Implementation Outcomes of Integrated Physical and Behavioral Health Programs

Background: The integration of physical and behavioral healthcare has been positioned as critical to achieving the triple aim of improving health outcomes, reducing cost, and realizing patient-centered care. Integration stands in contrast to fragmented systems of care that have been particularly detrimental to people with complex physical and behavioral health needs that are served by the public mental health system. The Affordable Care Act has provided a unique opportunity to reshape public mental health systems, but whether and how these systems can achieve integration remains an unanswered question. This study investigates the implementation of pilot programs designed to serve individuals with mental health and co-occurring chronic physical health conditions. These programs are part of a policy experiment currently being conducted by the Los Angeles County Department of Mental Health.

Methods: Site visits were conducted at 24 pilot programs. Programs fit within 1 of 3 possible models that include: Integrated clinic model (n=5); Mobile community treatment team model (n=5); Model designed to build on the specific strengths of underserved ethnic communities (n=14). In order to provide structure to program site visits, the Integrated Treatment Tool (ITT) was used as a guiding framework and index of integration. The tool was developed through support from SAMHSA and incorporates the best available evidence. For each visit, 3 members of an evaluation team spent a full day at each program. The primary data source was in-depth semi-structured interviews with program staff. Additional information was obtained through observation and documentation review. Following site visits, evaluators independently scored and provided a clear rationale for each of the 30 items contained within the ITT. A final report program report reflected group consensus. Cross-case analysis was utilized to develop overarching themes regarding the implementation of integrated programs.

Results: There was variation in ITT scores both within and between program models, with the overall average score of integration approaching a 3 out of 5 rating. Common challenges and strengths across programs were discernable and organized into 10 lessons learned that included: there are developmental stages of integration, policies/procedures and CQI are in early stages of development, peer specialist roles are still evolving, interdisciplinary team meetings work, and programs continue to face systems barriers to maximizing effective communication and coordination of care.

Discussion: This approach to implementation evaluation provides a snapshot in time of integrated physical and behavioral health programs that are rapidly changing and evolving as would be expected in an early phase of program development. Targeted efforts can support the development of integrated care programs both at the individual program and system level.