Behavioral health leaders at five health systems are driving a shift toward upstream integration through operational redesign. Their goals: embedding support directly into existing care encounters rather than relying on traditional referral models, and using integrated data to inform decision-making across their respective systems.
“Integration at scale requires redesigning our staffing models, embedding behavioral health data into the same systems as medical care, and building workflows that prioritize rapid access rather than the traditional referral models,” Elicia Bunch, vice president of behavioral health at Aurora, Colo.-based UCHealth, told Becker’s. “When behavioral health services are offered separate and distinct from medical care, stigma and barriers to care often prevent far too many patients from getting help.”
Embedding behavioral health into routine care
This shift reflects a broader move across health systems to integrate screening, intervention and follow-up into routine care. Rather than limiting behavioral health engagement to specialty settings, organizations are operationalizing integration through universal screening and shared care models.
At Norfolk, Va.-based Sentara Health, this approach includes standardizing screening across specialties.
“We’re trying to incorporate behavioral health in every discipline, so in primary care practices, our ambulatory division now is initiating the PHQ with all specialties,” Tracey Izzard, vice president of behavioral health services at Sentara, told Becker’s. “You go to your orthopedic doctor, and you get a PHQ, you go to the cardiologist, and you get a PHQ.”
Even as integration expands, leaders said maintaining focus on behavioral health within specialty care remains a challenge.
“When you run something like the Cancer Institute or the Heart Vascular Institute, psychiatry is an important part, but it’s only a part of about a million priorities that you have,” Bernard Jones, vice president for behavioral and mental health and the psychiatry department at Somerville, Mass.-based Mass General Brigham, said.
At the same time, demand for integration is increasingly coming from specialty leaders themselves. Mr. Jones said behavioral health is “part of the DNA of our system,” with service line leaders actively seeking to embed psychiatric care into treatment models.
“Transplant is a perfect example,” he said. “We think about the procedure itself, but our clinical leaders on the transplant center side understand the psychiatric and psychological implications of that transplant for the patient and for their families.”
Leaders also emphasized that team-based staffing models are critical to sustaining progress.
“It’s important to focus on team based staffing models, and when you can have team based staffing models that really supports the scaling of integrated care and allows all disciplines within the healthcare system to function at the top of scope,” Ms. Bunch said. “The common goal among all of our team members, whether therapists, nurses, physicians and care managers, is really identifying behavioral health related symptoms and intervening early.”
Emergency departments drive integration redesign
Emergency departments are a key pressure point for integration efforts, particularly for patients with complex behavioral and medical needs.
Researchers at Ann & Robert H. Lurie Children’s Hospital of Chicago found triage scores for children presenting in the emergency department with mental or behavioral health concerns were inaccurate in two-thirds of cases. For patients experiencing a mental health crisis, they wait on average three times longer in emergency rooms than those with medical needs.
To help address gaps in care and throughput, systems including Los Angeles-based Cedars-Sinai Medical Center and Sentara Health have introduced behavioral health and substance use navigators to engage patients before discharge — particularly those who frequently return to the emergency department.
At Sentara, implementing navigators significantly improved performance metrics. Average emergency department length of stay dropped from 2,740 minutes to 2,090 minutes in the first few months, Ms. Izzard said. Thirty-day readmission rates fell from 14.1% to 7.3% when navigators were engaged. Return visits also declined from 26.2% without navigators to 14% with navigator support.
Health systems are also developing specialized inpatient units for patients with both medical and psychiatric needs.
“Some psychiatric patients don’t simply have psychiatric illnesses,” Maurizio Fava, MD, chair of psychiatry at Mass General Brigham, said. “They have significant medical comorbidity, and when they need to be hospitalized, they need med-psych units, meaning units that are comfortable delivering both acute medical and acute psychiatric care.”
Shared data and telepsychiatry enable scale
Leaders said shared data infrastructure is foundational to scaling integrated care models.
“Integration only works if behavioral health information and medical information live in the same system and can inform shared decision-making,” Ms. Bunch said. “This really requires having access to screening tools, registries, outcome tracking, all within the same shared electronic health record.”
Health systems are investing in dashboards and analytics capabilities to support this work. At Sentara, leaders built data dashboards to track key performance indicators and inform care improvements.
“We’re still in the process of building new dashboards so that we can start to capture the data and that can inform our future practices and [create] shared accountability kind of across the enterprise and at the leadership level,” she said.
Telepsychiatry has also become a critical tool for scaling access, particularly across large and rural systems.
“[We] built a bench of psychiatrists and emergency department trained social workers, licensed them across all our seven states, and now serve about 43 sites, 24/7,” said Arpan Waghray, MD, CEO of Renton, Wash.-based Providence’s Well Being Trust. “You have the ability through your bench to be able to serve all of those patients within a 30-minute window, as opposed to what used to be the case.”
Leaders have also looked to hybrid in-person and virtual workforce models. These allow systems to address workforce shortages while maintaining local engagement.
Hybrid workforce models expand access
At Danville, Pa.-based Geisinger, leaders hired more than 100 behavioral health employees over two years and redesigned onboarding to reinforce integrated care culture. By pairing peer mentors with new hires, Geisinger uses onboarding as a way to connect virtual and in-person clinicians around shared patients and communities.
“One of the things we’ve done is invested deeply in a virtual backbone of services. Those integrated care providers become our boots on the ground to make sure our virtual care providers stay connected to their community,” Dawn Zieger, vice president of psychiatry and behavioral health at the system, said. “That mix of integrated care and virtual care is going to be our path forward to continue to build capacity.”
The model is designed to address workforce shortages while maintaining local connection across Geisinger’s 23-county footprint.
“We had a lot of work to do with self service and video visits to make sure that was an integrated workflow that met all the compliance requirements,” she said. “There was probably a year’s worth of work done to ensure that we were able to provide that quality experience with the requirements that allowed us to be fully compliant.”
The system is currently working on integrating scheduling workflows and processes for self-service scheduling as well as scheduling within referral clinics.
Standardizing care while preserving flexibility
As integration expands, leaders are balancing systemwide standardization with local autonomy.
Dr. Waghray described a “tight-loose-tight” model guided by the Quadruple Aim, a framework that seeks to improve patient experience, outcomes, cost and quality. Systems set clear expectations at the enterprise level, allow flexibility in how local markets meet those goals, and then require accountability through reporting.
“We can’t ignore that this care is delivered in places, whether it’s clinics or units or hospitals,” Mr. Jones said. “There’s always a balance of integration, but then letting the local centers lead and care for their patients in their best ways.”
Aligning leadership and front-line teams is also essential to scaling integration.
“We started integration with two key simultaneous actions,” Dr. Fava said. “We integrated the leadership team, and also brought front-line faculty and staff together across institutional lines and with leaders in integrated ways to engage front lines, so we could then build from there.”
Editor’s note: This is the second of a three part series exploring what behavioral health integration looks like financially, clinically and operationally. Check out Becker’s behavioral health newsletter to see more coverage on the topic.
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