1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?

As evidence of the benefits of integrated care becomes more widely known, increasing numbers of primary care practices and health systems are trying to integrate behavioral health and primary care in their own practices, and are looking for guidance on where to start, what aspects are most important for their own context, and how to pay for it. What are the different strategies for integrating behavioral health (including management of SUD) into primary care and what information and evidence is available to help clinicians and practices choose among them and then monitor implementation and performance? Are there developmental pathways through a sequence of steps that have proved to be effective?

2. Why are you struggling with this issue?

AHRQ created the Academy for Integrating Behavioral Health and Primary Care (the Academy) in 2010 to respond to the recognized need for a national resource and coordinating center for those interested in behavioral health and primary care integration. One of the first projects the Academy undertook was the Lexicon for Behavioral Health and Primary Care Integration (the Lexicon), a set of concepts and definitions developed by experts to provide a practical definition for behavioral health integration as implemented in practice settings. The Lexicon starts by defining Integrated Behavioral Health and Primary Care as "The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization." It then defines the different aspects of integration, such as what an “explicit, unified, and shared care plan” should include, and parameters for describing different configurations of care.

This systematic set of definitions enable clear communication and action among clinicians, care systems, health plans, payers, researchers, policymakers, business modelers, and patients working for effective, widespread implementation on a meaningful scale and is still and still the most frequently accessed page on the website. However, as the field of integration has evolved, the questions have moved from defining integrated care to how to choose among different strategies for integration and how to know whether integration is being done well. Models such as the Collaborative Care Model (CCM) and SBIRT have attracted the most attention, but a wide range of other approaches, including adapted CCM, co-location and telehealth are in use. At the same time, the ongoing Substance Use Disorder (SUD) crisis has spurred the development of a whole new set of approaches for how to integrate SUD management into other behavioral health treatment and primary care. Therefore, the Academy proposes an EPC scoping review of different strategies (defined as both program components and approaches to implementation) for integration of behavioral health, including SUD treatment, in primary care.

The Academy proposes a scoping review rather than a systematic review for two reasons. First, the decisional dilemma is not whether integration is beneficial, but rather which aspects are best to adopt when, where, and how. Second, the available studies are heavily skewed towards one specific model (the Collaborative Care Model) despite the wide spectrum of strategies employed in practice. Thus, a systematic review approach would likely lead to the conclusion that there is strong evidence for Collaborative Care Model and nothing else, and would lack enough detail about the different strategies in use to support development of the intended guide. If this topic goes forward, the Academy can help develop a more formal conceptual framework for categorizing the important elements to abstract for an integration strategy.

Potential KQ

1. What are the available strategies for integrating behavioral health, including management of SUD, into primary care settings?
   1. How do they vary by clinical focus, setting, core components, mechanism of integration, business models, and resources required?
   2. How do they define/redefine care team roles in the office practice, and what trainings are required?
2. What evidence is available on effectiveness of these strategies in terms of feasibility, implementation measures, patient outcomes, practitioner burden, costs, and sustainability?
   1. Which strategies have evidence of effectiveness for which patients (i.e. CVD and depression, maternal health, SUD/PPD, whole person care), settings, and contexts (include payment models as context)?
3. What are the best metrics for monitoring and evaluating integration? Should metrics be different as an integration strategy matures? How often should metrics be measured?
4. What are the barriers to implementing and sustaining integrated strategies and how can they be overcome?  What are the facilitators that implementors should capitalize on? Are there synergies among specific strategies?

A preliminary list of outcomes could include:

• Individual or family clinical outcomes (symptom or disease outcomes; functional status, quality of life)
• Population health or community health improvement for your clinic panel
• Public health or prevention measures
• Access: time to first "touch"—getting started with the problem
• Patient experience. Ease of quickly creating a relationship with the patient in context of trusted PC
• Available physician appointment time; better focused use of provider time.
• Reduced total cost of care—costs of delays, fragmentation, poor coordination, redundancy, failed referrals
• Clinician satisfaction—joy of practice; comfort and confidence with BH dimension of practice—less quitting.
• Care team skill, spirit, and function—higher functioning teams with intrinsic satisfaction of being in one
• Improved health equity / health disparities: Help burdened populations get what they need; social justice.
• Improved clinician education—better point-of-service learning experiences for a generation of clinicians
• Routinely good implementation with reach and fidelity, such as measured via RE-AIM

This topic was proposed by the National Integration Advisory Council (NIAC), which wants to develop a guide to help practices and health systems select the strategy for integrating behavioral health that best matches their needs and context. The NIAC is a group of experts in Primary Care, Behavioral health, Health care finance, Medical education, Patient advocacy, Health care for diverse populations, and Health care policy that advises the Academy. As the end users of the report, they could also serve on the TEP. The guide itself would be disseminated through the Academy website and Academy dissemination activities and partnerships with other HHS agencies.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

If the Academy is able to produce a guide based on the scoping review, we hope to see more primary care practices offer evidence-based integrated behavioral health, and more patients receiving high quality treatment for their physical and mental health needs. Eventually we would like to be able to link this to improved patient outcomes.

4. When do you need the evidence report?

The sooner the better. The end of 2022 would be ideal, but we can still use it if that deadline is not feasible.

5. What will you do with the evidence report?

The Academy, with the support of the NIAC, would use this review to develop a guide to help practices and health systems select strategies for integrating behavioral health that best matches their needs and context.  The guide would describe the different options, highlight what the evidence says, describe the advantages and disadvantages of each for different goals and practice settings, and offer metrics for monitoring implementation and success. This could be used by clinic administrators and clinician champions, health systems (including grant writing staff), and FQHCs; CMS and HRSA may potentially be interested. The Academy would then also develop a resource list to support implementation.