Development and Implementation of a Collaborative Care Model for Behavioral Health Organizations: Responding to Medicaid Transformation

Background and Purpose: A growing body of research has explored the process of integrating behavioral health care into primary care organizations, using a Collaborative Care model. A dearth of literature has investigated the process in reverse: integrating primary care into behavioral health organizations to improve screening and care of diabetes and hypertension for adults with serious mental illness. With Medicaid transformation, behavioral health organizations will be responsible for process-oriented metrics of service-provision related to diabetes and hypertension. This paper fills the gap by examining the processes used by two behavioral health organizations in a metropolitan, West coast city to adapt a Collaborative Care model and implement a new workflow that fulfills the requirements of Medicaid transformation regarding diabetes and hypertension screening and service provision.

Methods: Researchers interviewed 25 participants (organizational leaders and front-line providers of two behavioral health clinics and two partnering primary care centers) at two times: pre- and post-implementation. Purpose: to identify and refine necessary adaptations to a Collaborative Care model for behavioral health organizations to enhance integrated care of diabetes and hypertension. Interviews were semi-structured, recorded, transcribed verbatim, and entered into NVivo qualitative software for thematic analysis. Researchers observed weekly workgroup meetings at each behavioral health clinic during the 12-month process of adaptation and implementation. The research team met weekly to discuss observations and interview data. Minutes, memos, and field notes were kept to maintain an audit trail of observations and themes identified during the process of data collection and analysis. All research activities were approved by the state IRB.

Findings: Three main findings were identified: 1) Behavioral health and primary care organizations have complex and often divergent practice orientations, billing requirements, and electronic medical record systems; clearly defined MOUs and agreements defining partnership and service provision facilitated sustainment of workflow changes and coordinated care. 2) Education and training helped primary care providers develop strategies for client engagement and promotion of behavior change; behavioral health providers identified benefits of training in diabetes and hypertension management to effectively support and guide client health behavior change. 3) To improving outcomes for clients, providers exceeded basic requirements of generating a patient registry and referring to primary care; organizations developed evidence-based responses to structural and psychosocial barriers for clients to access primary care and enact recommended lifestyle changes.

Conclusion and Implications: Organizations can benefit from clear MOUs and clarity around how a medical provider will engage in team-based care. Workflow changes that only focus on the development of a patient registry and referrals to primary care may be insufficient; while a brokered model of service may be sufficient for primary care settings, behavioral health clinics serving people with complex psychiatry disabilities require interventions from a variety of staff roles to help clients resolve structural and psychosocial barriers to accessing primary care and engaging in recommended health behaviors. Training for both medical and behavioral health staff was identified as essential for effective, integrated care.