Designing behavioral health integration in primary care : a practical outcomes-based framework

Abstract

Patients with comorbid physical, behavioral, and social needs-often referred to as high-need patients-tend to be the most frequent utilizers of the health care system. The US health care system, with fragmented behavioral and medical health care sectors, is unable to effectively meet the complex needs of high-need patients. This results in high health care utilization, increased health care costs, and poor health outcomes among this population. Behavioral Health Integration in Primary Care (BHIPC) is widely promoted as a means to improve access, quality and continuity of health care services in a more efficient way, especially for people with complex needs. Hundreds of BHIPC programs are being implemented across health care settings in the US. However, the concept of BHIPC is wide-ranging, and it has been used as an overarching approach to describe integration efforts that vary in design, scope, and value. Research on how BHIPC is implemented in practice is limited. Practitioners and policymakers find it challenging to evaluate BHIPC programs and identify and scale-up its most critical elements. In this thesis, I develop a design-based framework that deconstructs the ambiguous concept of BHIPC into a set of tangible design elements and decisions. Furthermore, in order to inform how BHIPC is implemented in practice, I use this design-based framework to examine the behavioral health integration programs in four community health centers in Massachusetts. I found that by just comparing the underlying design elements, it is difficult to assess BHIPC programs and distinguish a successful program from an unsuccessful one. I therefore recommend and propose an outcomes-based framework for differentiating and evaluating BHIPC programs. I also recommend that future researchers refine and standardize the process measures I introduce so that they can be used as guideposts by primary care practitioners to develop their BHIPC programs.