Integrated Behavioral Health Care Models and Outcomes

INTEGRATED BEHAVIORAL HEALTH CARE: MODELS AND OUTCOMES OF CARE J O Y C E M . S H E A , D N S C , A P R N , P M H C N S - B C , F A A N S I L V E R H I L L H O S P I T A L V I R T U A L G R A N D R O U N D S M A Y 7 , 2 0 2 5

DISCLOSURES: IN COMPLIANCE WITH THE ACCME STANDARDS FOR COMMERCIAL SUPPORT OF CME, I DO NOT HAVE ANY RELEVANT FINANCIAL RELATIONSHIPS TO DISCLOSE IN RELATION TO THIS PRESENTATION. 2

EDUCATIONAL OBJECTIVES EDUCATIONAL OBJECTIVES 1) Describe the origins of integrated behavioral health care (IBHC). 2) Discuss the benefits and outcomes of care related to specific models of IBHC. 3) Identify strategies to develop crucial skills in IBHC in current and future mental health care providers. 3

CASE #1 CASE #1 37-YEAR-OLD MARRIED WHITE MALE, ARMY VETERAN, WHO PRESENTS TO HIS PRIMARY CARE OFFICE. CC: I M NOT SLEEPING - I FELL OFF OF A LADDER LAST WEEK - MY BACK IS KILLING ME AND I M RUNNING OUT OF SLEEP AND PAIN MEDICATION. PRESENTING SYMPTOMS: PAIN IS CURRENTLY A 9 OF 10; ONLY RESPONDS TO OXYCODONE 20 MG DOSES EVERY 4 HOURS. USING MORE XANAX THAN PRESCRIBED TO ADDRESS SLEEP ISSUES. CURRENT MEDICATIONS: OXYCODONE 20 MG EVERY 4-6 HOURS AS NEEDED FOR PAIN; XANAX 2-4 MG AT BEDTIME FOR SLEEP (PRESCRIBED BEFORE RECENT FALL). PAST MEDICAL HISTORY: SUSTAINED A CLOSED-HEAD INJURY FROM AN IED EXPLOSION 10 YEARS AGO. DESCRIBES A LONG HISTORY OF BACK INJURIES THAT STARTED IN THE SERVICE. SOCIAL HISTORY: MARRIED WITH 2 YOUNG CHILDREN; WORKS AS A COOK AT THE LOCAL DINER. RECENT CONTACT WITH POLICE OVER A DOMESTIC DISPUTE; SCHEDULED FOR A COURT DATE IN 2 WEEKS.

CASE #2 CASE #2 48 YEAR OLD DIVORCED, WHITE FEMALE, WHO PRESENTS TO THE BEHAVIORAL HEALTH CLINIC. CC: I DON T KNOW WHAT S GOING ON. I VE BEEN FEELING MORE DEPRESSED AND ANXIOUS FOR THE PAST MONTH. I M REALLY CRANKY WITH EVERYONE. I CAN T SLEEP BUT I FEEL EXHAUSTED. HPI: ONE MONTH HISTORY OF WORSENING DEPRESSED MOOD, ANXIETY, JUMPINESS , IRRITABILITY. DIFFICULTY SLEEPING, INCREASING FATIGUE. NO KNOWN PRECIPITANTS. NO PREVIOUS PSYCH HISTORY. CURRENT MEDICATIONS: GLUCOSAMINE AND CHONDROITIN 1500 MG DAILY; BIOTIN 10,000 G DAILY; VITAMIN B12 5000 G DAILY; VITAMIN D3 5000 G DAILY PAST MEDICAL HISTORY: RAYNAUD S DISEASE; POST- HYSTERECTOMY. FAMILY HX: MOTHER: HASHIMOTO S THYROIDITIS; FATHER: HTN SOCIAL HISTORY: DIVORCED, NO CHILDREN, ONE BROTHER (MARRIED AND LIVING IN ANOTHER STATE).

CASE #3 CASE #3 44 YEAR OLD MARRIED, WHITE FEMALE, WHO PRESENTS TO THE ONCOLOGY CLINIC. CC: I WAS ALWAYS A CRIER. HPI: SIX MONTH HISTORY OF NOT SLEEPING WELL (DFA, MNA). FEELS TIRED, LOW ENERGY. DECREASED APPETITE, HAS TRIED MJ WITH SOME EFFECT, NO OTHER DRUG USE. SOME ANXIETY, SOME DECREASE IN CONCENTRATION. MOOD VARIES, DENIES SENSE OF HOPELESSNESS OR S/I. CURRENT MEDICATIONS: PREVIOUSLY PRESCRIBED ATIVAN (DOSAGE UNKNOWN); PRESCRIBED ZOLOFT 25 MG DAILY BY PCP ONE WEEK AGO (TAKES IN AT NIGHT SINCE IT MAKES HER SLEEPY). PAST MEDICAL HISTORY: DX D WITH METASTATIC PANCREATIC ADENOCARCINOMA IN 5/23. DX D WITH TYPE 2 DM IN 9/23. SOCIAL HISTORY: MARRIED, LIVES WITH HUSBAND AND 20 Y/O SON (28 Y/O SON AND 2 GRANDCHILDREN LIVE IN ANOTHER STATE). FORMER LPN; NOW ON SSDI.

WHAT DO THESE CASES WHAT DO THESE CASES HAVE IN COMMON? HAVE IN COMMON? These scenarios could present in either primary care (PC) or mental health (MH) care settings. What initially appears to be simple or straightforward in terms of diagnosis or treatment, may in fact not be. All patients have a mixture of physical and behavioral health issues or concerns- even if they do not see that themselves. Treatment outcomes would likely benefit from collaboration between medical and psychiatric care providers. 7

ORIGINS OF ORIGINS OF INTEGRATED CARE INTEGRATED CARE History of acting in siloes: the physical and mental health divide promoted by Cartesian Dualism The biopsychosocial theory of George Engel emerged in the late 1970s and the multifactorial cause of disease became a part of mainstream medicine Note: traditional nursing assessment involved evaluation of a patient s physical, psychological, social, and spiritual status (NextGen Healthcare, 2021) 8

ORIGINS OF ORIGINS OF INTEGRATED CARE INTEGRATED CARE Data has shown that individuals with behavioral health conditions are also likely to have physical health issues. Those with severe mental illness (SMI) have been found to experience poorer health outcomes and earlier death than the general population (Hjorthoj, et al, 2017; Manderscheid & Ward, 2024) Stigma related to mental health diagnoses has led most patients to seek care from their PCP (Jetty, et al, 2021) 9

ORIGINS OF ORIGINS OF INTEGRATED CARE INTEGRATED CARE Policy changes in the early 2000s encouraged healthcare organizations to embed mental health (MH) care providers in primary care (PC) settings Reverse or bidirectional care also emerged in which PC providers become embedded in community-based MH care centers (Manderscheid & Ward, 2024) 10

ORIGINS OF ORIGINS OF INTEGRATED CARE INTEGRATED CARE In spite of the policy changes, issues persisted with coverage if the patient was seen for both physical and mental health care on the same day In 2013, the SAMHSA-HRSA Center for Integrated Health Solutions was created, offering a framework for various levels of IC (Manderscheid & Ward, 2024) 11 (Heath, et al, 2013)

ORIGINS OF ORIGINS OF INTEGRATED CARE INTEGRATED CARE Additional movements or concepts that have facilitated the adoption of IC include: Whole Person Care Person-Centered Care Shared Decision Making Virtual Care Telehealth Care (Manderscheid & Ward, 2024) 12

DEFINITION OF INTEGRATED DEFINITION OF INTEGRATED BEHAVIORAL HEALTH CARE ( BEHAVIORAL HEALTH CARE (IBHC IBHC) ) According to the Agency for Healthcare Research and Quality (AHRQ, 2025), integrated behavioral health involves 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 use conditions, health behaviors , life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. 13

GOALS/OUTCOMES OF GOALS/OUTCOMES OF IBHC IBHC Increased access to care Decreased stigma associated with MH care Decreased costs* Increased satisfaction with care among patients and providers Increased quality of care Increased quality of life** (*Variable results depending on the population, **Difficulty with measurement) (Alnasser, et al, 2025; Matthews, et al, 2024) 14

INITIAL MODELS OF IBHC INITIAL MODELS OF IBHC At the basic structural level, physical and mental health services can be: Coordinated: delivered by community MH and PC partnersthat are formally affiliated but physically separate; Key element is communication Co-Located: delivered in the same location but not necessarily the same offices; Key element is physical proximity Integrated: delivered in the same space within the same facility, sharing at least some of the practice space; Key element is practice change (Heath, et al, 2013) 15

(Heath, et al, 2013)

MODELS OF IBHC: MODELS OF IBHC: THE PRIMARY CARE BH (PCBH) THE PRIMARY CARE BH (PCBH) MODEL MODEL The PCBH model is a team-based primary care approach to managing behavioral health problems and biopsychosocially influenced health conditions (Reiter, et al, 2018, p. 112) Main goal: to enhance the primary care team s ability to identify and treat MH issues commonly seen in PC settings Incorporates a Behavioral Health Consultant or BHC into the primary care team; seen as an extension of the PCP The BHC operates as a generalist (e.g. sees patients of all ages and with any health condition) and provides education for staff and patients (Reiter, et al, 2018) 17

EXAMPLE OF THE EXAMPLE OF THE PCBH CHEROKEE HEALTH SYSTEMS CHEROKEE HEALTH SYSTEMS PCBH MODEL: MODEL: Located in Knoxville, TN, the model has PC physicians and behavioral health specialists working collaboratively as a multidisciplinary team They communicate regularly, share patient information, and jointly develop treatment plans Services are offered in PC clinics, community health centers, and specialty clinics The emphasis is on preventive care, early intervention, and ongoing support for chronic medical conditions, MH disorders, substance use issues, and psychosocial challenges (Cherokee Health Systems, 2025) 18

MODELS OF IBHC: MODELS OF IBHC: THE COLLABORATIVE CARE THE COLLABORATIVE CARE MODEL ( MODEL (COCM COCM) ) A systematic approach that integrates MH services into PC settings The care team is led by the PCP; it includes a Behavioral Health Care Manager (BHCM) who has a background in mental health care, and a consulting Psychiatrist or PMHNP The PCP would initiate a patient referral to the BHCM, who performs the initial evaluation and reviews with the consulting Psychiatrist/PMHNP The BHCM then provides the suggested treatment plan to the PCP, who reviews and implements it; the BHCM also uses a registry to track all patients and prioritize regular reviews 19 (Reist, et al, 2022)

MODELS OF IBHC: MODELS OF IBHC: THE THE COLLABORATIVE COLLABORATIVE CARE CARE MODEL ( MODEL (COCM COCM) ) (American Psychiatric Association, 2025) 20

EXAMPLE OF THE EXAMPLE OF THE COCM MOMCARE MOMCARE INTERVENTION INTERVENTION COCM MODEL: MODEL: The MOMCare intervention, following the CoCM structure, was integrated into several women s health settings in Seattle, Washington The targeted population was socio-economically disadvantaged women who were at risk for perinatal depression Outcomes for those in the MOMCare program were compared to those receiving standard care through public health maternity support services. Participants in the MOMCare program showed significant improvements in quality of care, depression severity and remission rates over an 18-month period (Grote, et al, 2015) 21

MODELS OF IBHC: MODELS OF IBHC: THE PATIENT THE PATIENT- -CENTERED MEDICAL HOME (PCMH) MEDICAL HOME (PCMH) CENTERED A model that aims to improve healthcare in the US by transforming how PC is organized and delivered (AHRQ, 2022) Not simply a place but a model for the organization of PC. Includes five functions or attributes: Comprehensive Care, Patient- Centered, Coordinated Care, Accessible Services, and Quality and Safety Aims to build better relationships between patients and their clinical care teams. (National Committee for Quality Assurance, 2025) 22

EXAMPLE OF THE PCMH MODEL: EXAMPLE OF THE PCMH MODEL: IBH MODEL IBH MODEL The Innovation in Behavioral Health (IBH) Model is an extension of the PCMH model developed to met the needs of people with moderate to severe behavioral health conditions, including psychiatric and substance-use disorders. Recipients will receive whole-person care in a behavioral health care setting; this setting will serve as a point of entry to identify and secure further care. Behavioral health providers will lead the care management team, which will address behavioral and physical health issues as well as health- related social needs (e.g. housing and food insecurity). (Manderscheid & Ward, 2024) 23

TECHNOLOGY AND TECHNOLOGY AND INTEGRATED CARE INTEGRATED CARE A shared EMR is essential for any model of IBHC to work effectively; the sharing of data enhances communication and encourages shared decision-making. Standardized screenings and patient monitoring can improve the identification of individuals who may need treatment and build on the work of self-awareness. Clinical decision support tools can promote patient engagement and ability to adhere to a treatment plan. (University of Utah, 2023) 24

TECHNOLOGY AND TECHNOLOGY AND INTEGRATED CARE INTEGRATED CARE Digital MH apps can reinforce skills learned in treatment sessions as well as provide additional sources of support. Building on the success of telepsychiatry during COVID, the use of telehealth can improve access to care, especially for those living in rural areas, struggling with disabilities, or facing transportation issues. (Johnson, 2025: Lombardi, et al, 2024) 25

TECHNOLOGY AND TECHNOLOGY AND INTEGRATED CARE INTEGRATED CARE 26 (University of Utah, 2023)

BEHAVIORAL HEALTH BEHAVIORAL HEALTH WORKFORCE AND IBHC WORKFORCE AND IBHC Paradigm shift for current clinicians Moving away from a purely clinical approach to one that also includes community-level interventions Identifying additional community-based resources Understanding the value- and appropriateness- of DMH strategies Preparation of future providers Incorporating IBHC content into all levels of education for MH providers Using simulation-based learning strategies to develop skills in multidisciplinary teamwork (Manderscheid & Ward, 2024) 27

BEHAVIORAL HEALTH BEHAVIORAL HEALTH WORKFORCE AND IBHC WORKFORCE AND IBHC Determining organizational readiness Use existing tools (e.g. the IPAT) to assess for staff openness to operating under a different model of care Identify potential IBHC Champions to support the implementation of IC processes Preparing patients and families Give the individuals who come to your organization time to understand what will be changing (and what won t) along with how those changes might impact them Encourage those who are able to provide input into the rollout process (National Council for Mental Wellbeing, 2021) 28

FINAL THOUGHTS FINAL THOUGHTS Our current healthcare system is broken and we are unable to meet the burgeoning needs for MH care across the country IBHC presents options for expanding our skills and resources Given their background in holistic assessment and care, and the high levels of trust that patients have in them, nurses are well prepared to lead in these IBHC systems 29

THANK YOU!! Joyce Shea jshea@fairfield.edu

References Agency for Healthcare Research and Quality (AHRQ). (2022). Defining the PCMH. Accessed May 1, 2025. https://www.ahrq.gov/ncepcr/research/care-coordination/pcmh/define.html Agency for Healthcare Research and Quality (AHRQ), The Academy: Integrating Behavioral Health and Primary Care. (2025). Part 1: A functional definition. Accessed April 30, 2025. https://integrationacademy.ahrq.gov/products/ibhlexicon/functionaldefinition?_gl=1*xpzek0*_ga*MTc wMTM0MTEwLjE3NDU4NjQ4NTQ.*_ga_45NDTD15CJ*MTc0NjA0OTI4OC4yLjAuMTc0NjA0O TI4OC42MC4wLjA Alnasser, I.M., Alharbi, M.O., Albishr, N.N., Alghafes, N.J., Khobrani, M.A.H., Alharthi, A.K., Alrahili, A.S., Alharbi, M.M., Altuwayjiri, R.A., & Alhomaid, T.A. (2025). Effectiveness of integrated care models for mental health conditions in family medicine in terms of outcomes, including access to care, treatment adherence, and patient quality of life. International Journal of Medicine in Developing Countries, 9(1), 205-214. DOI: 10.24911/IJMDC.51-1735063149 American Psychiatric Association. (2025). Learn about the collaborative care model. Accessed May 2, 2025. https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn Cherokee Health Systems. (2025). Integrated primary care and behavioral health model.Accessed May 2, 2025. https://www.cherokeehealth.com/about-us/integrated-health-model/ Grote, NK, Katon, WJ, Russo, JE, Lohr, MJ, Curran, M, Galvin, E, and Carson K. (2015).Collaborative care for perinatal depression in socioeconomically disadvantaged women: A randomized trial. Depress Anxiety, 32(11):821-34. doi: 10.1002/da.22405.

References Heath, B., Wise Romero, P., & Reynolds, K. (2013). A standard framework for levels of integrated healthcare. Washington, DC: SAMHSA HRSA Center for Integrated Health Solutions. Hjorthoj, C., Sturup, A.E., McGrath, J.J., & Nordentoft, M. (2017). Years of potential life lost and life expectancy in schizophrenia: A systematic review and meta-analysis. The Lancet Psychiatry, 4(4), 295-301. https://doi.org/10.1016/S2215-0366(17)30078-0 Jetty, A., Petterson, S., Westfall, J.M., & Jabbarpour, Y. (2021). Assessing primary care contributions to behavioral health: A cross-sectional study using medical expenditure panel survey. Journal of Primary Care & Community Health, 12, 1-6. DOI: 10.1177/21501327211023871 Johnson, D.J. (2025). Integrated behavioral healthcare in the modern age: There s an app for that. Journal of Technology in Behavioral Science, Published online April 29 2025. Accessed May 2, 2025. file:///C:/Users/jshea/Downloads/s41347-025-00525-y.pdf Lombardi, B.M., Zerden, L., & Greeno, C. (2024). Federally qualified health centers use of telehealth to deliver integrated behavioral health care during COVID-19. Community Mental Health Journal, 60, 215-223. https://doi.org/10.1007/s10597-022-01070-1 Manderscheid, R.W., & Ward, A. (2024). Looking toward the future of integrated care: History, development, and opportunities. The Journal of Behavioral Health Services & Research, 51, 609-617. DOI 10.1007/s11414- 024-0984-3 Matthews, E.B., Lushin, V., Macneal, E., & Marcus, S.C. (2024). The impact of structural integration on clinical outcomes among individuals with serious mental illness and chronic illness. Community Mental Health Journal, 60, 1372-1379. https://doi.org/10.1007/s10597-024-01293-4

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