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Implementation of Integrated Behavioral Health Care in a Large Medical Center: Benefits, Challenges, and Recommendations

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Abstract

Integrated behavioral health care (IBHC) models in primary care are positioned to address the unmet needs of traditional behavioral health models. However, research support is limited to specific populations, settings, and behavioral health conditions. Empirical evidence is lacking for expansion to larger health systems and diverse behavioral health conditions. This study examines perspectives on IBHC implementation in a large medical center. Semi-structured interviews were conducted with 24 health providers and administrators in two primary care clinics with IBHC. Thematic analysis demonstrated that participants had an overall favorable perception of IBHC, but also perceived implementation challenges, including difficulties with access, underutilization, team dynamics, and financial and interdepartmental issues. The findings suggest that IBHC implementation barriers in existing large health systems risk diminishing potential benefits and successful adoption. These barriers can be combated by incorporating systems change strategies into implementation frameworks, with a focus on barrier prevention and detection and long-term sustainability.

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Acknowledgments

We thank Audrey Bruell, Dennis Sunder, and James Terhune for their assistance in data collection and analysis.

Prior Presentation

Portions of the data were presented as a poster presentation at the American Psychiatric Association Annual Meeting in New York in 2018.

Author information

Authors and Affiliations

  1. Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Maria C. Prom MD & Victoria Canelos MD

  2. Boston University School of Medicine, Boston, MA, USA

    Victoria Canelos MD

  3. Department of Psychiatry, Boston Medical Center, Boston, MA, USA

    Pedro J. Fernandez MD

  4. Department of Psychiatry, UT Southwestern, Dallas, TX, USA

    Pedro J. Fernandez MD

  5. Department of Family Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA

    Katherine Gergen Barnett MD

  6. Department of Psychiatry, Boston Medical Center, Boston, MA, USA

    Cindy M. Gordon LICSW

  7. Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA

    Christine A. Pace MD, MSc

  8. Department of Psychiatry, Boston Medical Center and Boston University, Boston, MA, USA

    Lauren C. Ng PhD

  9. Department of Psychology, UCLA, Los Angeles, CA, USA

    Lauren C. Ng PhD

Authors
  1. Maria C. Prom MD
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  2. Victoria Canelos MD
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  3. Pedro J. Fernandez MD
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  4. Katherine Gergen Barnett MD
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  5. Cindy M. Gordon LICSW
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  6. Christine A. Pace MD, MSc
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  7. Lauren C. Ng PhD
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Contributions

All authors contributed to the study conception and design. Conceptualization and material preparation were performed by Lauren C. Ng, Pedro J. Fernandez, Katherine Gergen Barnett, Cindy M. Gordon, and Christine A. Pace, and data collection and analysis were performed by Maria C. Prom, Victoria Canelos, and Lauren C. Ng. The first draft of the manuscript was written by Maria C. Prom and Victoria Canelos, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Maria C. Prom MD.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest. Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number R25MH094612 and T32MH116140 and the Health Resources and Services Administration under award number K02HP308140100. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or HRSA.

Ethical Approval

This study involved research on human subjects. All procedures were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. This study was approved by the Boston University Medical Campus Institutional Review Board H-36333.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Guidelines

This study followed the guidelines of the Standards for Reporting Qualitative Research (SRQR).

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Appendix

Appendix

Qualitative Semi-Structured Interview Guide

  1. 1.

    What is integrated care in your setting?

    • How does it look? How is it done?

    • How do we know it is occurring?

    • In your mind, what does “integration” mean?

    • What are the specific services patients are receiving in integrated care?

    • Walk me through the details of the process of how a patient is referred to, treated by, and discharged from integrated care in your setting.

  2. 2.

    What is the purpose of integrated care?

    • Why do it?

    • Why do you think it was started?

    • What benefits of integrated care have you observed? How is it useful?

    • What downsides of integrated care have you observed? In what ways is it unhelpful?

  3. 3.

    How has integrated care changed the way you or your team provides patient care?

    • Have these changes improved your care? Why or why not?

    • In what ways are patients receiving more or less mental health care because of integrated care?

    • In what ways, if at all, has integrated care changed the process through which patients receive mental health care?

    • In what ways are patients who otherwise would not receive mental health care getting it? Why or why not?

  4. 4.

    Who are the patients who receive integrated care?

    • What characteristics of patients make them appropriate for integrated care? What types of problems or diagnoses are appropriate for integrated care?

    • What patient characteristics make them inappropriate for integrated care? What types of problems/ diagnoses are inappropriate for integrated care?

    • What are the provider red flags for emergencies?

  5. 5.

    In what ways, if at all, are patients benefiting from integrated care?

    • In what ways is integrated care meeting the needs of your patients?

    • In what ways is it not meeting their needs?

    • How, if at all, has integrated care impacted your patients’ mental or physical health or wellbeing?

    • How has integrated care impacted the way your patients think and feel about their medical care here at [institution]?

    • How, if at all, has integrated care impacted patient access to or connection to services?

  6. 6.

    How is integrated care working in your setting?

    • In what ways does the model you described fit or not fit within your clinic’s resources and structure (e.g., time, space, training, etc.)?

    • What could be changed that would help the integrated care program fit the needs of your clinic?

    • How much is the service used? What would increase the amount the service is used?

  7. 7.

    How do you fit in integrated care in your setting?

    • Describe your role? What are your responsibilities?

    • In what ways do you have or not have the training or knowledge you need to fulfill your role? What additional training would be helpful?

    • In what ways do you feel confident, or not confident, in your role with integrated care?

    • What pressures do you feel that integrated care has added to your job? What pressures has integrated care relieved?

  8. 8.

    In what ways, if at all, is integrated care working as a “team approach”?

    • Who are the other members of the integrated care team where you work? What roles and responsibilities do they have on the team?

    • How often and in what ways are the members of the integrated care team working together?

    • What could improve the ways that team members work together?

    • What is the relationship like between the primary care providers and the integrated providers?

    • In what ways do other members of your team have or not have the knowledge or training they need to fulfill their roles on the team?

  9. 9.

    How should we measure or evaluate integrated care?

    • What type of outcomes should be collected about integrated care?

    • How do you think integrated care is impacting health services, patient outcomes finances, etc.?

    • Are there any important factors about how integrated care is or is not working that you think we are missing?

  10. 10.

    How can we improve the integrated care here at [institution]?

    • What would make integrated care in your clinic more effective and useful?

    • What would be an ideal integrated care model for your clinic?

    • If you could change one specific thing about how integrated care is working, what would it be?

  11. 11.

    What do you want to know about integrated care at [institution]? Is there anything else we should ask that we have not asked already?

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Prom, M.C., Canelos, V., Fernandez, P.J. et al. Implementation of Integrated Behavioral Health Care in a Large Medical Center: Benefits, Challenges, and Recommendations. J Behav Health Serv Res 48, 346–362 (2021). https://doi.org/10.1007/s11414-020-09742-0

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