Researchers Investigate How to Integrate Behavioral Health Into Primary Care
Day-to-day behaviors such as diet, exercise and sleep profoundly affect health, but primary care doctors rarely have enough time to discuss such behavioral health changes to inspire improvement.
A Rutgers Health study published in the Journal of the American Board of Family Medicine identified six critical strategies for doing better and successfully integrating behavioral health services into primary care settings and improving patient lives.
More than 70% of primary care visits have some behavioral health component, said lead author Ann Nguyen, an assistant research professor at the Center for State Health Policy within the Rutgers Institute for Health, Health Care Policy and Aging Research. Yet conventional primary care visits offer physicians little time to address these issues comprehensively.
"The typical primary care doctor spends 15 to 20 minutes with you, tops," Nguyen said. "That's not enough time for somebody with a complex condition to tackle everything that's going on."
The researchers examined 10 federally qualified health centers and community health centers in New Jersey that implemented the "Cherokee Model" of integrated care between 2013 and 2019 and continued offering integrated behavioral health services three years after initial funding ended.
In the Cherokee Model, after seeing their primary care physician, patients with behavioral health needs receive an immediate "warm handoff" to a behavioral health clinician in the same facility.
"We really want to see behavioral and physical health happening all under the same roof as part of the same visit," Nguyen said. “Once you require patients to go to a different place, on a different day, with another copay, you create a significant barrier.”
The researchers identified six implementation strategies that contributed to long-term success: selecting experienced change champions to promote staff buy-in, providing specialized training on brief behavioral health interventions, developing ongoing training for new staff, creating dedicated physical spaces near examination rooms, establishing effective scheduling systems through both planned and ad-hoc methods, and identifying local billing codes and procedures with expert guidance.
Despite the demonstrated success, significant barriers to wider adoption remain. Behavioral health services often aren't reimbursed at high enough rates to cover costs. Health care systems have historically treated behavioral and physical health as separate domains, and many practices face physical space limitations and workflow challenges.
The researchers noted that health centers with limited space found creative solutions, such as putting workstations in hallways or having behavioral health consultants use the front desk during patient visits.
Evidence shows that integrated behavioral health improves clinical outcomes for psychiatric conditions such as depression, anxiety and substance use disorders, Nguyen said. It also increases patient and provider satisfaction while reducing system costs by preventing more expensive interventions later.
"This is not only a treatment model, but also a prevention model," Nguyen said. "We're catching things and changing behaviors early on, so patients don’t later on need expensive specialized services or end up in the ER."
The researchers are extending their study nationally, examining systems that have successfully implemented integrated behavioral health. They are also working with health systems to develop automated reports that visualize the financial and clinical impacts of integrated behavioral health.
“Behavioral health is a huge challenge, not just in terms of devising effective and economical ways that providers can offer it but also in terms of actually changing patient behavior,” Nguyen said. “Still, it’s vital that we find strategies that work because how patients behave day-to-day has a greater impact on wellbeing than anything we can do for them after they get sick.”
