Of Integration Models and Primary Care

Why integration?

Integrating medical and behavioral health care directly aligns with the Quintuple Aim of healthcare —to improve the patient experience, improve the health of the entire patient population, reduce the cost of healthcare , reduce provider burnout, and increase equity in the provision of healthcare services .

The reality many healthcare professionals recognize and often discuss is that the bulk of mental health conditions—from mild to severe, acute to chronic—are actually treated in primary care settings, not specialty mental health . This makes primary care the de facto mental health system for most Americans.

The Integration Landscape

There are several established models of behavioral health integration, including:

• Primary Care – Mental Health Integration (PC-MHI) used throughout the VA system
• Collaborative Care Model (CoCM) developed by the AIMS Center at University of Washington
• Primary Care Behavioral Health (PCBH) focused on population health and team-based care
• Various other hybrid and custom implementation models

Whether the differences between these models matter significantly—not just academically, but practically—is a matter of some debate. As Dr. Alexander Blount noted in his recent piece,

Models can offer useful approaches, but each site will have different needs, and each will find different programmatic adaptations more useful than others. Working from a “north star” of commitment to our patients, problems and opportunities will show themselves, and then a model will be one good source for ideas and routines that can help us move forward .

To be clear, these distinctions between models can have real-world consequences. For instance, in some places CoCM may have specific reimbursement codes, while PCBH and other models may not. By clearly articulating the different models and their unique strengths, we create space for funders and policymakers to build systems that support diverse integration approaches

Also, in full disclosure, even though I am s strong proponant of PCBH, I practice in an organization that uses PCBH, CoCM, and SBIRT all at the same time—I still currently maintain an CoCM caseload while providing the bulk of my services from a PCBH persepctive.

What Makes Primary Care Behavioral Health (PCBH) Distinct?

PCBH is defined as:

…a team-based primary care approach to managing behavioral health problems and biopsychosocially influenced health conditions. The model’s main goal is to enhance the primary care team’s ability to manage and treat such problems/conditions, with resulting improvements in primary care services for the entire clinic population. The model incorporates into the primary care team a behavioral health consultant (BHC), sometimes referred to as a behavioral health clinician, to extend and support the primary care provider (PCP) and team. The BHC works as a generalist and an educator who provides high volume services that are accessible, team-based, and a routine part of primary care .

One of the ways that this differs from other approaches is the intentioanlly centering around the principles of primary care—the “4 Cs” identified :

• First Contact
• Continuity
• Comprehensiveness
• Coordination

Within the PCBH model, we often use the GATHER acronym to provide services that align with the needs of primary care:

• Generalist
• Accessible
• Team-based
• Highly productive
• Educator
• Routine

I will discuss GATHER more in future posts.

What Problems Does PCBH Address?

The PCBH model tackles several critical challenges in our healthcare system:

1. Access barriers: Many patients are unwilling or unable to follow through with specialty mental health referrals. By integrating care directly into the primary care setting, we reach patients who would otherwise go untreated .
2. Treatment philosophy: PCBH uses brief, contextually-based interventions focused on improving functioning and quality of life rather than exclusively targeting symptom reduction .
3. Flexibility: Consistent with primary care’s approach, patients may engage with behavioral health consultants intermittently as needed, rather than following rigid treatment protocols .
4. Whole-person care: Perhaps most importantly, PCBH supports truly integrated biopsychosocial care, rather than a siloed model that artificially separates biomedical concerns from psychological and social factors .

Real-World Implementation

While Dr. Bauman and I work in the same region with the same model and overlapping training, our implementations have notable differences based on our specific populations and clinical settings–and yet there are significant similarities that would allow a BHC or PCP to move between our two systems and still know how to to provide integrated care seamlessly. This highlights an important strength of PCBH—it provides a framework that can be adapted to different contexts while maintaining core principles.

Just as with any Evidence-based Practice (EBP), including theoretical models, interventions, etc., we need to treat the patient in front of us. As another colleague once said to a group of us, population health approaches can help us improve health for the whole community, but in the moment, we always do what’s best for the person sitting in front of us, regardless of the model we’re using. The flexibility of the PCBH model allows for this dual focus, improving care across the entire patient population while remaining responsive to each person’s unique circumstances.

Conclusion

If we truly want healthcare that addresses the whole person—treating the patient in front of us rather than just their diagnosis—behavioral health integration isn’t optional; it’s essential. And while many of us in the field have a favorite model that we advocate for and talk about, what’s most important is centering the patients needs, and adapting to the setting in which one is working.

PCBH offers a framework that honors primary care principles, removes access barriers, and supports comprehensive biopsychosocial care. As we continue advancing healthcare transformation, understanding and advocating for effective integration models will be crucial to creating systems that truly serve our patients’ needs.

What has been your experience with behavioral health integration? I’d love to hear your thoughts in the comments below.

References