Flexible, practice-centric interventions improve behavioral health integration in primary care

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Patients with behavioral health conditions frequently seek care in primary care settings rather than with mental health specialists. Notably, 15.9% of patient visits to primary care primarily address mental health concerns. However, many practices struggle to meet these patients’ complex needs adequately, with only 26% to 44% of practices employing onsite behavioral health providers (BHPs), such as psychologists or social workers.

Integrated behavioral health (IBH), the intersection of behavioral health and primary care, is associated with improved patient outcomes and experiences. Yet, implementing effective, evidence-based IBH models can be challenging. To address these difficulties, a large-scale pragmatic clinical trial evaluated the effectiveness of a quality improvement (QI) toolkit designed to enhance IBH integration efforts in primary care practices.

The study, published in The Annals of Family Medicine, involved 42 randomized primary care practices. These participating practices were divided into two groups:

1. Intervention group: Implementing the integrated behavioral health and primary care (IBH-PC) toolkit.
2. Control group: Continuing with standard IBH services.

Eligible practices already employed colocated BHPs and demonstrated room for improvement in integration, as assessed by the Practice Integration Profile (PIP). The PIP is a validated tool that evaluate various dimensions of IBH, including workflows, communication and patient engagement. The study also included 2,945 patient participants, all of whom had multiple chronic medical and behavioral health conditions.

The IBH-PC toolkit offered structured QI resources tailored to practice needs, including workbooks, online education, a learning community and coaching by QI professionals paired with psychologists. Practices progressed through three key stages:

1. Planning stage: Practices assessed their current levels of integration using tools like the PIP and identified actionable goals relevant to their unique needs. This stage emphasized aligning practice priorities with patient needs and existing workflows, laying the foundation for subsequent changes.
2. Workflow redesign stage: Practices developed and piloted new processes to address their goals. Examples included improving patient identification methods, refining the referral process for behavioral health services and integrating behavioral health workflows into primary care. Iterative testing allowed practices to refine these changes for broader application.
3. Practice changes implementation stage: Redesigned workflows were embedded into daily operations, prioritizing sustainability and cultural integration. Practices established mechanisms for continuous quality improvement to ensure lasting improvements. This stage focused on embedding changes into practice routines and maintaining momentum for ongoing transformation.

Of the 20 practices included in the intervention arm, 65% completed all three stages, while 30% completed two stages.

Integration outcomes:

• Intervention practices demonstrated significantly higher levels of integration compared to the control group, particularly in workflow, integration methods and patient identification domains.
• Each completed intervention stage correlated with measurable improvements in PIP scores.

Patient health outcomes:

• No significant changes were observed in patient-reported outcomes between the intervention and control groups.
• Metrics included physical function, anxiety, depression and other indicators assessed using PROMIS-29, PHQ-9 and GAD-7 scales.
• The absence of measurable improvements might reflect limited direct patient engagement with BHPs, or the baseline care already addressing chronic conditions.

Researchers identified the practice-centered approach as a key strength of the intervention. By allowing practices to set their own goals and adapt the toolkit to their workflows, the intervention successfully addressed diverse needs across participating sites. However, achieving measurable patient health outcomes remains a challenge.

Researchers also noted that foundational changes, including improved integration workflows and team-based communication, might require additional time to translate into tangible patient health benefits. The findings underscore the growing importance of IBH, particularly in the wake of the COVID-19 pandemic, which amplified behavioral health needs and disrupted health care delivery.

“Primary care practices face an unprecedented challenge in the high demand for care to address the complex needs of patients with multiple chronic conditions,” the authors of the study wrote. “A practice-centric, flexible intervention aimed at improving the level of IBH in primary care can help practices transform to meet these needs and improve the health of their most complex patients.”