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While integration offers benefits to psychologists, physicians and the patients they share, there are important points to consider before you begin. This is the fifth of seven sections in the Guide to Innovative Practice Models.

Integrating behavioral health services into a primary-care practice is another option for psychologists interested in exploring innovative practice models. Instead of merely co-locating in or near a medical practice, psychologists offering integrated services become part of a medical team, readily available right there in the primary- care office. By allowing early identification, evaluation and treatment, integration helps both primary-care and mental health practitioners better meet patients' health needs.

Integrated behavioral health offers many advantages. For one thing, it’s frequently primary- care physicians and other medical providers who first spot depression, anxiety, substance use and other behavioral health issues in patients. Primary-care providers usually have a long-term relationship with patients but may not have the depth of training, comfort level and time to address such issues, especially given the standard 15-minute length of a primary-care appointment. If they identify a problem, they usually don’t have time to conduct a thorough assessment and work with the patient to determine next steps. For these busy professionals, being able to send a patient across the hall to a trusted psychologist or other behavioral health provider is a huge asset. It not only assures that the referred patient is receiving immediate, appropriate care, it also allows them to focus their medical expertise on their patients.

Integration helps psychologists meet patients’ needs, too. Specialty mental health care has its limitations. Getting people in the door is one major challenge. Stigma, long waiting lists, even logistical problems such as lack of transportation or child care can all keep people from getting the help they need. Being able to seek behavioral health services at a physician’s office can be more convenient and less threatening. In addition, integration allows for more efficient use of scarce mental health resources by treating most cases in primary care and reserving specialty mental health care for those with the most serious problems. Integration is also the direction that health care is moving, as the Affordable Care Act and other policy initiatives emphasize increased access, comprehensive care and integration.

Before you consider integration with a primary- care practice, consider the following points:

  • Training. Most psychology training still prepares practitioners for the traditional model of care rather than integration. Not all psychologists are prepared — or comfortable with — the fast pace, unpredictable schedule and wide range of issues that are the hallmarks of integrated practice. Training in specific approaches useful in overall medical care such as stress management, pain management, cognitive interventions for sleep and depression, and motivational interviewing are all helpful skills that can be implemented in primary care.
  • Buy-in. Early buy-in from all involved is crucial when it comes to integrating behavioral health services into primary care. Not every physician is open to integration, so you may have to approach several primary-care practices before you find one that’s amenable to your proposal. An increasing number of primary-care physicians are enthusiastic about the idea and looking for psychologists, so keep trying and network with other psychologists in your region who have been successful in this approach.
  • Cultural differences. All clinics have their own cultures. In bigger, busier clinics, for example, integration may feel more like co-location because you're not having face-to-face contact with physicians and other medical providers multiple times a day. In smaller clinics, the practice may feel more like a family.
  • Defined roles. When a psychologist joins a medical practice, physicians and other medical providers often don't quite understand the psychologist's role or know how to put a psychologist to the best use. Be visible. If you're always in your office, physicians may forget you're there. Remind them that you're ready to help. And don't let them ask you to do things that are inappropriate, such as assessing a patient over the phone. Make sure your role is clearly defined, and remember that your expertise has real value.
  • Coding, billing and reimbursement. These kinds of logistical issues can be one of the biggest challenges of integration. Reimbursement for codes isn’t consistent across insurers, for example. And the primary-care practice may not have billing staff available to help you.  For brief interventions, see if specific insurers have set up coding procedures for integrated care, and consider using the Health & Behavior codes, along with traditional mental health codes.  Inform your primary care partners about screening codes that they can use, which would then help to generate referrals.
  • Communication. Ask primary-care providers what they need to know and what information is helpful to them. Physicians and other medical personnel understand that providing services doesn’t just mean seeing patients face to face; they also know that having to write up notes and engage in other behind-the-scenes work also takes time. Cross-disciplinary meetings can help close that communications loop. It also helps to speak in medical terms, so understand the jargon. If psychologists from your practice are spread out across multiple primary-care practices, come together periodically.
  • Flexibility. In a primary-care setting, you never know what kind of patient will walk through your door. Embrace the unexpected and be flexible.

Alternative Practice Models: Geoffrey Kanter and Vince Bellwoar

Integrating with a Medical Practice  

The APA Practice Organization gratefully acknowledges the assistance of Jana Martin, PhD; Kevin Ryan, JD; Alan Nessman, JD; Karen Dale, RN; Geoffrey Kanter, PhD; and Vincent J. Bellwoar, PhD, in developing this material

Innovative Practice Models (IPM), formerly referred to as Alternative Practice Models, is now being used to avoid confusion with Alternative Payment Models.

Please note:  Legal issues are complex and highly fact specific and laws vary by jurisdiction. APA Practice Organization staff, consultants and speakers cannot provide legal advice. The information provided in this toolkit is an abbreviated compilation of several workshops and does not constitute legal advice. It should not be used as a substitute for obtaining personal legal advice prior to making personal decisions. Those needing legal advice should contact an experienced attorney licensed in your jurisdiction.

Date created: June 2017