Understanding integrated behavioral health care and the Collaborative Care Model
Shortages of behavioral health providers and difficulties in navigating insurance networks can make it hard for Oklahomans to access the mental health and substance use care they need.
An important part of the solution to these issues is integrating behavioral health services into primary care settings, which not only expands treatment capacity in the mental health workforce but also provides an entry point for people who might otherwise struggle to access care.
What is integrated care?
Integrated care is an umbrella term encompassing several models that combine physical health care with mental health and substance use care. These models aim to improve overall, whole-person health outcomes through coordinated, cohesive care carried out by a multidisciplinary team.
Through universal screenings for mental health conditions in primary care, integrated care can lead to earlier identification of, and intervention for, mental health and substance use conditions. This can prevent conditions from worsening and help patients avoid more costly care later, like an emergency room visit or hospital admission.
It is also a powerful way to decrease stigma around mental illness and substance use — when patients are screened for these conditions in the same way they would have their blood pressure checked at a doctor’s visit, it reinforces the idea that mental health is health. Many people with mental health and substance use conditions are more likely to visit a primary care provider within a given year than they are to seek out specialty mental health care on their own, making primary care an important entry point for behavioral health care.
When mental and physical health care is integrated in primary care settings, treatments for both can inform and complement each other, and patients benefit from improved coordination between different types and levels of care.
While Oklahoma has shortages of behavioral health providers across nearly every license type, the state has a robust workforce of primary care providers. Through integrated care practices, Oklahoma can better leverage its primary care providers while expanding the reach of its behavioral health providers.
Integrated care models
Many models exist for integrating behavioral health services into primary care. In this section, we highlight three integrated care models some of their key features:
Collaborative Care Model
The Collaborative Care Model is an evidence-based model for integrating mental health and substance use services in primary care settings.
Under the model, patients receive care from a primary care team and mental health professionals, including a behavioral health care manager and a consulting psychiatrist. By serving as “consultants” to primary care providers, psychiatrists who work in the Collaborative Care Model can serve a far greater number of patients than they could in traditional one-on-one psychiatry visits.
In a previous Healthy Minds analysis, we estimated that a psychiatrist who works in the Collaborative Care Model can serve approximately 226,800 patients over their lifetime — about 13 times more than a psychiatrist not practicing in the Collaborative Care Model, which we estimate can serve about 17,500 patients in their lifetime.
Psychiatrists’ lifetime patients served
Like other integrated care models, practices that work in Collaborative Care address mental health and substance use on a population level, in part by regularly screening every patient. Studies have shown that Collaborative Care leads to better mental and physical health outcomes. In a large analysis of 79 randomized controlled trials of Collaborative Care, researchers found that patients being treated in the model for depression or anxiety showed better short-term and long-term outcomes compared to those treated otherwise.
It has also been shown to be cost-effective: another study found that people receiving Collaborative Care are 54% less likely to go to the emergency room and 49% less likely to require inpatient psychiatric care.
Core principles of Collaborative Care include:
- A patient-centered, multi-disciplinary team that works together to provide coordinated, comprehensive health care for people with physical and mental health care needs.
- A population-based care approach means care teams use a registry and conduct regular caseload consultations to track changes in patients’ symptoms to identify those who aren’t improving and ensure no patient falls through the cracks.
- Measurement-based care means patients’ symptoms are regularly assessed to track changes and adjust treatment. This could look like repeated screenings using evidence-based tools to mark progress over time.
Primary Care Behavioral Health (PCBH) Model
Under the Primary Care Behavioral Health (PCBH) Model, behavioral health consultants are embedded in the primary care setting. These consultants are trained mental health providers — they could be clinical psychologists, social workers, or licensed professional counselors, for example.
The behavioral health consultant works with the primary care provider on all aspects of a patient’s behavioral health care, including same-day warm handoffs when a patient has behavioral health needs. The consultants are generalists, working with patients of all ages to address mental illness, substance use disorders, chronic disease, preventive care needs, social problems, and medically unexplained symptoms.
Behavioral health consultants conduct short evidence-based screenings, assessments, and interventions with patients in order to see a high volume of patients each day.
The Primary Care Behavioral Health model is well-suited for addressing patients’ behavioral health needs as they arise. Compared to the Collaborative Care Model, interventions in the PCBH model are often briefer and delivered by a mental health clinician, whereas the Collaborative Care Model centers on longer-term relationships between the patient and their care team to manage chronic mental health issues.
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Like in other models, SBIRT involves universal screening of all patients for mental health and substance use concerns and embedding a behavioral health professional into the primary care team.
If a patient screens positive, the primary care provider or the behavioral health professional conducts a brief intervention. If the patient needs more extensive treatment, the primary care team refers the patient to a behavioral health provider or facility with which they have a relationship or agreement to share notes and track the patient’s progress together.
Policy and progress in Oklahoma
Oklahoma has made progress on implementing integrated care practices — the SBIRT and PCBH models are used in clinics across the state. While Collaborative Care has not been used extensively in Oklahoma so far, we expect to see increased use of the model soon, a result of a Healthy Minds-led bill to activate billing codes that support the model’s use.
Oklahoma was also recently awarded a 5-year federal grant to implement the model in primary care sites across Oklahoma. Through the grant, the Oklahoma Department of Mental Health and Substance Abuse Services will initially work to implement the Collaborative Care Model at Warren Clinic locations in North Tulsa, East Tulsa, and Broken Arrow, all part of the Saint Francis Health System.
Oklahoma’s Child and Adolescent Psychiatry and Mental Health Access Program is another important example of an integrated care solution to address the mismatch in supply and need for child and adolescent psychiatrists in Oklahoma.
The program supports pediatric primary care providers by virtually connecting them with child and adolescent psychiatrists for consultations about their patients’ behavioral health needs, exponentially increasing psychiatrists’ reach. The program offers greater access to care for children in Oklahoma, but also helps pediatricians develop more psychiatric expertise to share with colleagues in their communities.
Through programs like OKCAPMAP and other models to bring behavioral health care into primary care settings across Oklahoma, our state can maximize and extend the reach of its primary care and mental health workforces — and ensure more Oklahomans can access the care they need, when and where they need it.
This primer was adapted from Healthy Minds’ 2021 report, Integrating behavioral health into primary care in Oklahoma.
