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Levels of Integrated Behavioral Health Care

Integrated behavioral care isn’t an all-or-nothing proposition. Rather, it is practiced on a continuum, based on level of collaboration between health care and behavioral health care professionals. The following excellent description of collaboration levels, is put forth by William J. Doherty, Ph.D. Susan H. McDaniel, Ph.D. and Macaran A. Baird, M.D., and summarized in Behavioral Healthcare Tomorrow, October, 1996, 25-28:

Level One: Minimal Collaboration

Mental health and other health care professionals work in separate facilities, have separate systems, and rarely communicate about cases.

Where practiced: Most private practices and agencies.
Handles adequately: Cases with routine medical or psychosocial problems that have little biopsychosocial interplay and few management difficulties.
Handles inadequately: Cases that are refractory to treatment or have significant biopsychosocial interplay.

Level Two: Basic Collaboration At a Distance

Providers have separate systems at separate sites, but engage in periodic communication about shared patients, mostly through telephone and letters. All communication is driven by specific patient issues. Mental health and other health professionals view each other as resources, but they operate in their own worlds, have little sharing of responsibility and little understanding of each other’s cultures, and there is little sharing of power and responsibility.

Where practiced: Settings where there are active referral linkages across facilities.
Handles adequately: Cases with moderate biopsychosocial interplay, for example, a patient with diabetes and depression where the management of both problems proceeds reasonably well.
Handles inadequately: Cases with significant biopsychosocial interplay, especially when the medical or mental health management is not satisfactory to one of the parties.

Level Three: Basic Collaboration On-Site

Mental health and other health care professionals have separate systems but share the same facility. They engage in regular communication about shared patients, mostly through phone or letters, but occasionally meet face to face because of their close proximity. They appreciate the importance of each other’s roles, may have a sense of being part of a larger, though somewhat ill-defined team, but do not share a common language or an in-depth understanding of each other’s worlds. As in Levels One and Two, medical physicians have considerably more power and influence over case management decisions than the other professionals, who may resent this.

Where practiced: HMO settings and rehabilitation centers where collaboration is facilitated by proximity, but where there is no systemic approach to collaboration and where misunderstandings are common. Also medical clinics that employ therapists but engage primarily in referral-oriented collaboration rather than systematic mutual consultation and team building.
Handles adequately: Cases with moderate biopsychosocial interplay that require occasional face-to-face interactions between providers to coordinate complex treatment plans.
Handles inadequately: Cases with significant biopsychosocial interplay, especially those with ongoing and challenging management problems.

Level Four: Close Collaboration In a Partly Integrated System

Mental health and other health care professionals share the same sites and have some systems in common, such as scheduling or charting. There are regular face-to-face interactions about patients, mutual consultation, coordinated treatment plans for difficult cases, and a basic understanding and appreciation for each other’s roles and cultures. There is a shared allegiance to a biopsychosocial/systems paradigm. However, the pragmatics are still sometimes difficult, team-building meetings are held only occasionally, and there may be operational discrepancies such as co-pays for mental health but not for medical services. There are likely to be unresolved but manageable tensions over medical physicians’ greater power and influence on the collaborative team.

Where practiced: Some HMOs, rehabilitation centers, and hospice centers that have worked systematically at team building. Also some family practice training programs.
Handles adequately: Cases with significant biopsychosocial interplay and management complications.
Handles inadequately: Complex cases with multiple providers and multiple larger systems involvement, especially when there is the potential for tension and conflicting agendas among providers or triangling on the part of the patient or family.

Level Five: Close Collaboration In a Fully Integrated System

Mental health and other health care professionals share the same sites, the same vision, and the same systems in a seamless web of biopsychosocial services. Both the providers and the patients have the same expectation of a team offering prevention and treatment. All professionals are committed to a biopsychosocial/systems paradigm and have developed an in-depth understanding of each other’s roles and cultures. Regular collaborative team meetings are held to discuss both patient issues and team collaboration issues. There are conscious efforts to balance power and influence among the professionals according to their roles and areas of expertise.

Where practiced: Some hospice centers and other special training and clinical settings.
Handles adequately: The most difficult and complex biopsychosocial cases with challenging management problems.
Handles inadequately: Cases where the resources of the health care team are insufficient or where breakdowns occur in the collaboration with larger service systems.