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Creating Connections: An Early Look at the Integration of Behavioral Health and Primary Care in Accountable Care Organizations

behavioral health examination

Executive Summary

Individuals with mental illness are among the highest need, costliest patients in the U.S. health care system, yet they receive inadequate behavioral health care. Researchers have proposed various models that integrate behavioral health with primary care. These approaches have the capacity to improve patient care and outcomes in terms of both physical and behavioral health. However, implementing integration models under traditional fee-for-service payment structures presents significant challenges. Emerging payment models—like accountable care organizations (ACOs)— may allow for more coordinated care, including integrated behavioral and physical health care. ACOs are groups of providers held accountable for the quality and total cost of care of a defined patient population. Under the model, groups of providers receive modified reimbursements that offer incentives to reduce costs and improve care.

This report explores how ACOs are approaching the integration of behavioral health into primary care by showcasing two models of behavioral health and primary care integration. The two ACOs vary in their approach to integration as well as in other characteristics. The first, Crystal Run Healthcare ACO, is using a combination of integration approaches, which we refer to as a colocation plus collaboration model. The goal is to improve collaboration among providers through proximity and improved information sharing. While the roles of the behavioral health and primary care providers remain relatively traditional, colocation within the same building creates an opportunity for improved care transitions and communication between providers. This ACO also is using information technology systems to enable better communication and foster knowledge sharing between behavioral health specialists and primary care providers (PCPs).

The second ACO, Essentia Health, has developed an integrated model that embeds several behavioral health specialists within primary care teams, colocates providers, and establishes structures for frequent communication and close collaboration in patient care. This model is often referred to as a primary care behavioral health model. The behavioral health providers’ roles are adapted to support the primary care physician, and the primary care physician retains supervision of the patient’s psychiatric care. The goal is to build the capacity of PCPs to treat behavioral health patients and reduce the need for referrals to behavioral health specialists.

Both ACOs stated that early, informal feedback on their programs was overwhelmingly positive. More data will be needed to evaluate the effectiveness of integrated care for patient outcomes and the factors that lead to long-term, successful integration. However, from these case-studies two factors arise as vital to the successful implementation of integrated care models: 1) participation in a nontraditional payment system, such as an ACO, and 2) informed selection of an appropriate model of integration. Additionally, these case studies suggest the important roles of payers, states, or learning collaboratives in increasing the use of integrated care models. These partners are ideally situated to provide educational opportunities to ACOs considering or pursuing integrated care. The success and widerange adoption of these models will rely on those ACOs and their partners at the forefront of care delivery transformation to adopt, test, and refine the models.

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Publication Details



Katherine Tierney, Health Policy Fellow, The Dartmouth Institute for Health Policy and Clinical Practice

[email protected]


K. Tierney, A. Saunders, and V. Lewis, Creating Connections: An Early Look at the Integration of Behavioral Health and Primary Care in Accountable Care Organizations, The Commonwealth Fund, December 2014.