An Evidence Roadmap for Implementation of Integrated Behavioral Health under the Affordable Care Act

The Affordable Care Act (ACA) created incentives and opportunities to redesign health care to better address mental and behavioral health needs. The integration of behavioral health and primary care is increasingly viewed as an answer to address such needs, and it is advisable that evidence-based models and interventions be implemented whenever possible with fidelity. At the same time, there are few evidence-based models, especially beyond depression and anxiety, and thus further research and evaluation is needed. Resources being allocated to adoption of models of integrated behavioral health care (IBHC) should include quality improvement, evaluation, and translational research efforts using mixed methodology to enhance the evidence base for IBHC in the context of health care reform. This paper covers six key aspects of the evidence for IBHC, consistent with mental and behavioral health elements of the ACA related to infrastructure, payments, and workforce. The evidence for major IBHC models is summarized, as well as evidence for targeted populations and conditions, education and training, information technology, implementation, and cost and sustainability.

Keywords: Integrated behavioral health, primary care, affordable care act, collaborative care, depression, implementation science

1. Introduction

The health care system in the United States has been re-oriented to promoting quality patient-centered care at a lower cost for the entire population [1]. Such an approach requires attention to heretofore-marginalized mental and behavioral health concerns, which historically had been largely managed separately from physical health, or not at all. The Patient Protection and Affordable Care Act (ACA) of 2010 presented many opportunities and incentives for expanding access to and sustainability of behavioral health services in the U.S.[2]. As discussed by Croft and Parish [2], the ACA presents pathways to increased adoption of integrated behavioral health care (IBHC) by 1) enhanced access to care through increased insurance coverage (e.g., through Medicaid expansion and health insurance exchanges) and mental health parity (i.e., mental health and addiction services must be covered as essential benefits on the exchanges), 2) finance and reimbursement changes that support mental and behavioral health care through increased Medicaid and Medicare payments for primary care, health homes for those with serious mental illness, accountable care organizations (ACOs), co-location of primary care and behavioral health in community-based behavioral health settings, and home and community-based support services for Medicaid beneficiaries; and 3) infrastructure supports, including funds for workforce development and training programs. Thus, the ACA supports a number of structural, financial and workforce development changes needed to adopt and sustain high quality IBHC.

IBHC (also sometimes referred to as collaborative care [3]) is broadly defined as a set of elements (structures and processes) designed to address a range of mental and behavioral health needs in concert with primary care ( Table 1 ). Dissemination of IBHC is increasing, but evidence-based models and interventions are often not implemented with fidelity, and there is wide variability in how IBHC is defined and implemented in real world settings [4],[5]. At the same time, there are only a few truly evidence-based models, especially beyond depression and anxiety, and further research and evaluation is needed. Given the ACA's emphasis on implementation and dissemination of evidence-based interventions [6], those seeking to implement IBHC would benefit from knowing the evidence. The purpose of this paper is therefore to support health care organizations (from small, independent practices to large fully integrated health care systems) seeking to implement IBHC by presenting an evidence roadmap, to inform decisions about the structures and processes needed to do integrated care well.

Table 1.

2. Roadmap to the evidence

Integrated behavioral health care is effective

A driving factor in the decision to pursue organizational change – and IBHC is a major change – is evidence for the effectiveness of a new approach to care. Numerous reports on the evidence for IBHC conclude that the evidence supports the use of integrated care for managing both depression and anxiety in primary care settings, while noting that the effectiveness varies across settings, populations, and targeted health concerns [7]–[10]. In 2008, Butler and colleagues published an in-depth report on mental health integration in primary care, concluding that the purported benefits of integrated care for managing both depression and anxiety were supported by the evidence [7]. Several years later, Butler produced another report showing that integrated care improves depression outcomes, but noted level of integration (e.g. degree of shared treatment decision making or extent of co-location) in the care process or in provider roles was not related to better outcomes [8].

In their systematic review, Oxman, Dietrich, and Schulberg [11] described the research on collaborative care models as representing a third generation of research on the treatment of depression in primary care, following a first generation of multifaceted, collaborative care interventions and a second generation grounded in the principles of the chronic care model and guideline-based care. In this third generation, there was increased emphasis on effectiveness rather than efficacy in the context of translation, dissemination and sustainability, and attention to aging populations. An enhancement of “consultation-liaison skills” and better relationships between primary care clinicians and mental health specialists was considered an important advancement in the field. While Oxman et al concluded that referral to specialty mental health care would likely lead to better outcomes at an individual level, they also acknowledged that overall population health would be best improved with the more limited care made available from within primary care because of increased access.

Consistent with Oxman et al [11], Gilbody and colleagues' meta-analysis revealed considerable heterogeneity in effects for earlier studies (in the 1980s and 1990s), while the post-2000 evidence demonstrated more stable estimates of the effectiveness of IBHC for managing depression [12]. Gilbody and colleagues also found that the degree of effectiveness was related to medication adherence and the professional background and supervision method of case managers, specifically the use of case managers with mental health training and regular, planned supervision. More recently, Thota and colleagues again concluded that collaborative care for depression is effective at both the individual patient and public health levels [10], and can be economically viable [13]. In another review, Katon and Selig [14] noted that a population-based approach that coordinates the care of depression from within primary care should be particularly effective for reducing overall prevalence of depression. They suggest that three activities well-suited to primary care are key to secondary prevention of depression – improved diagnosis (including screening for risk factors and early evidence of minor depression), preventing chronicity, and preventing relapse/recurrence by virtue of more frequent contact and opportunities for tracking and monitoring symptomology.

Thus, IBHC is, overall, known to be effective for increasing access to behavioral health services and improving outcomes, with the evidence primarily supporting effectiveness in the domain of depression. As discussed below, much of the research to date has focused on depression and thus the body of evidence for conditions beyond depression remains small. Once acknowledging the value of and deciding to adopt IBHC, the next decision to be made concerns HOW to adopt an IBHC approach. An understanding of the evidence for classic (e.g., care management for depression) and contemporary (collaborative care systems addressing a range of behavioral health needs [15]) models and frameworks can inform the HOW, depending upon the needs, resources, and priorities of the organization.

3. Models and Frameworks

Systematic reviews of the evidence for IBHC have examined several of the IBHC models [7],[10],[16],[17]. A brief sampling of the models subjected to research and formal evaluation are described here and summarized in Table 2 . Each model is characterized in terms of key elements, including the care team , the setting , the consultation and referral arrangements , and the clinical processes (including screening, triage, treatment, and monitoring treatment response) (see Table 1 for definitions of these elements).

Table 2.

Regular telephone follow up for a year (weekly at first, and then less frequent as depression lessens)

Psychiatrist supervises and provides guidelines for the care manager, provides consultation services to the PCP, and facilitates appropriate use of additional mental health resources

Care management: patient education, counseling for self-management and adherence, assessment of treatment response and communication with other clinicians

Psychiatrist prepares a practice to implement the model through initial and ongoing psychiatric education re: diagnosis, risk assessment and care plans

Co-located mental health specialists provide traditional psychotherapy (e.g., cognitive behavioral therapy) as well as “curbside” consultation for PCPs

Triage: in which level of care is increased depending on patient need, risk or severity, ranging from behavioral health consultation, to specialty consultation, to fully collaborative care

Appropriate training and re-training of expectations, for both mental health and medical care providers

Nurse care managers encourage patients to seek medical care for their medical conditions through patient education and motivational interviewing and assist patients with accessing and navigating the primary care system through advocacy and addressing system-level barriers, such as lack of insurance

Care management for depression. In general, the model with the most empirical support for its effectiveness is care management for depression (i.e., IMPACT) [7],[8]. IMPACT was originally conceptualized as a chronic disease management program for older adults with depression [18],[19]. IMPACT involves a team-based approach to managing depression from within primary care. The acute and maintenance phases of depression are tracked by the care manager, a nurse or psychologist who provides education, care management, and medication support or brief psychotherapy.

Similarly, the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study utilized care managers who used a protocol-based intervention to monitor depression treatment adherence and response and provide guidelines-based recommendations to physicians, who were the sole decision makers [21]. Compared to usual care, the intervention led to increased access to depression care, greater declines in suicidal ideation, earlier treatment response, and higher rates of remission at 4, 8 and 24 months [22],[23].

Three component model. The three component model (TCM) is also characterized by care management and enhanced mental health support, and explicitly includes the concept of a “prepared practice” [24]. A prepared practice is one in which providers have received education on how to follow new practice protocols [24]. The Re-Engineering Systems for Primary Care Treatment of Depression (RESPECT-D) project was a cluster randomized trial of an intervention based on the three-component model [25]. Intervention patients had approximately double the odds of achieving a 50 percent reduction in depression symptoms as well as remission at 3 and 6 months. The project was supported by training manuals and quality improvement resources, rather than research protocols and grant funding – potentially making this a more sustainable approach [26]. The implementation and evaluation of RESPECT-D in the military setting (RESPECT-Mil) for the treatment of service members with post-traumatic stress disorder and depression showed that the three component model was feasible, acceptable, and led to clinically significant improvement in that context [27].

Co-located collaborative care. The Strosahl [28] primary mental health care model of co-located collaborative care is distinguishable from the aforementioned care management models because master's or doctoral level mental health specialists are located onsite in a primary care clinic and provide services to patients of that clinic, often in collaboration with a PCP.

While widely adopted as a collaborative care model, there is limited empirical evidence on this model, with a few exceptions. In the Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study, co-located mental health and primary care for mental health/substance abuse was compared to enhanced referral to specialty mental health care [29]. In PRISM-E, there was evidence demonstrating that co-located collaborative care led to increased access to mental health and substance abuse services compared to enhanced referral [30]. However, clinical outcomes were generally comparable across the two conditions, although enhanced referral to specialty mental health appeared to be superior for patients with major depression [31],[32].

The US Veterans Health Administration has embraced collaborative care, and has implemented a variety of models, including care management models targeted to depression [33] and other mental health conditions [34], and a blended model (co-location plus care management) in a number of their practices across the country [35]. The VA's White River Model incorporates comprehensive mental and behavioral health care into primary care, with co-located behavioral health providers (therapists and psychiatrists) as part of the care team, information technology to support assessment and tracking, care management, and chronic disease management. Screening and triage are also important processes of care. Patients can receive brief or long-term individual psychotherapy or group psychotherapy for a number of mental disorders, including depression, anxiety, stress/anger management, post-traumatic stress disorder, and substance use. Based on “before-after” study designs, this model appears to have led to improvements in access to care, patient and provider satisfaction, and adherence to evidence-based guidelines for depression treatment, and decreased cost of mental health care in the context of this capitated, single payer system [36],[37]. Furthermore, in a comparison with VA facilities that had not implemented this model, facilities with mental health integration showed greater increases in rates of detection of mental health disorders [38].

Primary care in specialty mental health. Sometimes referred to as “reverse integration”, primary health care can be provided to patients with severe mental illness in specialty mental health settings, either through co-located primary care providers or care coordination. The VA system has also tested several reverse integration models [39]–[41]. For instance, the Primary Care Access, Referral, and Evaluation (PCARE) study is a randomized trial of primary care management for patients with severe mental illness being cared for in a community mental health center [39]. At the PCARE 12-month follow-up, intervention patients were significantly more likely than usual care patients to have received recommended preventive services (58.7% vs 21.8%), to have experienced greater improvements in mental health status, based on the SF-36 (8% improvement vs 1% decline), and to have lower cardiovascular risk, based on Framingham Cardiovascular Risk scores [39].

4. “Active ingredients” of IBHC?

Past attempts have been made to determine “active ingredients” of IBHC – those structures and processes necessary and sufficient for effective IBHC. In a review from the Canadian Collaborative Mental Health Initiative (CCMHI), Craven and Bland [16] reached conclusions supporting several elements of integrated care as key factors in improving outcomes, including practice preparation, co-location, collaboration (especially when paired with treatment guidelines), systematic follow-up, patient education, sensitivity to patient preference, and counseling to promote treatment engagement and adherence. In a meta-analysis and meta-regression of specific intervention content, eight aspects of these interventions that varied across 34 studies on collaborative care for depression were tested as predictors of depression outcomes [12]. These variables included setting (USA vs non-USA), recruitment method, patient population, PCP training, case manager background, case management sessions, case manager supervision, and case management content. Of these, four were at least marginal predictors of depression symptoms in multivariate analyses—setting (in favor of non-USA studies), recruitment method (in favor of systematic identification through screening rather than referral by clinicians), care manager background (in favor of those with mental health expertise), and care manager supervision (in favor of those receiving regular/planned supervision). While difficult to separate from other aspects of multifaceted interventions, care management does appear to be an important factor in depression care [17]. However, care management functions in different ways across different contexts, and it is not clear which are the most effective components, which background or training is needed, or whether ongoing supervision of care managers is necessary.

The extent to which members of the care team collaborate (versus provide separate care in parallel) distinguishes many practices that provide integrated care. In a meta-analysis of studies evaluating the effects of interactive communication between primary care clinicians and specialists - defined as “direct, personal interaction with specialists… such as curbside consultations” (Foy, p. 247) [42]—randomized trials involving collaboration between PCPs and psychiatrists exhibited a small to medium effect size for mental health outcomes in favor of collaboration. This is consistent with recent findings of a Congressional Budget Office review of Medicare Demonstration Projects, which found that in-person interactions between care managers, providers and patients were uniquely associated with programs that demonstrated improved outcomes [43]. This in-person interaction can be contrasted with enhanced referral and/or collaboration from afar. While some have concluded that referral to specialty mental health care would likely lead to better outcomes at an individual level, it was also acknowledged that overall population health would be best improved with the more limited care made available from within primary care because of increased access [11].

5. Targeted Populations and Conditions

Decisions about care teams, care delivery settings and clinical processes to be implemented may also be influenced by the characteristics of the patient population served. While comprehensive services for all may be ideal, practical limitations dictate the need to narrow down the population to be targeted by IBHC services, and the types of clinical concerns to be managed internally versus referred out. The skills and training of the care team, needs of the patient population, available resources—and the evidence—inform the decision about targeted populations and conditions.

Targeted Populations. The evidence base for IBHC addresses certain populations more than others, including older and middle age adults, veterans, and patients cared for in HMO settings, although the evidence is still limited to the disease contexts previously noted. For instance, both IMPACT and PROSPECT focused primarily on geriatric populations. In contrast, there is a limited amount of evidence on integrated care for children and adolescents. The Youth Partners-in-Care (YPIC) study was an RCT of the effects of a care management quality improvement intervention compared to enhanced usual care, in youth ages 13 to 21 with depression [44]. Although generally consistent with standard care management, YPIC care managers were masters or doctoral level psychotherapists who delivered cognitive behavioral therapy (CBT) or coordinated delivery of other treatment options, and were not supervised by additional mental health specialists. Modest but statistically significant improvements in depression outcomes and patient satisfaction were observed. Some limited evidence exists for IBHC for peripartum women [45] and ethnic minorities such as Hispanic/Latino(a) patients [46].

Targeted Conditions. The main body of evidence in IBHC concerns the management of depression, a pervasive and burdensome illness but by no means the only mental health problem confronted in primary care. Growing evidence exists in other mental health domains, such as panic disorder [47], substance abuse and addiction [32],[48], and bipolar disorder [49]. In the Netherlands, a RCT comparing collaborative stepped care versus care as usual for the treatment of panic disorder and generalized anxiety disorder in primary care showed improvements in the group receiving the collaborative stepped care model, which held one year post−test [difference in gain scores from baseline to 3 months: −5.11, 95% confidence interval (CI) −8.28 to −1.94; 6 months: −4.65, 95% CI −7.93 to −1.38; 9 months: −5.67, 95% CI −8.97 to −2.36; 12 months: −6.84, 95% CI −10.13 to −3.55] [50],[51]. This approach was applied to patients with other mental health diagnoses, including depression, and the group receiving the collaborative stepped care model experienced an earlier treatment response, at four months post-test, compared to care as usual (74.7% v. 50.8%; p = 0.003), but no significant differences between the groups eight and 12 months post-test as both groups showed improvement [52]. The VHA has tested several telemedicine models for patients with post-traumatic stress disorder (PTSD). RESPECT-PTSD was based on the three-component model (telephone care management, with psychiatrist supervision), which did not improve symptoms or functioning but did increase use of mental health services [53], and the total number of care manager calls was positively correlated with number of psychiatry visits (r = 0.63, p < 0.05) and amount of reduction in PTSD symptoms (r = 0.66, p < 0.05) [54]. In the VHA's TOP study (also primarily telemedicine), the off-site care team included nurse care managers, pharmacists, psychologists and psychiatrists; using interactive video technology, psychologists provided cognitive processing therapy, and psychiatrists conducted psychiatric consultations. This study did show significant improvements in PSTD symptoms among the intervention arm patients [55].

Much of the most recent literature on IBHC involves management of multiple psychiatric and/or physical comorbidities. Many IBHC model features (e.g., care management, interdisciplinary collaboration, clinical monitoring and follow-up, stepped care) reflect an instantiation of Wagner's Chronic Care Model [56], and thus can be used to co-manage multiple chronic diseases. It is also thought that treating mental illness may have direct and/or indirect effects on other illnesses, possibly because of physiological, social, cognitive, and/or behavioral factors common to the comorbid conditions [57]. In a pilot study of a patient-centered depression care management intervention characterized by several elements of integrated care (e.g., education and adherence monitoring), elderly adults with comorbid depression and hypertension were found to have lower depression scores, lower blood pressure, and greater medication adherence at six weeks [58].

Based on the IMPACT model, the Multifaceted Diabetes and Depression Program (MDDP) targets comorbid diabetes and depression in a low-income, predominantly Hispanic population [59]. MDDP incorporates several IMPACT-like features, with diabetes depression clinical specialists (DDCSs) serving in the care manager capacity, stepped care for depression, supervision by a PCP, and an available consultant psychiatrist. In addition, MDDP involved “sociocultural enhancements” (e.g., addressing social stigma towards mental health), education and counseling in self-management of both depression and diabetes, and patient navigation services. Consistent with the results of other combined depression-and-diabetes collaborative care interventions [60] and subgroup analyses of patients with diabetes in the original IMPACT study [61], MDDP resulted in improved depression, functioning and financial status and reduced symptom burden for both depression and diabetes – but there were no objective effects on diabetes control (e.g., change in HgA1c).

There are mixed results regarding whether effective treatment of mental illness (in the context of IBHC) can lead to improved outcomes for comorbid chronic diseases. Longer term follow-up and/or the addition of more intensive chronic disease-specific intervention content may be required to observe an effect on these other outcomes. For instance, the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study implemented a twelve-week antidepressant therapy intervention in sequence with a six session pain management intervention (followed by a six month continuation phase) in patients with comorbid depression and musculoskeletal pain [62]. Treatment algorithms were coordinated by nurse care managers in primary care settings, who were supervised by a physician depression specialist. Not only did patients in the intervention experience significantly greater improvements in depression than those in usual care, they also experienced significantly greater improvements in pain severity and interference.

The TEAMCare intervention focused on patients with diabetes or coronary heart disease or hyperlipidemia and depression and utilized nurse case managers with specialist consultation working with primary care physicians in an attempt to increase adherence to medication and other self-care behaviors for both depression and co-morbid physical illnesses [63]. The TEAMCare intervention failed to demonstrate significant effects on medication adherence, but led to significant changes in provider prescribing behavior [64]. An early implication of these findings is that treating mental illness may aid in improving coping skills (e.g., emotion coping) and self-regulation/self-management, which have subsequent salutatory effects on stress and pain, which helps to improve functioning and quality of life – even if short term effects on medical illnesses are not observed.

A broader focus on the range of behavioral health needs of patients in primary care [15], including basic psychosocial needs, health behavior modification, and the myriad mental health conditions presenting in primary care is much less common in the research literature. There is evidence demonstrating the effectiveness of behavioral medicine interventions in primary care settings [65],[66] and limited but compelling literature on how to integrate behavioral medicine in primary care [67].When broadly focused models are evaluated, the designs are generally less rigorous, the outcomes studied are generally more process-oriented (rather than clinical), and the conclusions are less generalizable outside the context in which the evaluation took place. The primary exception to this rule is that reverse integration models often seek general medical care (e.g., not just for diabetes) for a range of patients cared for in specialty mental health (e.g., not just patients with schizophrenia). By design, necessity and/or default, these broad health focused models are concerned with process and system capacity, such as defining and expanding the roles of health care professionals (e.g., advanced practice nurses) [68].

6. Workforce Development, Education and Training

A critical component of IBHC is the workforce needed to deliver behavioral health services in collaboration with primary care. However, there is a looming workforce shortage of mental health professionals who can deliver quality behavioral services in primary care settings [69]. Behavioral health providers from case managers to master's level therapists to doctoral level or medical providers are not well equipped to practice at the top of their license in these settings [69],[70]. Furthermore, the vast majority of educators and supervisors of behavioral health and mental health field have not practiced or developed skills in IBHC settings. Opportunities for training and education in IBHC are in embryonic stages of development and it is rare for mental health providers to have participated in coursework, supervised clinical experience or direct experience in primary care settings. The ACA recognizes the workforce shortage and supports education and training in mental health and behavioral health professions. The ACA's Mental and Behavioral Health Education and Training Grants (Sec. 5306 MBHETG of the ACA) are expected to influence the future training of behavioral health providers. Consequently, the ACA supports “programs designed to increase the number of professionals and paraprofessionals (to) service high priority populations ….and plan to service medically underserved in health professional shortage areas or in medically underserviced areas.” [71]. Recommendations for workforce development include incentive programs that recruit providers to underserved settings, like the National Health Services Corps, which could support integrated training clinical training programs [72].

IBHC competencies and curriculum. In order to prepare for a new breed of mental health providers to work in primary care settings, there needs to be a foundation of knowledge, skills and professional values that support this training. However, mental health training has lagged behind other healthcare professions in defining core competencies for behavioral healthcare professionals. The Interprofessional Education Collaborative is one interdisciplinary organization whose goal is promote new models of team-based care and interprofessional communication for healthcare reform [73]. Behavioral health groups such as social workers, counselors, psychologists, psychiatric nurses, and psychiatrists are beginning to re-tool their professional competencies toward IBHC training [74]. There are a number of guidelines from psychologists, psychiatric nurse practitioners, social workers and psychiatrists that outline a set of core competencies for integrating their professions into primary care [75]–[78].

Creating team-based care training, clinical experience in primary care and quality improvement focus are essential for new models of care [69],[79],[80]. The Annapolis coalition on Behavioral Health Workforce Education [74] outlined the recommendation for improving the relevance of graduate education. They proposed several areas for improvements; some of the key elements include competency based training using evidence-based practice guidelines along with values, knowledge and skills for new models of care—including population management and interdisciplinary approaches. Essentially, educators are proposing a paradigm shift from a narrow focus on individual mental health to four pillars of IBHC practice: 1) evidence-based practices of integrated care, 2) research methods, 3) interprofessionalism and 4) quality indicators and outcomes [71]. Training in integrated care requires a broad range of services at a faster pace, of shorter duration, and with frequent team-based communication [70]. The roles of behavioral health in ACA organizations, therefore, are focused on expanding traditional mental health skills and services. These models include implementing BH into the medical home through establishing workflows for complex patients, expanding the workforce through clinical training programs, strengthening evidence for IBHC and designing evaluation protocols to assess impact of IBHC [81].

Current state and future needs in training and education. Even though there is an urgent call for training a new breed of mental health professionals, we lack data on the effective training models, adequate credentials, and team configurations [72]. Models of training or practice that may be valid in mental health specialty clinics may not be applicable for primary care settings. The specific roles, tasks, and skills for diverse mental health providers in primary care are not well understood. While there is a growing number of within discipline training sites, certificate programs, or re-tooling programs that offer IBH in primary care, there is no consistency or definition on what constitutes the basics of integrated primary care training [69]. Consequently, education and training need to be evaluated and developed for the growing IBH workforce from a range of disciplines.

Table 3 outlines the disciplines, training, clinical experience and evidence-based practices that are currently available. At this stage, there is an urgent need for all mental health disciplines to evaluate our current training models that contribute to quality IBHC practice.

Table 3.