Behavioral Health - Key Activity 6

KEY ACTIVITY #6:

Expand Access to Integrated Care

 

This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; behavioral health integration.

Overview

Expand access to integrated care by offering connection to behavioral health services in the primary care setting. Depression, anxiety, substance use disorder, and other health conditions are frequently co-occurring. Opportunities to identify and address the range of healthcare needs of patients is enhanced in an integrated delivery system where hand-offs between primary care and behavioral health are supported. Behavioral health integration offers essential access to care to people with behavioral health needs, including therapy, referrals, and other needed services. The primary care setting is a familiar care access point and may support patients to overcome hesitancy around seeking behavioral healthcare.

As noted elsewhere in this guide, there is a severe shortage of BH providers in California. Combined with the stigma often associated with behavioral health issues and their treatment, this has resulted in a mismatch between the prevalence of BH conditions and the number of people who have access to effective treatment. Closing the gap between need and access to care presents a major challenge, but research has shown that integrating behavioral health into primary care is an effective approach to achieving this end.

While BH integration provides access to needed BH services through trusted entry points to the healthcare system, it is imperative to maximize the use of limited available BH resources. This includes making care delivery efficient by standardization of protocols, using a team approach, leveraging technology, and other means.

Access to integrated behavioral healthcare lowers barriers to care for all and may especially benefit groups who have been historically disadvantaged from receiving mental health services or are otherwise reluctant to seek care. See Key Activity 11: Use a Systematic Approach to Address Inequities within the Population of Focus for a discussion of known inequities in care and additional strategies for addressing inequitable outcomes.

When patients are engaged in behavioral health services, their social needs may be more likely to be addressed. 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 behavioral health specialists who have been trained to appear as empathic and nonjudgmental, prompting referrals and connections by leveraging other members of the integrated care team.

This activity relies on strategies similar to inreach and outreach, including population reports and registries that identify patients who would benefit from behavioral health engagement. These registries can be utilized by care team members who might be tasked with engaging patient in behavioral health services. In addition, EHR alerts or prompts can be leveraged to identify patients for engagement. Care managers and/or behavioral health team members might use care management applications to document engagement efforts. Messaging platforms can be leveraged to support team communication and warm handoffs.

Some health centers may focus extra resources on patients identified as having elevated risk through risk stratification algorithms.

See Appendix D: Guidance on Technological Interventions.

Action steps

1. Encourage "no wrong door" to behavioral health.

Suggested team member(s) responsible: Clinic manager or director with clinical champions (e.g., BH lead, CMO) and IBH implementation team.

The clinic manager or director works with clinical champions (e.g., BH lead, CMO) to clearly allow all staff to refer patients to behavioral health when staff deem it necessary (e.g., positive screen or any other reason). The IBH implementation team designs workflows for all staff to be able to refer patients to behavioral health.

This means any staff member can refer a patient to behavioral health at any time for any reason. For example, a receptionist may speak by phone to a tearful patient, a medical assistant may administer the PHQ-2 with positive screening results, or a nurse passing through the waiting room may be engaged in urgent conversation by a waiting patient. Staff are encouraged to refer the patient to the care team’s behavioral health specialist in all of these circumstances. See Key Activity 2: Enhance the Culture of Integrated Behavioral Healthcare for more about universally training all relevant employees in administering and responding to sensitive screenings. Additionally, consider ways to build behavioral health screening into other instances of patient engagement, such as waiting for a nurse visit or in a pre-visit screening call.
 

2. Evaluate current warm handoff practices to enhance effectiveness and feasibility.

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

Many organizations already have some type of warm handoff practices. An ideal state is for the medical provider or other staff trained in empathic communication techniques to respond to a patient’s positive screen by connecting the patient to BH, whether it is through a warm handoff or setting an appointment.

Enhance warm handoff practices by deploying unbillable trained staff instead of billable clinicians to respond to warm handoffs. This can assist with financial feasibility by reserving direct warm handoffs to a clinician for high-risk, complex needs patients. Staff training must also include responding to patient reports of suicidal ideation in a timely manner.

Consider evaluating the percentage of patient visits that include warm handoffs, effectiveness in lowering missed first appointment rates, impact on patient and provider experience, and financial feasibility, due to the lack of reimbursement in California.
 

3. Address biases to promote equitable access to care.

Suggested team member(s) responsible: All staff.

Increase self-awareness of staff biases and enhance cultural humility to support equitable detection, referral patterns, and treatment. The research identifies deep inequities in detection, referrals and treatment of mental health conditions for people of color and patients from the LGBTQ+ community.

  • Ensure diverse representation among the staff and care team to enhance sensitivity to different cultural identities.
  • Provide anti-bias and cultural humility training at intervals to ensure wide staff participation.
  • Surface champions among the staff team and build opportunities in regular staff meetings to share cultural humility approaches and challenges.
  • Regularly review data on access to and engagement in care, specifically through the lens of equity, and look for groups who have less access to or engagement in care to identify those for whom the current care design is not effective. This information is instrumental in identifying areas in which to test ways to improve access and engagement among the effected groups. See Key Activity 11: Use a Systematic Approach to Address Inequities within the Population of Focus for more.

Resources to consider:

 

4. Leverage peer support.

Suggested team member(s) responsible: Members of the patient and family advisory council, community health workers, and community-based leaders or influencers working together with clinical staff to design a peer support program.

  • Peer support training: Train individuals with lived experience to provide peer support to patients dealing with behavioral health challenges. Best practices on peer support specialists are included in this resource from the Steadman Group and in the University of Kansas’s Community Tool Box resource on peer Support Groups.
  • Support groups: Establish support groups to create a sense of community and shared experiences among patients. Rely on the behavioral health specialist to guide the process and frame the support group to meet the needs and build on the strengths of the patient group.
  • Collaborate with community resources: Strengthen partnerships with local community organizations offering peer support services to expand the range of available resources. County mental health agencies or organizations provide peer support specialists as a reimbursable benefit for Medi-Cal patients. To learn more about which counties provide peer support resources, visit the Medi-Cal Peer Support Services site.

 

5. Leverage community resources.

Suggested team member(s) responsible: Clinic staff with care coordination responsibilities.

This strategy is described in more detail in other places in this guide:

 

6. Sustain the integrated care practices in the face of conflicting demands.

Suggested team member(s) responsible: Senior leadership and IBH implementation team.

Develop methods to support and sustain the integrated care team, including setting attainable goals for care delivery, fostering communication among the care team, developing standard workflows to guide care delivery, and providing adequate training and supervision.