Behavioral Health - Key Activity 4

KEY ACTIVITY #4:

Develop Strategies to Maximize Capacity of IBH Services

 

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

Overview

This key activity involves conducting a gap analysis to determine the scope of needed behavioral health support and developing strategies to provide such support. Strategies may include training medical assistants and CHWs to provide behavioral health support, enhancing medical providers’ skills to identify and support behavioral health needs, and recruiting a range of behavioral health support functions.

Like much of the nation’s healthcare delivery system, there is a severe shortage of BH providers in California. A report published by the University of California, San Francisco in 2018 – even before the pandemic sent need skyrocketing – predicted that, by 2028, demand for behavioral health clinicians will be 40% more than supply. This shortage is a significant barrier to sufficient staffing of IBH departments across California’s practices. The overwhelming majority of Community Health Centers (CHCs) are deeply understaffed to meet the behavioral health needs of the community served. Research consistently shows that 70% of primary care visits are psychosocial-related,[1] and over 40% of primary care patients want and need behavioral health services.[2]

Chronic disease management is enhanced by attending to behavioral health needs, as patients are better able to engage in chronic disease management activities, including the behavior change that is required to manage their chronic conditions, when their behavioral health needs are met. Additionally, patients are more likely to feel connected to and supported by the practice when their BH needs are met, potentially increasing the kept appointment rate.

At the same time, working in integrated ways offers team members the camaraderie and support of sharing and shouldering the work together, supporting staff retention. On a practical level, each member of the integrated care team learns new skills in the process of working in integrated ways together.

People of color and non-English-speaking patients have worse access to behavioral health services in comparison to white English-speaking patients. Expanding the capacity of behavioral health services, with a focus on BH providers who are culturally and linguistically concordant with the population served, is fundamental to equitable health outcomes.

Relevant health information technology (HIT) capabilities to support this activity include patient registries, care guidelines, quality reports, outreach, care management and care coordination data, and patient surveys. Tools needed for business intelligence include patient population-level data (e.g., total patients served, including REAL data, managed care plan (MCP) attribution), provider productivity (particularly behavioral health), and access data.

See Appendix D: Guidance on Technological Interventions.

Action steps and roles

As most organizations have some level of IBH services, it may be helpful for the leadership team, including BH leaders, to complete an IBH organizational depth- assessment. A baseline assessment of behavioral health capacity can help in developing a plan for future broadening and deepening of BH services.

1. Conduct a gap analysis to determine the number of BH providers necessary to meet the patient population's needs.

Suggested team member(s) responsible: IBH implementation team.

A simple gap analysis formula is based on research that consistently shows 70% of primary care visits are psychosocial-related[3] and over 40% of primary care patients want and/or need behavioral health services.[4] However, not all patients with behavioral health conditions will be best served by the practice. Estimating the number of patients with behavioral health needs that may be appropriate for care from county behavioral health systems or another system of care is important in developing an accurate estimate of the number of patients who are most likely to obtain BH care within the practice. This calculation will vary between organizations, as each practice is unique, as are the surrounding communities. Some communities will have more resources to care for people with BH conditions, in which case a practice may refer out a higher percentage of patients. Many practices, however, are in communities with few resources for BH care; practices may be the primary or only provider for BH care in the region. In this case, calculating a gap analysis would include a higher number of patients with BH needs being cared for within the practice.

By taking into account the number of full-time equivalent (FTE) behavioral health providers and the number of patients an average behavioral health provider sees per month, organizations can estimate a rough number of the behavioral health providers required to meet the practice’s patient population needs.

Most practices will fall within the range of needing one behavioral health provider per 1,000 to 3,000 patients or one behavioral health provider per one to two primary care providers (PCPs typically have panels of about 1,400 patients). The PHMI Care Teams and Workforce Guide emphasizes this ideal ratio (see Figure 3 for ideal ratios and Figure 4 for recommended licensure):

  • One BH specialist, such as a licensed clinical social worker (LCSW) or licensed marriage and family therapist (LMFT) to every two PCP panels to provide day-to-day support both for the care team and patients with behavioral health needs. Currently in California, LMFT services are considered part of the prospective payment system (PPS) rate. While most health centers seek to hire a BH specialist for whom they can bill separately, there are some teams that hire an LMFT to provide brief targeted interventions and support holistic patient care. This staffing model for integrated BH provides a more indirect return on investment through its potential positive impacts on primary care provider retention.
  • One consulting BH provider (e.g., clinical psychologist or other psychiatric prescriber) for every 10 PCP panels to provide pharmacological treatments or extensive psychological testing.

The ratio is meant to give practices a framework and goal for developing behavioral health as a core service line over time. The necessary staffing ratio will be clarified through continuous monitoring of emerging patient needs and maintaining current and evolving knowledge of community resources. As care team members, such as primary care providers and nurses are increasingly confident in their ability to assess and respond to patient health behavior changes, behavioral health resources will increasingly be leveraged for care delivery focused on patients with behavioral health conditions that require a higher level of care.

FIGURE 3: RECOMMENDED RATIOS AND RESPONSIBILITIES FOR SELECT CORE CARE TEAM AND EXPANDED CARE TEAM MEMBER TO SUPPORT BEHAVIORAL HEALTH INTEGRATION


Collaborating Care Team Member
Primary Responsibilities
Recommended Ratio*

CORE CARE TEAM

Day-to-Day; Organized, Evidence-Based Care

Primary Care Provider (PCP)
Provides direct patient care, including diagnoses and treatment.
One FTE per panel

Medical Assistant (MA)
Assists the PCP with direct patient care and is responsible for patient flow on the day of a visit, including pre-visit planning and visit/room preparation.
One FTE per panel

Social Health Support/Community Health Worker (CW)
Helps identify and connect patients to social health services.
0.5 FTE per panel

Behavioral Health Specialist
Provides day-to-day support for care team and patients with behavioral health needs.
0.5 FTE per panel

EXPANDED CARE TEAM

Behavioral Health Integration

Behavioral Health Consultants
Clinical psychologist and psychiatrist provide additional behavioral health services through psychological evaluation, substance use disorder diagnosis and treatment, and prescribing medications.
One FTE shared across approximately 10 panels

Medication Management

Clinical Pharmacist
Medication management and patient/provider medication education.
One FTE shared across approximately 10 panels

FIGURE 4: CARE TEAM DUTIES AND RECOMMENDED LICENSURE FOR BEHAVIORAL HEALTH INTEGRATION


Care Team Role
Expanded Duties
Recommended Education/Licensure

  • Has lived experience with the process of recovery from mental health or substance use concerns, or both, either as a consumer of these services or as the parent or family member of the consumer.

Behavioral Health Specialists:

Licensed Social Worker (LCSW)

Marriage and Family Therapist (MFT)

  • Provides day-to-day support for the care team and patients with behavioral health needs.
  • Works with expanded care team members, including the clinical psychologist and psychiatrist to manage patients with more complex needs.
  • Can provide brief interventions using evidence-based techniques such as behavioral activation, problem-solving treatment, and motivational interviewing.

As per state licensure.

Consulting Behavioral Health Providers:

Clinical Psychologist

  • Provides psychological evaluation and conducts more extensive testing than the behavioral health specialists.
  • Works closely with the PCP and the other behavioral health consultants but cannot prescribe medications.
  • Provides treatment ranging from cognitive behavioral therapy, family therapy, group therapy, and hypnotherapy.

As per state licensure.

Psychiatrist or Psychiatric Mental Health Nurse Practitioner (PMHNP)

  • Provides direct mental health and substance use diagnosis and treatment, including prescribing medications.
  • Works closely with the PCP and the care team, including the behavioral health specialists.

MD with specialty training in psychiatry.

NP with specialty training in psychiatry.

Clinical Pharmacist

  • Reviews medical records and assesses progress towards goals to improve patient health.
  • Makes suggestions and collaborates with providers on medication management.
  • Completes patient visits for medication review and management.
  • Makes recommendations for medication adjustments, dosage titration, initiation, and discontinuation, and monitors laboratory values in collaboration with providers and patients.
  • Educates patients about the use of their medications.
  • Attends team meetings for chronic disease management and participates in the development of patient care plans.

Note: See Care Teams Resource 1 for additional information.

Doctor of Pharmacy degree.

Many have completed post-graduate training.

2. Identify core strategies to increase BH provider capacity.

Suggested team member(s) responsible: IBH Implementation team.

Most practices are not at the ratio of BH providers necessary to meet the needs of the practice’s population. Below are options for increasing capacity to provide integrated behavioral healthcare.

  • Expand the scope of care team members to provide mental health counseling.
    • Motivational interviewing, cognitive behavioral interventions, behavioral activation, psychoeducation, skillful listening, and supportive counseling are all evidenced-based treatments for behavioral health conditions. Licensure is not legally or ethically necessary to engage in these interventions. Grouped together, these interventions can be referred to as behavioral health counseling, behavioral health coaching, or other names that fit within your practice’s conventions.
    • Training selected CHWs, case managers, SUD counselors, and care coordinators in the interventions above can significantly increase access to IBH services. Providing clinical supervision, support, and continued learning from licensed clinicians ensures continual growth and safety. Mental health counselors without traditional licenses or degrees have been shown to have to have outcomes comparable to licensed clinicians and are widely used in lower-income countries as a solution to clinician scarcity.[5]
    • In addition to addressing access, this strategy addresses the need for more linguistic and cultural concordance in the BH workforce with the community served.
  • Two training providers that offer programs to build capacity of frontline staff include The Lay Counselor Academy, Harvard University’s EMPOWER initiative, and CETA Global. Note these offerings may have an associated fee.
    • Asian Health Services, Hill Country Health and Wellness, and San Ysidro Health are just a few of the California Community Health Center (CHC) practices that have invested heavily in this strategy.
  • Reduce barriers to enhance recruitment of licensed BH providers.
    • Eliminate criteria that are barriers to employment for licensed and unlicensed associate social worker (ASW) clinicians, such as mandating full-time work, employee status, and in-person work. Recruit for any number of hours from anywhere in the state.
    • Salud Para La Gente and Alexander Valley Health Centers use this strategy successfully by hiring licensed clinicians who live in different areas of California and are fully remote.
  • Focus on associate social worker (ASW) recruitment.
    • In California, ASWs are billable for the PPS rate for FQHCs since May 2020. Focus on recruitment of ASWs, who are less expensive than licensed clinicians, more likely to be bicultural and bilingual, and able to bill for the same rate as licensed clinicians. ASWs are required by the Board of Behavioral Sciences of California to have two to three hours of supervision a week; if supervision needs exceed the practice’s licensed clinician capacity, contract for outside supervision.
    • Community Medical Centers, which has one of the most robust BH departments in California and one of the highest ratios of BH providers to PCPs, utilizes this strategy.

Implementation tips

Deepening integrated care may feel like a big lift and can appear overwhelming to staff. Practice leaders will need to emphasize shared values and develop a north star for care transformation. Leadership must regularly name the challenge of the scarcity of behavioral health providers, recognize the care team’s efforts to navigate that challenge, highlight the strategic importance of growing the team’s capacity to provide behavioral healthcare, and celebrate wins along the way.

See the below resources for examples of how this activity has been implemented.

Endnotes

  1. APA PsycNet [Internet]. psycnet.apa.org. Available from: https://psycnet.apa.org/record/2016-59132-000  
  2. Saunders H, Mar 17 SMP, 2023. Medicaid Coverage of Behavioral Health Services in 2022: Findings from a Survey of State Medicaid Programs [Internet]. KFF. Available from: https://www.kff.org/mental-health/issue-brief/medicaid-coverage-of-behavioral-health-services-in-2022-findings-from-a-survey-of-state-medicaid-programs/  
  3. APA PsycNet [Internet]. psycnet.apa.org. Available from: https://psycnet.apa.org/record/2016-59132-000  
  4. Saunders H, Mar 17 SMP, 2023. Medicaid Coverage of Behavioral Health Services in 2022: Findings from a Survey of State Medicaid Programs [Internet]. KFF. Available from: https://www.kff.org/mental-health/issue-brief/medicaid-coverage-of-behavioral-health-services-in-2022-findings-from-a-survey-of-state-medicaid-programs/ 
  5. Faust D, Zlotnick C. Another dodo bird verdict? revisiting the comparative effectiveness of professional and paraprofessional therapists. Clinical Psychology & Psychotherapy. 1995 Oct;2(3):157–67.