Technology for advancing behavioral health integration: implications for behavioral health practice and policy

Abstract

Behavioral health integration (BHI) encompasses the integration of general health, mental health, and substance use care. BHI has promise for healthcare improvement, yet several challenges limit its uptake and successful implementation. Translational Behavioral Medicine published the Continuum-Based Framework by Goldman et al., 2020 to create comprehensive guidance for BHI within primary care settings. Technology can help advance BHI and provide evidence to support it. This commentary describes challenges and illustrative use cases in which technology solutions help organizations achieve BHI through the Continuum-Based Framework domains. Two rounds of semi-structured interviews with field leaders, practice sites, and technology stakeholders identified key barriers in BHI amenable to technology solutions, applications of technologies, and how they facilitate BHI. Findings showed that technology can facilitate the implementation and scaling of BHI by reducing care fragmentation and improving patient engagement, accountability and financial sustainability, provider experience and support, and equitable access to culturally competent care. Continued efforts by stakeholders to address legacy policy and implementation issues (e.g. incentives, investment, privacy, and workforce) are needed to optimize the impact of technology on BHI.

Introduction

Integration of behavioral health interventions (i.e. mental health and substance use treatment) into primary care and other general medical settings is challenging, especially for populations experiencing steep inequities in health and healthcare. Behavioral Health Integration (BHI) is multifaceted, requiring coordinated policies, and actions at the regulatory (e.g. federal, state), organizational, and practice levels to produce its intended effects [1]. Barriers to BHI uptake and implementation are well-described; they include regulatory obstacles, workforce shortages, workflow inefficiencies, privacy concerns, underpayment, and stigma [2, 3]. Given the challenges of BHI in practice and the need for guidance about how to accomplish BHI at scale, several models for BHI have been developed. The Continuum-Based Framework (CBF) by Goldman et al. [4] aims to create comprehensive guidance for BHI within primary care settings. It organizes key components of integrated care into domains along a developmental continuum and has demonstrated usefulness for advancing BHI in primary care practices based on their priorities and resources [4, 5]. Models of BHI have been adapted for serious illness care as well as integration of primary care into behavioral health settings (i.e. reverse integration) [5, 6].

The use of technology has evolved rapidly in the areas of electronic health records (EHRs) and management, informatics, and telehealth strategies, especially in response to the Coronavirus disease 2019 (COVID-19) pandemic [7]. These technologies may offer novel solutions for advancing BHI in multiple ways. Little guidance is available, however, on how technologies can optimize BHI. This commentary describes the use of technology to reduce barriers to BHI and details policy implications at the intersection of technology and BHI.

Methods

This commentary draws on a larger study of technological applications for integrated behavioral healthcare. We used the CBF of BHI to structure a literature review of technologies across all domains of BHI [4]. Based on this review, we compiled a list of field leaders in each of the domains. We then conducted two stages of semi-structured interviews using interview guides informed by the literature review. In the first “high-level” round of interviews (n = 20), we spoke with leaders in the fields of research and technology (n = 8), academia (n = 4), health group, system or plan (n = 3), government/accreditation (n = 2), nonprofit or advocacy organizations (n = 2), and a financial system (n = 1) to ask about core challenges to BHI (including barriers to equity), available technologies that facilitate core components of BHI across the CBF domains, and ways to increase BHI access for marginalized populations.

Findings from this initial round of interviews informed the second round of semi-structured “use-case” interviews (n = 12) with representatives from care delivery sites that use innovative technologies to facilitate core components of BHI. Sites interviewed included telemedicine BH providers (n = 7), technology companies (n = 2), an urban health system (n = 2), and a rural health system (n = 1). Interview participants were recruited nationally and sampled purposively to represent perspectives from both urban and rural care settings. Interview topics included technology applications, demonstrations, and discussions of outcomes data.

For this commentary, we review findings from the second round of use-case interviews to identify novel technologies that address specific challenges to BHI along the domains of the CBF. These use cases were chosen as illustrative examples to demonstrate how technology is being harnessed to address such challenges.

Results

We highlight five critical issues impeding BHI, aligned with the CBF, and present case examples illustrating how technology is being harnessed to address them. Table 1 summarizes technological applications for BHI according to the CBF domains.

Care fragmentation and information exchange

Information exchange and successful screening and referral among providers are key domains of BHI identified in the CBF (domains #1 and #3). Our review showed that care fragmentation is a consequence of inadequate structures and processes for supporting information exchange and is a barrier to BHI. Effective and efficient communication between patients (and caregivers) and providers, and between providers, is needed to ensure that care is coordinated, low-burden, and effective [8]. A range of technologies such as digital patient portals can potentially increase connections between patients and a range of provider types [9]. Similar technologies such as integrated electronic health systems, e-consults, and automated referral systems, can decrease fragmentation and facilitate coordination among multiple types of patient care [10]. A systematic review that evaluated the impact of patient portals on health outcomes and efficiency found that portal use improved communication across specialties, thus reducing existing care silos [9]. Technology Use Case: Reducing care fragmentation and enhancing BHI through technology-enhanced screening, referral, and access to care. Representatives from a Federally Qualified Health Center (FQHC) described using an EHR combined with a “warm handoff” model to improve communication and reduce care fragmentation thereby enhancing BHI. In their model, primary care providers screen patients for physical and psychological needs. Providers then initiate a live BH referral to either a masters- or doctorate-level BH provider for further screening and treatment planning, or an in-network 24/7 virtual consulting psychiatrist. This model originated in a rural location, with scarce resources and particularly fragmented care, hence the need for such technology. Their real-time warm handoff reduced the risk of incomplete referrals and increased connections to necessary specialty care. This is consistent with research in which, e.g. patients who were initiated via the warm handoff model had fewer days from referral to scheduled or completed follow-up behavioral health encounters, as well as greater total behavioral health encounters [11].

Patient engagement and multidisciplinary teams

The CBF identifies patients as key members of BHI providers’ multidisciplinary teams (domain #6). Similarly, our review identified low patient engagement as a barrier to BHI implementation. Patients with complex care needs are at risk of low engagement and low quality of care from factors including missed appointments and poor adherence to care plans [12]. Digital tools, such as a warm handoff consultation-based model in primary care have demonstrated success in increasing patient engagement in urban settings. Fewer primary care appointment no-shows/same-day cancelations, and greater systems utilizations were observed in patients initiated to care through a warm handoff model [13].

Technology Use Case: Improving patient engagement in BHI through ongoing person-centered care management. One-care delivery company described how it uses technology and telehealth to provide person-centered BHI and optimize patient engagement. They developed an “Ops-Hub” platform that combines their EHR and patient relationship management system, with specific functions. These include, e.g. Ops-hub prompts care providers to document patient information including patients’ biological, psychological, and social care needs early in their engagement with the company; the platform then prompts patients to update or revise them every 90 days. It also prompts clinician outreach to patients based on ER visits or inpatient stays, facilitating the opportunity for improved patient engagement. The platform also promotes care coordination by enabling care coordinators to match members with appropriate service providers (in- or out-of-network) and grant them access to their files, thus reducing patient information sharing burden and improving the reliability of medical information shared. The platform launches various care activities in alignment with members’ whole-person needs (psychoeducation, texting communication, etc.), thereby directly engaging patients in care. An additional function of the Ops-hub includes ongoing assessment of patient satisfaction to continually tailor care to individuals’ needs; a report of outcomes data is pending.

Accountability, payment models, and sustainability

With the growth of value-based payment models, systematic quality metrics (CBF domain #7) are critical for BHI sustainability by strengthening internal quality improvement and external reporting of progress. Our review consistently shows that anticipated health plan and payer costs from BHI start-up and continued operations are major barriers to its uptake and sustainability [14, 15]. Any potential financial benefits of BHI are not typically realized until populations are stabilized (~2 years) [14]. Although value-based and integrated care strategies may contribute to future cost savings, results are mixed for behavioral health [15, 16]. Additional challenges to the financial sustainability of BHI include care coordination activities that are frequently uncompensated [17]. In newer value-based payment models, the BH side of care lacks validated quality metrics that meaningfully capture the BH providers’ work and outcomes that demonstrate the value of the service [16], especially compared to traditionally medically-focused payers [18]. Critically, the data collection and analytic capacities needed to demonstrate the quantity and quality of services for financial sustainability are frequently out of reach for community behavioral health providers [19]. In Goldman et al.’s (2020) demonstration of the CBF, Management Support activities, were among the least likely components of the framework to advance after a year of participating in the project.

Technology Use Case: Reducing BHI costs through technology-facilitated systematic quality improvement. One company has developed an assessment and outcomes tool that includes risk screens to identify potentially high-cost patients. A proprietary scoring system based on tenets of measurement-based care and psychotherapy outcomes theory is used to screen and monitor patients’ behavioral health and to stratify patients according to the potential for high-cost care needs. In a study of 30 clinics, patients enrolled in this technology platform experienced improved clinical outcomes and decreased emergency department utilization by 34% in the 6-month period post-technology implementation, compared to patients receiving treatment as usual [20].

Provider experience, support, and the BHI workforce

Clinician well-being is key to the sustainability of the BHI workforce, its multidisciplinary teams, and the health system at large (CBF domain #6) [20]. Technology can reduce providers’ work burden by automating routine tasks (e.g. data entry), facilitating referrals, and expanding treatment options through decision support [21]. Delegating routine tasks to digital tools not only offers the opportunity for improved provider well-being but also greater overall organizational sustainability [21]. Among providers working with patients enrolled in a technology-enabled BHI program (including clinical decision support), improvements in BH outcomes were observed [20]. The integration of technology into practices is essential for provider support and efficiency.

Technology Use Case Example: Improving provider experience with decision support. One multispecialty medical group demonstrated how their multifunction EHR may improve the provider experience. Its functions include an EHR-linked screener (e.g. the Alcohol Use Disorders Identification Test) [22] that automatically prompts providers with best-practice advisory pop-ups to help them identify the next appropriate care steps. It also includes a Consult Behavioral Health Order function to engage behavioral health providers in care next steps, making use of the group’s primary care hybrid model (including an integrated behavioral health department to offer a full range of services) for remote consultation and in-person BH assessment support, triage, treatment planning, and delivery. The medical group also offers patients real-time support, consultative medication support, and access to brief, self-serve treatment interventions including app-enabled Cognitive Behavioral Therapy (breathing, mindfulness, and relaxation) and exposure therapies for phobias delivered via virtual reality platforms. These functions can help alleviate pressure on providers whose patients face the reality of waitlists for clinician-delivered BH care. While promising, there is a need for more rigorous evaluations of the impacts of these technologies on providers’ experience.

Equity considerations in clinical workflow

All CBF domains are important for increasing access to culturally and linguistically appropriate services. Racial-ethnic minorities, youth and older adults, people involved in the criminal justice system, LGBTQ+ populations, and people experiencing homelessness all have elevated rates of behavioral health morbidity and limited access to outpatient behavioral health services [23]. These inequities are perpetuated by a dearth of culturally and linguistically appropriate care, geographic variability (e.g. concentration in urban areas), and financial factors (e.g. cash-only services). For example, rates of outpatient mental health service use are more than twice as high for White (25.3 per 100 people) individuals than for Black (12.2 per 100) or Hispanic (11.4 per 100) individuals [24]. Furthermore, surveys of professional organizations consistently show low rates of racial-ethnic representation in the mental health professional workforce, thus limiting equitable access to culturally congruent care [25].

Technology Use Case: Improving equity through linkages to culturally paired community and social services. A “cultural experience company” partners with health insurers to identify members with low healthcare utilization and connect them with appropriate care. In their model, community health guides (CHGs) utilize a technology platform to collect a comprehensive picture of their member patients’ history, cultural background, and whole-person needs (i.e. general medical, behavioral health, and other social determinants of health) through a standardized discovery screen. The CHG acts as a healthcare navigator, connecting patients to priority services, and feeding back patient information to their centralized data system to inform future outreach. The CHG uses patients’ preferred communication channels (e.g. texting or email) and language to alert members of their health plan offerings that match the members’ needs. Preliminary data on this approach showed that their platform facilitated engagement with 38 342 National Medicare Advantage plan members who had not seen a doctor in 16–48 months, resulting in 33% of members having their Annual Wellness Visit within six months of initial engagement [25].

Discussion and Implications for Behavioral Health

Research findings from the literature review and use-case interviews suggested a complex relationship between technology and its role in expanding access to care. Building on the positive technological use cases highlighted above, here we explore the broader policy implications, emergent benefits, and remaining challenges to technology enhancements to BHI. which will require attention before many benefits can be realized on a large scale.

Care fragmentation and information exchange

Data showed that technology such as a customized EHR and warm handoff model provides the opportunity to improve provider communication and initiate efficient referral processes. This is consistent with previous research demonstrating that the use of such digital patient portals can reduce existing care silos through improved communication across specialties [26]. Of course, leveraging technology for clinical information exchange also entails privacy concerns that must be accounted for in implementation and practice.

The privacy and consent risk-benefit analysis practices for new technologies are well-documented [27]. These assessments include whether patients and providers have sufficient space and technological support for safe engagement in telehealth services within their home and community environments [28]. Additionally, they address concerns about the detailed nature of behavioral health assessments and data sharing among providers. For instance, technologies often analyze patient information to perform clinical functions like predicting risks or matching treatments. Interviewees highlighted products that use patient health data to identify individuals at behavioral health risks (case-finding), raising issues of patient awareness, and consent regarding such practices being incorporated into their health records. While sharing patient information is crucial for care coordination, the increasing complexity and comprehensiveness of data require careful evaluation of privacy and consent issues. Advances in health technology sometimes lead to the compilation and utilization of patient information without the patient fully understanding how their data is being employed [29].

Patient engagement and multidisciplinary teams

Technology has promise for improving patient communication and engagement in a bidirectional manner. Patients play a central role as multidisciplinary team members, and continued engagement is paramount for joint treatment decision-making, continued symptom monitoring, and ultimately improved patient outcomes (CBF domains #3 and #4).

The COVID-19 social distancing requirements opened up new avenues of patient communication and engagement, facilitated by increased patient openness to nontraditional or novel channels for engaging in care. As demonstrated in our use-case examples, some of these technologies are adaptable to a patient’s preference and specific needs, thus increasing the likelihood of prolonged and continued engagement. For example, one interviewee shared that people “grow attached” to applications that they regularly use, just as they do with devices themselves, allowing for continued engagement with technology-enabled care after peak pandemic restrictions. The implications of this are significant as technology has the potential to support a range of accessible ways in which patients and providers can communicate to organize, coordinate, and improve care engagement.

Accountability, payment models, and sustainability

Technology holds promise for advancing BHI by enhancing practices’ capacity in the CBF domain of Systematic Quality Improvement (#7). Findings are consistent with studies showing that technology has significant potential to automate data management, analytics, and reporting practices that can support quality improvement. Specifically, our case example showed that technology can facilitate case-finding for potentially high-cost patients and stratify them to appropriate BH care.

Yet the primary challenge facing BH practices now is ensuring consistent resource allocation to implement validated tools that integrate data automation into clinical and other routine operations. Previous research highlights gaps in process and outcome reporting, BH, that hinder effective BHI [24]. These gaps stem from limited infrastructure and workforce capacity for managing data and analytics, which directly impact practice site participation in federal and state grants that require clinical encounter tracking, calculations of remission, and other clinical improvements [16, 30]. Furthermore, the integration of these data for accountability and incentive payments is crucial for newer care and payment models.

Moreover, nonphysician and nonhospital settings, such as community mental health and substance abuse centers, have faced limitations under the HealthTech Act [31], hindering sustainable BHI implementation at these organizational levels. Policymakers must address these disparities in practice readiness for technology-driven system advancements like BHI. This can be achieved by strategically allocating resources to support practice sites in meeting foundational BHI requirements. Additionally, policymakers should leverage implementation science to guide practices in effectively adopting and utilizing technology [31].

Provider experience, support, and the BHI workforce

Much of the promise of novel technologies for BHI is in digital tools that can act as clinician extenders and help address workforce issues that limit BHI capacity. Technology can reduce providers’ work burden in myriad ways described above and shown in Table 1. Moreover, leadership delegating routine tasks to digital tools not only offers the opportunity for improved provider well-being but also greater overall organizational sustainability [21].

At the same time, the same workforce shortages that impact clinical care and complex practice management required for BHI (e.g. in terms of EHR management, quality monitoring, and reporting) also impact practices’ capacity to identify, implement, and sustain the use of BHI technology tools. Mental health professionals have been slower to adopt artificial intelligence, and implications from research are at least 3-fold: (i) at the individual level, professionals must value tools that retain a humanistic approach to care; (ii) at the organizational level, digital professionals and leaders must collaborate on funding structures and promote buy-in; and (iii), at the societal level, digital and mental health professionals should collaborate to create formal technology training programs specific to mental health to address knowledge gaps [32].

Equity considerations in clinical workflow

Health and behavioral health inequities are profound among certain sociodemographic groups and the results of this study suggest that technology has the potential to advance BHI practices that could improve equitable integrated care. Specifically, the case example in which a “cultural experience company” used technology to create linkages to culturally congruent community and social service providers is consistent with the emerging literature showing that BHI can remove human errors that might lead to prejudice or discrimination to improve equity in certain care processes such as case-finding, screening, and monitoring. Similarly, existing research supports digital communication among large and diverse patient populations, who may prefer such communication channels to traditional in-person care. For example, one recent systematic review demonstrated the high efficacy of artificial intelligence chatbots in smoking cessation, treatment or medication adherence, reduction of substance misuse, and promoting healthy lifestyles [33].

Simultaneously, while technologies have the potential to improve equity in BHI through increased access to customized forms of care, no single solution will resolve deep histories of discrimination and stigma entrenched in health systems. Technology tools must be developed with input and participation from diverse groups to ensure that technology does not further marginalize the very populations intended to serve, including older adults, people with cognitive impairments or physical disabilities, individuals facing financial barriers, and people with low technical literacy.

Policymakers must consider and address technology inequities at the level of practice organizations. Gaps between general medical, behavioral health, and social service technologies are well-documented [29, 34] and have impeded system interoperability efforts and BHI overall. Similarly, large health systems may have more capacity to implement and maintain new technologies while smaller, rural, and independent provider groups may not. Ensuring training for new staff in areas where turnover is high must also be planned for and supported. In short, while the findings from this study suggest that technology can increase access to and engagement in culturally appropriate, whole-person care, we urge those in charge of funding and implementing technology to consider supports and services to ensure that new technologies are available and accessible across users and communities to advance equity in BHI.

Conclusion

The technology solutions for advancing BHI described in this report offer early examples of how technologies can help resolve long-standing barriers to its broad and sustainable implementation. Overall, our findings underscore the need for rigorous research quantifying the structures needed to implement BHI technology, processes for optimal implementation and utilization, and the outcomes from both efficacy and effectiveness studies of the tools in use, especially. Empirical research is needed to identify high-value technologies that are worthy of widespread dissemination. Pre-planning and implementing knowledge mobilization and dissemination supports are needed as part of the health system, and practice improvements are needed to ensure that technology-supported changes to the healthcare system are evidence-based, patient-centric, and available to differently resourced provider organization types. Ultimately, technologies are tools to deliver person-centered care to the people who need it and develop systems that bolster equitable, continued patient engagement and quality and efficiency of care.

Acknowledgements

The authors report no financial relationships with commercial interests. The authors recognize Dr Henry Chung for helping to develop the framework on which this study was based and for his advisory contributions to the project.

Funding Sources

This study was supported by the Commonwealth Fund. Additional funding was provided by the Foundation for Opioid Response Efforts. The views presented here are those of the authors and do not necessarily reflect those of the Commonwealth Fund or the Foundation for Opioid Response Efforts or their directors, officers, or staff.

Conflict of interest statement. Dr. Harold Alan Pincus is employed by (all not-for-profit or public) Columbia University, New York State Office of Mental Health/Research Foundation for Mental Hygiene, and the RAND Corporation (Adjunct Staff). All research and training projects are funded by not-for-profit or public sources. He serves on the clinical advisory committees for AbleTo and is a consultant for the National Committee for Quality Assurance (NCQA).

Human Rights

This article does not contain any studies with human participants performed by any of the authors.

Informed Consent

This study does not involve human participants and informed consent was therefore not required.

Welfare of Animals

This study does not contain any studies with animals performed by any of the authors.

References