The Broward County Ryan White Part A Program (Broward County) identified a need to integrate primary care with behavioral health services, including linking clients to mental health and substance use services. This both connected clients to needed services and destigmatized mental health needs. Broward County trained providers on trauma-informed care, and modified contracts and standards of care to require that medical providers conduct mental health screenings. The intervention seeks to increase the percent of clients who are linked to mental health treatment, retained in care, and virally suppressed.
Fort Lauderdale, FL
Behavioral health services are a common need among people with HIV and were identified as a priority by the Broward County HIV Health Services Planning Council. Additionally, there was historically an underutilization of mental health services across the jurisdiction.
Broward County funds six providers for HIV medical care and disease case management, who are expected to see clients at least twice a year. The standards of care were modified to require providers to conduct a behavioral health assessment at each of these visits, using the Patient Health Questionnaire – 9 (PHQ-9).
Medical providers were required to have mental health services available either on-site or through a partnership with a mental health provider, and were expected to do a handoff to mental health services after a positive screening.
All providers were trained to deliver trauma-informed medical and mental health care. This training, described in greater detail below, was developed using the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Concept of Trauma and Guidance for Trauma-Informed Approach and involved a two-day training by an outside consultant.
From 2017–2019, Broward County evaluated the impact of the intervention.
| Category | Information |
|---|---|
| Evaluation data | Client care data, annual client satisfaction surveys |
| Measures | Number and percent of clients:
|
| Results | From 2017 to 2019:
|
Source: Communication with the Best Practices Compilation team. 2020–2021.
“The bigger thing with mental health services is the stigma around it. So, we're also trying to normalize having a behavioral health assessment and just being connected automatically to a mental health specialist, just like you would for any other comorbidity.”
- Readiness assessment. At the beginning of the project, Broward County worked with each medical and case management provider to assess the capacity for integrating behavioral health into their medical practices. Some sites already had on-site services while others had to hire staff and modify their internal structure to set up for the intervention. Overall, the initial level of effort was moderate as most providers already offered behavioral health services within their organization. This meant that the main changes were to workflow to align with the new service delivery requirements.
- Staff training. Broward County engaged outside consultants to deliver trainings for providers and all staff involved in the IPCBH program. The first day of training included an overview of integrated care and the expectations of the program. The second day focused on the behavioral health assessment, how to use it, and a workshop with providers to plan for implementation.
- Revised standards of care. Provider contracts with the jurisdiction's standards of care were modified to reflect the integrated care requirement, including a requirement for a documented PHQ-9 assessment with each medical visit. Broward County added guidance on how to bill for services like the assessment.
- Referrals for mental health services. Separately, Broward County also funds two mental health providers for clients who need a more intensive level of care. Medical providers are expected to refer to these outside agencies as needed.
Photo Source: HRSA Ryan White HIV/AIDS Program Photo Library
- Broward County continues to support their medical providers with ongoing training and management, including regular meetings and annual service reviews. The IPCBH, mental health, and substance use treatment providers initially met monthly for one year and after the first year transitioned to meeting quarterly. Broward County also completed site visits with each provider after one year to walk through their care delivery process.
- Some providers who applied for the county's mental health funding before the intervention now only apply for medical funding because they can bill behavioral health under IPCBH. This approach normalizes access to mental health through primary care. However, more intensive services are available through the mental health funding category, meaning the providers who no longer access this funding may not have as comprehensive services available.
- The timeline for implementation was ambitious; the initial phase of training providers and editing contracts to align with the new service delivery structure was around eight months before providers started to deliver the service. A more detailed timeline and plan for implementation would have been useful, including planning for changes to the Client Management Information System, evaluation, and to address any implementation issues.
- The evaluation component was not planned ahead of time, and once the project began, the jurisdiction had to focus on service delivery and had challenges modifying their data system to support evaluation.
- Medical providers were initially expected to hand off clients to mental health services on the same day or within 24 hours of the appointment. This proved to be unrealistic, in part due to client schedules, so the expectation was modified to have an appointment made within 24 hours instead.
- This program has been challenging for providers who were doing behavioral health both through IPCBH and standalone mental health services, particularly because of how screenings and services need to be billed. Providers who are considering integrating care might benefit from keeping mental health services (i.e., therapy, substance use services) separate and unchanged to differentiate these services more clearly from the assessment and linkage piece under IPCBH.
- Broward County had initially allowed some flexibility to use the PHQ-9 or PHQ-2 assessment, but found that having one required assessment allowed for standardization.
“Going back, I think it would have been better to change just our medical standard of care…that we follow an integrated model and we still funded mental health separately.”
- A Standard Framework for Levels of Integrated Healthcare
- The PHQ-9
- Building a Trauma-Informed Approach to Integrating HIV Primary Care and Behavioral Health Services presentation from the 2018 National Ryan White Conference on HIV Care and Treatment
- SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach
