Integration of Primary Care and Behavioral Health Services in Midwestern Community Health Centers: A Mixed Methods Study

Introduction: Integrating behavioral health (BH) and primary care is an important strategy to improve health behaviors, mental health, and substance misuse, particularly at community health centers (CHCs) where disease burden is high and access to mental health services is low. Components of different integrated BH models are often combined in practice. It is unknown which components distinguish developing versus established integrated BH programs. Method: A survey was mailed to 128 CHCs in 10 Midwestern states in 2016. Generalized estimating equation models were used to assess associations between program characteristics and stage of integration implementation (precontemplation, contemplation, preparation, action, or maintenance). Content analysis of open-ended responses identified integration barriers. Results: Response rate was 60% (N = 77). Most CHCs had colocated BH and primary care services, warm hand-offs from primary care to BH clinicians, shared scheduling and electronic health record (EHR) systems, and depression and substance use disorder screening. Thirty-two CHCs (42%) indicated they had completed integration and were focused on quality improvement (maintenance). Being in the maintenance stage was associated with having a psychologist on staff (odds ratio [OR] = 7.16, 95% confidence interval [CI] [2.76, 18.55]), a system for tracking referrals (OR = 3.42, 95% CI [1.03, 11.36]), a registry (OR = 2.71, 95% CI [1.86, 3.94]), PCMH designation (OR = 2.82, 95% CI [1.48, 5.37]), and a lower proportion of Black/African American patients (OR = .82, 95% CI [.75, .89]). The most common barriers to integration were difficulty recruiting and retaining BH clinicians and inadequate reimbursement. Discussion: CHCs have implemented many foundational components of integrated BH. Future work should address barriers to integration and racial disparities in access to integrated BH. Keywords: behavioral health, primary care, integration, health centers
Nearly one in five adults in the United States experiences a mental health or substance use disorder each year (National Institute of Mental Health, 2019). An important strategy to address [...]