Behavioral Health - Key Activity 2


Enhance the Culture of Integrated Behavioral Healthcare


This key activity involves the following elements of person-centered population-based care: behavioral health integration.


Promoting a culture of integrated care delivery begins by establishing a clear vision of whole-person care and its implications, ensuring that all clinic staff understand their respective roles in supporting care of the whole person, and addressing the physical, social and behavioral needs of the clinic’s patient population. Although there are a number of models and strategies of IBH for which an evidence base has been developed, there is no single model that is a fit for every organization. Practices should not let their concept of an ideal model get in the way of implementing something that works within their own setting. It’s important for the practice to be continually moving toward an integrated whole-health system with both primary care and behavioral health services. Most organizations continually evolve integrated care services over time, modifying their integration strategies as they gain experience or the availability of resources changes.

Integration of behavioral health and primary care is still relatively new, starting in the early 2000s. Developing integrated care is not as straightforward as simply hiring a behavioral health provider to the practice. It is an ongoing process of culture change and transforming care delivery to support whole-person care. Integration requires more than clinical integration; it requires integration of behavioral health leaders into senior or executive leadership, integration of operational processes related to behavioral health, and intentional power sharing among the care team with purposeful design of workflows. These efforts collectively contribute to an enhanced organizational culture that incorporates the perspectives of multiple professions working together to support patients and families in their care.

Working as a multidisciplinary team in an integrated way provides opportunities for the team to understand a wide range of drivers for health outcomes. Ideally, integration helps the care team make care recommendations that better accommodate patient experience and engage more meaningfully with the interconnectedness between physical health, emotional health and social needs.

IBH enables the care team to tend to whole-person care, making every effort to desilo interventions and interactions with patients. This approach enables essential screening and monitoring of behavioral health needs and the delivery of comprehensive care, with care coordination and collaboration among an integrated care team. For example, a behavioral health specialist reviews the pre-visit plan, notes that the patient is due for diabetes screening, provides grief counseling and offers to link the patient to the medical assistant who then uses a standing order to provide necessary screens (e.g., foot check, etc.). Benefits of integrated behavioral health extend beyond the patient to care team members, as well. Professionals working in integrated settings report increased skills and greater satisfaction with their work as they feel better able to meaningfully respond to patient needs.

IBH services will vary considerably in capacity between practices. Practices in more rural areas typically have much larger IBH departments with significant BH case management and psychiatry resources, while those in urban areas often have smaller IBH departments and nascent case management and psychiatry. This is typically due to the differences in BH resources in the surrounding community; when communities have insufficient BH resources and county systems are constricted, rural practices often build departments to meet all or most of their patient’s BH needs. When communities are rich with BH resources, urban practices often rely more on outside referrals for BH care. In this way, each practice’s IBH vision will be informed by community BH resources as well as the patient population’s needs.

Integrated behavioral health enables patients to gain support in the primary care setting, expanding access to care for groups underserved by community-based behavioral health care. The Agency for Healthcare Research and Quality (AHRQ)’s integration academy provides further discussion of the role of behavioral health integration in reducing inequities by reducing fragmentation, stigma, and healthcare utilization and quality of care and health outcomes, especially for people with depression, anxiety, diabetes, high cholesterol and high blood pressure.

Integrated care allows a team to take a whole-person care approach and begin to understand more fully the root causes of poor health outcomes, potentially leading to improved outcomes in the patient population. Unmet social needs are often a contributor to various behavioral health conditions (see Key Activity 10: Develop a Social Needs Screening Process that Informs Patient Treatment Plans). A culture of integrated healthcare enables the care team to identify unmet needs and help patients connect to community resources. Furthermore, patients who might be hesitant to endorse needs on a social needs screening form may be more likely to disclose these needs in a session with care team members who come off as empathic and nonjudgmental, prompting referrals and connections. Integration of behavioral health screening and counseling, coupled with screening for social needs, can lead to a comprehensive care plan that aligns care to support individuals’ holistic needs and build on their strengths.

Relevant health information technology (HIT) capabilities to support this activity include pre-visit planning tools; care guidelines; registries; clinical decision support; care dashboards and reports, including behavioral health screenings and social needs data; quality reports; outreach and engagement; and care management and care coordination. See Appendix D: Guidance on Technological Interventions.

To enable team coordination, thought must be given to how access relevant technology and how data capture can be distributed, consistent and integrated into workflows and how data is accessible across team members. Where possible, it is desirable to avoid duplication of data entry, siloing of information in standalone applications and databases, and the need to work in multiple applications requiring separate login.

Action steps and roles

1. Co-create a shared updated vision for IBH in the practice.

Suggested team member(s) responsible: IBH implementation team with senior leaders.

This is an opportunity to evaluate current IBH services, both strengths and shortcomings, and collaborate to establish a shared vision, aims, and strategies for enhanced integrated care. Because integrated behavioral health often means different things to different team members and leaders, this is also a time to align understanding about goals and strategies.

One technique for creating a shared vision is to use patient Journeymapping.[1] It can be especially illuminating to map both examples of current patient journeys through each step of obtaining primary care and behavioral health services as well as the ideal patient journey. Mapping ideal patient journeys can facilitate a shared vision for integrated care, with patient preferences, experiences and outcomes as the north star.

2. Align integrated care strategies to the strengths and needs of the population.

Suggested team member(s) responsible: IBH implementation team with senior leaders.

Practices have an array of information to review to learn about population needs, including screening results, community or secondary data sources, care team experiences, and patient experience data. Dedicate care team meeting time to reviewing the needs of the population served and current capacity to provide care.

  • Using EHR reports to identify the number of patients with prescribed psychotropic medications can provide a population-level view of a subset of patients with behavioral health conditions in the practice.
  • Review aggregate universal screening data to better understand the behavioral health needs of the population. See Key Activity 7: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Behavioral Health Screening and Follow-Up for guidance around leveraging the EHR to understand which patients are due or overdue for screening. More about screening for depression, anxiety, unhealthy substance use, and adverse childhood experiences is detailed later in this guide.
  • Review EHR reports for current population outcome data and develop improvement aims. See Key Activity 11: Use a Systematic Approach to Address Inequities within the Population of Focus for more about ensuring an equity lens on your review data and selection of improvement aims.
  • An evolving view into strengths and needs of people in the population can emerge through the repeated administration of the Three Part Data Review.[2] Consider deploying a care team member with enhanced listening skills to learn from five to 10 patients per quarter. At the same interval, query care team members and review quantitative data, then leverage an existing meeting to assemble the learning from the three-art data review, identify themes, surface opportunities for improvement, and plan tests of change.
  • Calculate the current capacity for providing behavioral health services and the established level of need. Develop short- and long-term population health goals; for most practices, it is unlikely there is currently enough capacity to meet the practice population’s behavioral health needs. See Key Activity 4: Develop Strategies to Maximize Capacity of IBH Services for more information.


3. Confirm a set of IBH strategies that aligns with the organization’s aims, the population’s strengths and needs, and organizational capacity.

Suggested team member(s) responsible: IBH implementation team with senior leaders.

Assess the existing state of behavioral health integration within the clinic to define the organization’s current strategies for IBH while keeping the overarching vision as a north star.

Integrating behavioral health into your practice may involve an embedded behavioral health specialist on the care team, co-location of services working with a behavioral health partner, a telehealth model, or a blended approach.

Define a set of strategies to meet the specific needs and build on the strengths of the patient population, and then develop workflows for behavioral health conditions to guide the care team in defining their roles. Co-designing strategies and workflows with patients is an impactful way of ensuring relevance of interventions and strengthening partnerships with patients; the practice’s consumer advisory board is a natural fit for this. Codifying workflows and using them to guide staff and onboard new team members supports standardized care delivery and fosters team members’ growing comfort in addressing behavioral health and social needs.

Examples of aims and strategies of the updated IBH vision might be:

  • Increasing the ratio of behavioral health clinicians to one to every two primary care providers.
  • Incorporating a behavioral healthcare manager or BH care coordinator on each care team.
  • Ensuring primary care providers (PCPs) are competent, comfortable and willing to manage medications for depression, anxiety and attention deficit hyperactivity disorder (ADHD).
  • Increasing operational integration.
  • Training all SUD providers to do mental health counseling.
  • Integrating psychiatric specialists into the practice.
  • Developing a feasible model for warm handoffs, using interns or community health workers (CHWs).


4. Develop relationship-based collaboration among the multidisciplinary care team.

Suggested team member(s) responsible: IBH providers or leaders, outside trainers.

IBH requires a practice to assess the skills and capacities your team has and make reasonable efforts to align needed support with the needs and strengths of your patients. When the IBH care team is assembled, the ongoing work of cultivating relationships among care team members begins. Leadership must establish expectations that care team members will identify their own skills and learn about those of their colleagues, learning about each other’s roles with patients and families and among the care team. Leadership will support the team to acknowledge and have the resources to spend the time and effort required to develop trust among the care team and continuously attend to the development of a shared language. Conduct regular check-ins to reinforce shared language and update the shared language based on emerging research and best practices. Develop and support staff capacity to recognize and manage their own trauma histories that they bring into patient care.

Build opportunities to develop a shared understanding among the care team. Staff training is a great opportunity to leverage reflection time and highlight staff members’ strengths and learning potential (e.g., identify roles who could provide screening, brief intervention and referral to treatment (SBIRT) interventions at the time of the visit). Train all staff in trauma-informed care and early identification. Assess staff understanding of health equity, health literacy and cultural humility; implement training programs to address gaps. For connection to social needs resources, train staff (e.g. front desk staff, medical assistants, behavior health specialist, etc.) on available community resources.

For more on this topic, see Key Activity 12A: Fostering Collaborative Teamwork with a Focus on Power Sharing Among Disciplines.

5. Universally train all relevant employees in administering and responding to sensitive screenings.

Suggested team member(s) responsible: IBH providers or leaders, outside trainers.

Screenings are only effective when patients feel comfortable with self-disclosure. People with substance use disorders, adverse childhood experiences, and other mental health conditions are often understandably hesitant to endorse symptoms in screening, given that behavioral health conditions are historically stigmatized and many patients who have disclosed these conditions may have experienced judgment in healthcare settings.


6. Establish parity of behavioral health and medical departments.

Suggested team member(s) responsible: CEO, CMO, CBHO, board.

Transforming the care delivery system to address whole-person health and improve population well-being requires integration of behavioral health leadership at the executive level. Elevating BH leadership to chief behavioral health officers (CBHOs) with parity to chief medical officers (CMOs) and a seat at the executive leadership table is fundamental to creating true integrated care systems.

Implementation tips

See Key Activity 3: Enhance Operational Integration of Behavioral Health for other tips and resources that will support operational integration.


  1. Philpot LM, Khokhar BA, DeZutter MA, Loftus CG, Stehr HI, Ramar P, Madson LP, Ebbert JO. Creation of a Patient-Centered Journey Map to Improve the Patient Experience: A Mixed Methods Approach. Mayo Clin Proc Innov Qual Outcomes. 2019 Sep 24;3(4):466-475. doi: 10.1016/j.mayocpiqo.2019.07.004. PMID: 31993565; PMCID: PMC6978601. 
  2. Population Health Guide for undertaking a three-part data review [Internet]. [cited 2024 Feb 26]. Available from: