Persistent workforce shortages are pushing behavioral health leaders to rethink how care is structured — and many are finding the answer not in any single model, but in stacking several at once.
“I see an optimal level of [behavioral health] integration into primary care occurs when we have multiple validated models layered,” Mike Franz, MD, executive medical director of behavioral health at Cambia Health Solutions, told Becker’s. “Layer[ing] them one on top of each other really provides some synergy to at its best support the primary care team, starting with the primary care provider.”
Dr. Franz describes five models as the foundation of what he calls an “optimal environment” for integrated behavioral health in primary care.
The 5 models
Primary care behavioral health model: An embedded behavioral health clinician works directly within the primary care team, sharing treatment plans, conducting real-time assessments and performing “warm handoffs” during patient visits. The model emphasizes immediate access to behavioral care within the clinic and requires protected time for unscheduled, in-the-moment interventions.
Collaborative care model: A team-based, largely asynchronous model in which a psychiatrist, care manager and primary care provider collaborate. The care manager and psychiatrist review cases regularly, often without direct patient interaction, and provide treatment recommendations based on measurement-driven criteria, with the goal of improving outcomes and graduating patients from the program over time.
E-consults: A primary care provider-initiated, one-time consultation with a psychiatric specialist for complex cases. The specialist conducts a detailed chart review and provides targeted recommendations, including medication adjustments or psychosocial strategies, with the option for future re-consultation if needed.
Psychiatric access lines: State- or institution-supported phone consultation services that allow primary care providers to receive real-time guidance from psychiatric specialists while the patient is still in the clinic. These interactions enable immediate clinical decision-making and are typically followed by written recommendations.
Project ECHO: A virtual, hub-and-spoke education model where specialists train and mentor primary care providers over a series of sessions, often lasting around 12 weeks. Through case discussions and didactics, the model builds primary care capacity to manage complex behavioral health conditions independently.
Here is how a health system and a mental health institute are layering behavioral healthcare models.
Huntsman’s hybrid model
Salt Lake City-based Huntsman Mental Health Institute has spent nearly a decade refining what it calls a hybrid behavioral health integration model, blending same-day access in primary care with population-based collaborative care.
Teresa Lopez, director of behavioral health integration, has helped build the model since its 2015 pilot phase. Integration is not one-size-fits-all and requires clinical redesign, billing transformation, cultural shifts and sustained data tracking to prove impact and expand access amid workforce constraints, she said.
Huntsman now operates the hybrid model across 11 primary care sites and more than 20 specialty clinics, with 38 full-time equivalents. The approach combines the primary care behavioral health model — which offers same-day, and sometimes one-time, therapeutic visits during a patient’s physician appointment — with the evidence-based collaborative care model to treat patients with anxiety or depression.
The results are striking. The system can see roughly six times more patients per individual social worker each year compared to a traditional outpatient mental health clinic.
“A social worker in an outpatient clinic may have a panel of about 100 to 120 patients they see over a course of a year,” Ms. Lopez said. “Our [licensed clinical social workers] are exceeding 800 patients a year that they’re seeing because of this model.”
The dual-model approach also carries a financial rationale. Many health systems adopt one integration model because billing and reimbursement structures differ between them. Using both gives Huntsman more flexibility, she said.
“It was really important to us that we were helping to push our system toward more of that value-based care work through the collaborative care model, but also because we wanted to be able to capture the billable work being done through psychotherapy brief visits,” Ms. Lopez said.
Under the collaborative care model, services are billed monthly based on time and submitted under the primary care provider. The primary care behavioral health model, by contrast, is billed per visit under the behavioral health provider and reimbursed fee-for-service. Leaders are still developing a more unified structure to better understand the model’s profit-and-loss performance.
To make the model work operationally, Huntsman shifted away from traditional 60-minute therapy sessions, a format that does not align with the pace of primary care. Social workers instead conduct focused, problem-oriented sessions that address symptoms and establish next steps, similar to a primary care visit. The collaborative care model also requires maintaining a patient registry and tracking outcomes over time, allowing the system to demonstrate measurable progress to patients, providers and payers.
Providence’s 2-model approach
At Renton, Wash.-based Providence’s Well Being Trust, CEO Arpan Waghray, MD, told Becker’s the system uses two integrated care models — collaborative care and the patient-centered behavioral health model — both of which embed psychologists directly into care.
“What happens is the primary care doctor is visiting with a patient, and through the course of the visit, they have a conversation about something that might be hard. It’s not only necessarily behavioral health,” Dr. Waghray said.
Within these models, providers can treat patients experiencing depression and anxiety as well as provide support for health behaviors such as smoking cessation, obesity or medication adherence.
“These very well-trained psychologists in primary care clinics are able to help the patient navigate some of those terms, help them adapt, and help them get to a much better place where they’re able to stay with the treatment plan and get the health outcomes needed.”
In some markets, psychiatrists join primary care physicians for informal peer learning sessions — brown bag lunches where clinicians talk through the most common referral reasons in a practical, non-academic format.
“When you talk about integration, it’s much more than just having a psychiatrist or social worker available in a model across the city,” Dr. Waghray said. “They truly become a part of the care team.”
That integration extends to perinatal care, an area Dr. Waghray said remains underserved.
“Perinatal mood and anxiety disorders are the most common complication of childbearing — more so than gestational diabetes,” he said. “Every new mom gets a glucose test, but every new mom does not get an Edinburgh depression rating scale. That should change.”
Providence addresses this gap by embedding screening into well-baby visits rather than waiting for an obstetrician appointment. New mothers struggling with clinical depression may not have their first OB visit for eight to 12 weeks, leaving them without support during that window.
“What we do know is that they all will come in for their well-baby visit at week four,” Dr. Waghray said. “Working with the pediatrician to incorporate screening tools, and then having a therapist available if they were to score high, to get them seamlessly connected — that is a core part of integration.”
The approach has shown measurable results. Over 18 months, Providence moved from the 25th percentile nationally to the top quartile on the HEDIS depression treatment response metric across all its clinics — a shift Dr. Waghray attributed directly to the integrated model.
“The level of improvement at that scale for 200-odd clinics across seven states could not happen only with a few behavioral health providers,” he said. “It had to be true integrated models.”
At the Becker's Fall Behavioral Health Summit, taking place November 4–5 in Chicago, behavioral health leaders and executives will explore strategies for expanding access to care, integrating services, addressing workforce challenges and leveraging innovation to improve outcomes across the behavioral health continuum. Apply for complimentary registration now.
