A practice-based implementation strategy bundle for integrating behavioral health in primary care: a matrixed multiple case study.

backgroundIntegrated behavioral health (IBH) is an evidence-based approach to addressing mental health in primary care settings. It typically involves augmenting a primary care team with a behavioral health professional (e.g., psychologist, licensed clinical social worker) who sees patients for brief, focused concerns; can function as a bridge to specialty care; and provides medical providers with support and education about patient behavioral health concerns. IBH has slowly begun to disseminate across the United States, but practices encounter significant implementation barriers. How IBH is implemented has not been systematically studied outside of trials, yet this study could provide a rich foundation for selecting and optimizing implementation strategies that can increase the speed of IBH scale-up.

methodsUsing rapid ethnographic assessment (REA), we conducted site visits, interviews, and surveys at a stratified sample of five primary care clinics in three different healthcare systems in two Midwestern states. We coded the data in a primarily deductive analysis approach using Stephens' IBH Cross-Model Framework (CMF) to characterize the IBH intervention; the Practical, Robust Implementation and Sustainability Model (PRISM) to characterize implementation barriers and facilitators; and the Expert Recommendations for Implementing Change (ERIC) taxonomy of implementation strategies. Using a matrixed multiple case study design, we identified implementation strategies that clinics found effective in implementing and sustaining IBH.

resultsDespite geographic variability, the clinics primarily served low-income and-resource populations. A strong pattern emerged regarding common IBH aspects targeted for internal implementation support, associated barriers, and strategies used for them. Successful implementation strategies included accessing additional funding for start-up, creating new clinical teams, revising professional roles, promoting adaptability, facilitating relay of data to clinical providers, and purposely reexamining the implementation process. The Normalization Process Theory (NPT) mechanisms of coherence, cognitive participation, collective action, and reflexive monitoring were all clearly identified in successful implementations. DISCUSSION: Implementation of IBH is an ongoing process of implementing, maintaining, and improving many specific processes. People with knowledge of the IBH practice model and desire to implement and sustain it are critical, as are policies and programs that support initial and ongoing implementation, and an organizational culture that embraces IBH as its standard of practice.