Integration of Behavioral Health in Population-Based Approaches to Caring for Patients in Primary Care (Based on the presentation given at the MPA Annual Convention April 2016)

In May 2008, the Minnesota legislature adopted health care reform legislation that allows primary care clinics in Minnesota to become certified as Health Care Homes (HCH).  The HCH program provides “an approach to primary care in which primary care providers, families and patients work in partnership to improve health outcomes and quality of life for individuals with chronic or complex health conditions (Minnesota Department of Health, Health Care Homes).”  The goals for HCH are based on the “Triple Aim” put forth by the Institute for Health Care Improvement.  These aims are 1) improving patients’ experience of care, 2) improving health from a population perspective, all while 3) reducing the cost of health care (Institute for Health Care Improvement).

This shifted the perspective of many primary care clinics, as clinics tended to focus on patients who showed up asking for care.  These aims ask clinics to proactively reach beyond their clinic walls and provide evidence-based care for patients in a systematic manner.  Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”  At the core of population management is defining a group of patients (e.g., those on chronic opioids, patients with elevated PHQ-9 scores, patients with diabetes with blood pressures over a set point, etc.) and using available data to actively follow and review patients to ensure the condition is being optimally managed in relation to available evidence-based guidelines for treatment.

So, how does this all relate to integrated behavioral health?  When first starting to provide behavioral health (BH) services in primary care clinics, the focus is typically on how direct clinical services will be provided (where BH is located; which patients should see BH; schedule set up for flexibility).  Yet, there is a very important role, beyond seeing patients, for primary care teams engaged in population-based work.  BH clinicians are skilled at listening for the patient’s perspective, understanding psychosocial contributors to health care conditions, engaging patients in their own care, and helping to develop patient centered plans that can be carried out by both patients and providers.  Within population based approaches, we identify three areas: panel management (reviewing registries to identify action steps); population management (creating protocols to address a particular population); and transitional care management (returning to outpatient care after hospital visits).  Below we provide a few examples of how BH clinicians have been involved in population-based activities at three of our family medicine residency clinics. 

Interprofessional Team Meetings (ITMs)

Panel Management:  At Smiley’s clinic, when patient panels were first developed, these panels were given to physicians monthly.  Leadership initially expected the physicians would find time to review over 8+ panels and note on each panel what they wanted the care coordinator to do in regard to the patient.  This almost never happened, secondary to time constraints and other barriers.  Additionally, other team members were not systematically involved.  As a result, a new panel management system was created with input from front desk, patient care staff, nursing, care coordinators, pharmacy, behavioral health and physicians.  This led to the creation of Interprofessional Team Meetings (ITMs).  Each physician has one patient slot held each month at the beginning of a clinic shift for the ITM.  This meeting is attended by behavioral health, pharmacy, the care coordinator and the physician.  The team discusses complex or challenging patients on the chronic disease management panels during this 20-minute meeting and creates a plan for going forward.  Any team member can bring up a patient they are concerned about.  The team designates a member for completion of each piece of the plan. The care coordinator records the plan of care and this “to do” list is reviewed at the next panel meeting to determine what happened and what should happen next.

Chronic Pain Management

Population Management: At Bethesda Clinic, a team based approach to the management of patients with chronic pain was developed in response to concerns about opioid overuse in this population and a desire for equity in how patients with chronic pain were assessed and treated.  BH providers were an integral part of the development of the assessment and treatment approach for patients with chronic pain.  BH also served a critical role in education within the clinic to increase provider buy-in and follow through on key elements of the care model.

In an effort to standardize the approach to pain care, the team developed a panel of patients receiving opioids to flag patients who had received over three prescriptions for opioid therapy within the past 12 months.  During ITMs the multidisciplinary team reviews cases to determine if ongoing opioid therapy is recommended and, if so, develops a plan to ensure that all quality elements of the clinic process for the assessment and treatment plan have been implemented, including BH assessment as a standard part of care for all patients with chronic pain.  For new patients seeking opioid therapy for chronic pain concerns, the approach requires a multi-visit assessment, including a BH assessment to screen for risk factors for possible opioid misuse, other psychosocial contributors to the patient’s pain experience, and to assist in the development of a patient-centered care plan. 

Transitions of Care Meetings (TCM)

Transitional Care Management:  At Broadway Clinic, the team developed an approach to ensure patients recently discharged from the hospital receive the follow-up and care they need to stay healthy and reduce the risk of re-hospitalization. The clinic is notified when a patient is going to be discharged from the hospital.  Patients are contacted to schedule a TCM at the primary care clinic within a week of discharge.  The patient, behavioral health, pharmacy and the primary care physician are at the TCM.  Patients are aware that multiple team members will be present.  All team members go in together so patients only need to state their story one time.  The physician introduces the team and the rationale behind this visit.  The team and patient create a shared agenda and then collaborate to determine how to best meet patients’ medical, behavioral health, and social needs to optimize their healthcare.

Lessons Learned

There have been many starts, stops, changes, and modifications to these population based approaches along the way.  We have by no means found “the” answer on integrating behavioral health into this type of care at primary care clinics, but are sharing what has worked at our clinics.  Key lessons learned developing population based approaches are shared below:

  1. Identify Clinic Needs: Many of these projects gained momentum because of struggles the clinics were having and other forces taking place in health care.  Pay attention to the stress points in clinic and start there.
  2. Time: These types of initiatives cannot just happen on the fly, squeezed into overloaded work schedules.  Time needs to be blocked for them to be successful. 
  3. Standard Work:  Clear expectations about how work is shared by the team (who does what) and timelines for work are critical to keep things moving forward. 
  4. Team input and buy-in:  All members of the team need to have a voice in creating the process.  If someone is left out, an important piece that can sink the whole initiative may be missing. 
  5. Accurate panel data:  Panel data needs to be “accurate enough.” Much time can be spent talking about the invalidity of the data which side tracks the work. Behavioral health is often helpful in helping the team keep the focus on the big picture which is great patient care.
  6. Reimbursement: We are still living in a fee-for-service world and much of this work is not directly reimbursable within that system. At the same time, we are increasingly being held accountable for population outcomes and the health care system appears to be moving in the direction of total cost of care.  We needed to look beyond fee for service, but also bill when it was appropriate and we were able to do so. 

Regardless of where clinics may be in their population health journey, remember that identifying a shared vision within the team to inform your steps along the way is critical.  Prepare to pilot, assess, revise and keep going!

Dana Brandenburg, Psy.D., LP and Christine Danner, Ph.D., LP
Drs. Brandenburg (Smiley's Family Medicine Residency Program) and Danner (Bethesda Family Medicine Residency Program) are Assistant Professors in the Department of Family Medicine and Community Health at the University of Minnesota.  At their respective clinics, they provide integrated behavioral health services, lead the behavioral health curriculum, and co-direct a primary care psychology post-doctoral fellowship program.  


  1. Institute for Health Improvement.

  2. Minnesota Department of Health, Health Care Homes

  3. Dowell, D., Haegerich, T., Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016, JAMA 315(15), 1624-1645.
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