state information-sharing laws. Some integrated practices maintain an integrated record-keeping system.

Build Primary Care Capability In-House

Behavioral health organizations bring primary care providers on-site to address the needs of individuals in their organization. General screening (e.g., blood pressure, blood work for basic labs) and wellness activities (e.g., classes on nutrition and smoking cessation) are offered on-site and targeted specifically to individuals and families with behavioral health issues and concerns. Walk-in and advance appointments are accepted, and the behavioral health and primary care providers work together to address the needs of the population.

A note about financing: Finding sustainable financing is an important part of making integration work. Some may argue that it is the most critical component. In a changing health care environment, new models and demonstrations are opening up new financing options for behavioral health organizations to further integrate primary care services. Because these models are changing and may be state- or area-specific, we have included a few general questions about financing and the business case for integration in this self-assessment. Additionally, we have linked to some useful resources on financing that may help organizations identify possible pathways for funding this work. Engage financial staff in discussions when deciding on a potential model and assessing the organization’s readiness from a financial perspective. Though this assessment includes a section that prompts consideration of the financial aspects of integration, it is important to note that this is not a comprehensive resource for selecting an organization’s financial approach.

How To Use The Self-Assessment

This self-assessment is designed to facilitate a candid analysis of the current practices and processes within your organization that support integration. The accompanying scoring tool will help you understand how your current practices and processes map to the different integration approaches. The scoring tool will also help you to identify possible next steps in your integration work.

Pre-Work:

Prior to beginning the assessment, it will be helpful to work with staff in your organization on the following:

  1. Collect data on demographics, service utilization, and other characteristics of your current population (whom you serve, what you deliver, and how often). Your organization may find these data through a variety of sources, such as individuals’ electronic health records, claims data, conversation with individuals and providers, and other sources.
  2. Gather information on current clinical, operational, and cultural practices and processes (the organization’s infrastructure).
  3. Decide whether you want to assess processes related to one particular approach or all approaches. A high-level description of each approach is available in the "Three Approaches to Integration" section above.
  4. Collect information about how existing services are paid for (e.g., Medicare and Medicaid reimbursement, commercial insurance, grants) and where there may be flexibility to add or change services your organization provides.

Self-Assessment:

The self-assessment comprises five sections:

  1. Section I: Understanding Your Population
    This section of the self-assessment is intended as a reflection tool for your organization. Organizations may find it useful to think through the characteristics of the population and review considerations for how these characteristics affect their choices of how to integrate. Organizations that have already selected an approach or done similar analyses in the past do not need to complete this section.
  2. Section II: Assessing Your Infrastructure
    This section is intended to help you evaluate your organization’s current operational and cultural practices in order to identify specific recommendations for continued improvement.
  3. Section III: Identifying the Population and Matching Care
    This section is intended to help you examine processes to identify the target population and match identified individuals with appropriate care.
  4. Section IV: Assessing Three Approaches to Integration
    This section outlines three approaches to integration: formal or informal relationships with primary care providers and community organizations, co-located care, or in-house primary care capability.Organizations can answer the questions in all sections or just the sections that are most relevant for their organization. Please note that there is some repetition across sections, as there are common elements required for each approach.
  5. Section V: Financing Integration
    This section identifies a few questions that may be helpful for organizations to consider as they think about financing and building a business case for integrating care.

Process For Completing The Self-Assessment:

  1. We recommend that you select a group of leaders and staff who collectively have expertise on all levels of the organization (e.g., finances, operations, clinical processes, leadership practices, staff practices) to complete the self-assessment. The time needed to complete the assessment will vary depending on how many sections are completed. It could take between 90 minutes for a more cursory review or a full day or more for in-depth analysis and conversations. You may ask specific individuals to complete specific sections of the assessment, or you may ask a few individuals to complete as much of the assessment as possible. Some examples of staff who may help complete the assessment include senior leadership, office/program managers, referral coordinators, behavioral health providers, nurses, and any staff providing primary care (if applicable).
  2. When you finish, we recommend that you come together as a team to discuss discrepancies between answers.
  3. After you complete the self-assessment and accompanied scoring tool, we suggest setting up time to debrief with key leaders and identify your goals and next steps. Organizations have found that including comments and notes while answering questions helps to identify opportunities for further discussion in the organization. In addition to answering the questions outlined in the scoring tool, we encourage you to make notes in the column provided.

Integration is not easy; a number of barriers can make integration of primary care and behavioral health challenging. These include information sharing regulations, challenges financing the work, and cultural differences between primary care and behavioral health providers. Despite these challenges, behavioral health organizations are finding ways to increase overall integration. Many of the questions in the assessment relate to overcoming common barriers to integration.

Completing The BHICA

Staff working in the behavioral health setting will be asked to evaluate their population, their organization’s processes, and their cultural norms. The Understanding Your Population section is open-ended responses intended to spark conversation and organizational reflection. The finance section is intended to be a self-reflection tool to guide conversations and planning within your organization. Most questions in this section have “yes/no” responses with blanks for open-ended responses. Please use the notes column to identify areas for further discussion. The culture section asks respondents to rate agreement with the statement from “strongly agree” to “strongly disagree.” In some questions in the approaches and operational sections, there are “yes/no” responses, since they do not specifically address processes. For the other elements, respondents will be asked whether the organization has a certain process in place. If yes, they will be asked whether the existing process is reliable. Respondents will also be asked whether a reliable process is possible, given the organization’s existing resources.

The process elements in the Tool will fall into an Assessment Category (green, yellow, orange, or red) based on the responses. The Assessment Categories are described in Interpreting Your Results. An interactive evaluation grid is provided so that you can easily identify the Assessment Category for each element based on your responses. Additional guidance about the results of the evaluation, including the Assessment Categories, is provided in Interpreting Your Results.


[1] For the purposes of this tool, families refer to immediate family and natural supports identified by the individual.

[2] Peek CJ and the National Integration Academy Council. Executive Summary--Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-1-EF. Rockville, MD: Agency for Healthcare Research and Quality. 2013. Available at: http://integrationacademy.ahrq.gov/sites/default/files/Lexicon_ExecSummary.pdf

[3] Stephens S. Blueprint for Change: Achieving Integrated Health Care for an Aging Population. American Psychological Association, 2007. Retrieved from: http://www.apa.org/pi/aging/programs/integrated/integrated-healthcare-report.pdf.

[4] Butler M, Kane RL, McAlpine D, Kathol, RG, Fu SS, Hagedorn H, Wilt TJ. Integration of Mental Health/Substance Abuse and Primary Care No. 173. Agency for Healthcare Research and Quality, 2008. Retrieved from: http://www.ahrq.gov/downloads/pub/evidence/pdf/mhsapc/mhsapc.pdf.

[5] Parks J, Svendsen D, Singer P, Foti ME. Morbity and Mortality in People with Serious Mental Illness. National Association of State Mental Health Directors, 2006. Retrieved from: https://www.nasmhpd.org/sites/default/files/Mortality%20and%20Morbidity%20Final%20Report%208.18.08.pdf

[6] Piatt, E. E., M. R. Munetz, et al. (2010). "An examination of premature mortality among decedents with serious mental illness and those in the general population." Psychiatr Serv 61(7): 663-668.

[7] http://integrationacademy.ahrq.gov/lexicon