The Medical Home and IntegratedBehavioral Health: Advancing the PolicyAgendaJeremy Ader, ABa, Christopher J. Stille, MD, MPHb, David Keller, MDb, Benjamin F. Miller, PsyDb, Michael S. Barr, MD, MBAc,James M. Perrin, MDd

abstractThere has been a considerable expansion of the patient-centered medicalhome model of primary care delivery, in an effort to reduce health care costsand to improve patient experience and population health. To attain thesegoals, it is essential to integrate behavioral health services into the patient-centered medical home, because behavioral health problems often firstpresent in the primary care setting, and they significantly affect physicalhealth. At the 2013 Patient-Centered Medical Home Research Conference, anexpert workgroup convened to determine policy recommendations topromote the integration of primary care and behavioral health. In this articlewe present these recommendations: Build demonstration projects to testexisting approaches of integration, develop interdisciplinary trainingprograms to support members of the integrated care team, implementpopulation-based strategies to improve behavioral health, eliminatebehavioral health carve-outs and test innovative payment models, and developpopulation-based measures to evaluate integration.

Primary care is in the midst ofa substantial redesign. This effort totransform the “largest platform ofhealthcare delivery” into patient-centered medical homes (PCMHs) isbuilt around the determination toreduce the cost of health care and toimprove the experience of the patientand the health of the population.1 Tofully achieve these “Triple Aim” goals,the PCMH must be equipped todiagnose, treat, and manage bothphysical and behavioral healthconcerns, which often first present inthe primary care setting. For thepurpose of this article, we use the termbehavioral health to include bothmental health and substance use.

In May 2013, the Society of GeneralInternal Medicine, the Society ofTeachers of Family Medicine, and theAcademic Pediatric Association, inpartnership with the Agency forHealthcare Research and Quality

(AHRQ), the Veterans HealthAdministration, the US Department ofVeterans Affairs, and theCommonwealth Fund hosteda conference to discuss and update theevidence around the PCMH and todetermine policy-relevant strategies toadvance the model. At this conference,1 of 5 expert workgroups sought todetermine research and policypriorities regarding the integration ofbehavioral health and primary care.These priorities served as the basis forthe recommendations outlined in thisarticle. The workgroup consisted ofresearchers, policymakers, a family andpatient advocate, and primary care andbehavioral health clinicians.

Across the United States, an estimated26.2% of people over the age of 18 livewith a behavioral health disorder,which often goes undiagnosed oruntreated.2 Given that those withbehavioral health issues often first

aYale School of Medicine, New Haven, Connecticut;bUniversity of Colorado School of Medicine, Aurora,Colorado; cNational Committee for Quality Assurance,Washington, District of Columbia; and dHarvard MedicalSchool, Boston, Massachusetts

Mr Ader drafted the initial manuscript, oversawdiscussions of comments and edits, andincorporated edits into the manuscript; Drs Stille,Keller, Barr, Miller, and Perrin provided significantcontributions to the discussions that led to theinitial manuscript, reviewed the manuscriptthroughout its development, and offered substantialcomments and edits; and all authors approved themanuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-3941

DOI: 10.1542/peds.2014-3941

Accepted for publication Jan 30, 2015

Address correspondence to Jeremy Ader, AB, YaleSchool of Medicine, 129 York Street, 2M, New Haven,CT 06511. E-mail: jeremy.ader@yale.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,1098-4275).

Copyright © 2015 by the American Academy ofPediatrics

FINANCIAL DISCLOSURE: The authors have indicatedthey have no financial relationships relevant to thisarticle to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: Dr Barr is theexecutive vice president of the Quality, Measurement& Research Group at the National Committee forQuality Assurance; the other authors have indicatedthey have no potential conflicts of interest todisclose.

COMPANION PAPER: A companion to this article canbe found on page 930, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2015-0748.

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present to the health care systemwith physical symptoms, primarycare clinicians have a uniqueopportunity to recognize and treatthese problems early on.3

Additionally, behavioral healthproblems are common among peopleliving with multiple chronicconditions and can significantly affectphysical health.4 The PCMH modelhas typically focused on the care ofpatients with chronic medicalconditions. However, with access toadequate resources and expertise, thePCMH model can be better equippedto provide basic physical andbehavioral health care that is morecomprehensive and seamlesslyintegrated.5–7

PCMH models that incorporatebehavioral health services areincreasing in number.8,9 Thesemodels, though often implementeddifferently, may be classified into 3groups based on the type ofbehavioral health integration:coordinated, colocated, and fullyintegrated. In coordinatedapproaches, primary care physiciansand behavioral health specialistspractice in separate facilities andwork together, often via telephone,e-mail, or other online services toprovide care.3 In the MassachusettsChild Psychiatry Access Project, forexample, primary care clinicians areable to call a regional team ofbehavioral health specialists, whichtypically includes a psychiatrist,a case manager, and a social worker,to make diagnostic referrals and toreceive psychopharmacy support andtreatment advice.10 Similar programsare now being implemented in .30states.11 The colocation approachesare more advanced forms ofaddressing behavioral health(eg, referring out for behavioral health),in which the primary care provider andbehavioral health specialist practicewithin the same facility and worktogether to varying degrees toaddress patient needs. Referrals maystill be used, but they are in houserather than out of house. In the

Washtenaw Community HealthOrganization, for example, cliniciansfrom the community mental healthcenter are placed within primary carepractices and see referred patients.3

Finally, in integrated approaches,behavioral health specialists operatewithin the primary care system andare a regular part of primary caredelivery and treatment. In addition toseeing specific patients, behavioralhealth clinicians have a major role inadvising, consulting, and teachingprimary care physicians, althoughthese roles are rarely reimbursed. Inthe Buncombe County Health Centerin North Carolina, behavioral healthspecialists use the primary caremedical record system and facilitiesand practice as part of the primarycare team to both advise the team andprovide direct treatment.3

Additionally, a recent trial found thatpediatric practices that used theDoctors Office Collaborative Caremodel to improve collaborationbetween care managers andpediatricians to address behavioralhealth problems achieved improvedbehavioral health outcomes.12

Because of its ability to see morepatients and have services moreavailable in the moment of need, theintegrated approach is often morewhole-person focused and is bestpositioned to facilitate coordination,intervene early, and providetreatments for a wide range ofbehavioral and physical healthproblems.13–17 However, there aresignificant challenges to thisapproach.18,19 Seamless integrationdemands a complete system redesign,including the blending of separatepractice cultures, shared medicalrecords, introduction of newworkflows, an integrated, team-basedapproach to treatment, andconsideration of availablereimbursement options.3,20 Forpractices that are not yet ready totake these steps or are not supportedby an appropriate reimbursementsystem, the initial steps to coordinateor colocate behavioral health can

serve as progressive stepping-stones.21–23

Although the evidence base for thecoordinated approach is limited,screening patients for behavioralhealth problems and providing briefinterventions in consultation withremote behavioral health specialistshas the potential to improvebehavioral health care.24

Coordination may be an attractivefirst step toward integration,although reimbursement fortelehealth services remains a barrier,and the approach requires primarycare clinicians to develop strongrelationships with behavioral healthspecialists.3 To advance thisapproach, practices and policymakerscan look to the National Committeefor Quality Assurance (NCQA)Patient-Centered Specialty PracticeRecognition Program, which calls forformal agreements between practicesand clinicians to help facilitatecoordination between primary careand specialty or subspecialtypractices.25

The colocation approach, on the otherhand, has a much greater evidencebase. By practicing in the same place,behavioral health specialists andprimary care clinicians cancommunicate more often and moreeffectively.3 Furthermore, thisapproach allows warm handoffs, inwhich the primary care providerphysically introduces patients to thebehavioral health care provider,reducing stigma and improvingtreatment intiation.12,26–27 However,although they practice in the samelocation, there remain limitations tocolocation because behavioral healthand primary care may still operate inseparate systems with differentmedical records, appointmentprocedures, and reimbursementprocesses. Although colocation maynot be as effective as full integration,it has demonstrated numerous healthand cost benefits and may be the bestoption for practices that are not yetprepared, or do not have access to an

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appropriate reimbursement system,to transition to an integratedapproach.3

Although there are a variety of waysto integrate behavioral health intoprimary care, the 3 approachesoutlined here are well suited tosupport successful behavioral healthintegration. Evidence suggests thatthe fully integrated model providesthe greatest potential to improvebehavioral health care, but eachapproach ultimately providesa structure for the inclusion ofbehavioral health care teams,population-based practices, shareddecision-making, and other essentialelements of behavioral healthintegration.

For PCMH models to deliver high-quality behavioral health care to thepediatric population, a number ofunique considerations must beaddressed. First, pediatric behavioralhealth care requires a particularlystrong focus on prevention, especiallygiven that so many adult behavioralhealth problems originate inchildhood or adolescence.28 Second,prevention and treatment ofchildhood and adolescent behavioralhealth problems demand highlyengaged teamwork with the family orcaregiver, as well as the educationsector.29,30 Last, the publicadministration and funding ofpediatric behavioral health is highlycomplex and often fails to adequatelyserve certain populations, such aschildren in preschool.31

Although gaps in knowledge remain,the current evidence base presentsimportant opportunities toimplement specific policy actions toadvance behavioral healthintegration.32 In March 2014, 6 familymedicine associations published a setof joint principles calling for theintegration of behavioral health intothe PCMH, and 8 additional leadinghealth care associations also recentlyendorsed behavioral health andprimary care integration.20,33 Inthe following paragraphs we present

5 policy recommendations to improvethe delivery and expand the stateof knowledge of integrated behavioralhealth and primary care. Theseactions are designed to support thedevelopment of approaches ofintegration, the care team,population-based practices, andpayment and evaluation systems(Table 1).

TEST SELECTED APPROACHES OFBEHAVIORAL HEALTH AND PCMHINTEGRATION THROUGHDEMONSTRATION PROJECTS ANDEVALUATE USING A COMMONCONCEPTUAL FRAMEWORK

The current evidence shows thepotential of a number of integratedapproaches to improve physical andbehavioral health, and well-fundeddemonstration projects can now helpscale and evaluate these approaches.To assess the generalizability ofspecific approaches, it will beimportant to implement thesedemonstration projects in a variety oflocations and practice types.However, participating practices mustdemonstrate that they are preparedand well-equipped to transition toa given approach. Furthermore, theremust be standardized assessments todetermine whether integration istruly taking place. These standardizedassessments should use measuresfrom the NCQA PCMH criteria34,35

and the AHRQ Integrated BehavioralHealth Care Measure Atlas(Table 2).36

Evaluation of these demonstrationprojects must involve rapid cycleassessments that providepolicymakers with key informationneeded to continuously improve thedemonstration projects. Additionally,all evaluations must be based on thecommon conceptual frameworkoutlined in the Lexicon for BehavioralHealth and Primary CareIntegration.37 There are a range ofterms related to the integrated PCMHthat are often used inconsistently andambiguously. For example, the termbehavioral health has been usedinterchangeably with the term mentalhealth, and terms used to describedifferent integrated PCMHapproaches can also be ambiguous.The definitional framework outlinedin the lexicon aims to providea universal vocabulary to increase theclarity and productivity ofconversations and thereby acceleratethe progress of behavioral healthintegration.

IDENTIFY CRITICAL MEMBERS OFINTEGRATED PCMH TEAMS THAT ARENECESSARY TO IMPLEMENT BESTPRACTICES AND DEVELOPINTERDISCIPLINARY PROFESSIONALTRAINING PROGRAMS FOR ALL TEAMMEMBERS

Integrated behavioral healthtreatment in the PCMH often involvesa team of professionals who worktogether to provide and coordinatecare. Although this team may includea range of professionals, the patientand the family or caregiver mustalways be the central membersbecause behavioral health is heavilyinfluenced by family and personalcircumstances. Families andcaregivers also provide a number ofkey roles in patient treatment,assisting in developing shared careplans, supporting patient self-management, and addressing socialdeterminants of health.38,39 Patients,families or caregivers, researchers,

TABLE 1 Policy Recommendations to Improvethe Integration of Behavioral Healthand Primary Care

1 Build demonstration projects to testexisting approaches; evaluateusing common conceptual framework

2 Develop interdisciplinary trainingprograms to support criticalmembers of the care team

3 Implement strategies to improvepopulation health; strengthenrelationships between primarycare practices and communityresources

4 Eliminate carve-outs; align innovativepayment models with demonstrationprojects

5 Develop population-based measuresto evaluate behavioral health integration

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and policymakers must worktogether to establish the optimal rolesfor patients and families or caregiversand to determine how they mightchange under various circumstances.For example, how does the role of thepatient change as he or shetransitions from adolescence toadulthood? Patients, families orcaregivers, and policymakers mustalso work together to developeffective engagement strategies, tools,and support structures to implementstrategies found to be most effective.

In addition to the patient and familyor caregiver, the integrated PCMHcare team often includes a behavioralhealth specialist, a primary careclinician, and a care manager, anda number of additional roles mayexist. The different team memberscarry out various roles, includingassistance with self-management,coordination of care, and facilitationof access to preventive services andcommunity resources.40 However,more research is needed to helpdetermine the essential range ofresponsibilities and personnel

necessary to create high-functioning,integrated teams. For example,evaluation of the Veterans AffairsCollaborative Care for Depressionmodels has demonstrated theimportance of the depression caremanager in managing treatments andcoordinating care between primarycare clinicians and behavioral healthspecialists.41 Additionally, it isimportant to determine the ideal sizeof the team. Although a larger teammay offer more perspectives andareas of expertise, it also createsmore opportunities forcommunication errors andmisunderstanding of roles.42 Last,a number of workflow andcommunication challenges must beaddressed. For example, if differentmembers of the team are responsiblefor different domains of care, how dothey communicate care developmentsto one another quickly andeffectively? Additional research mustdetermine the best ways for differentmembers of the care team to worktogether and with the patient andfamily or caregiver to provide care

that is as streamlined andcoordinated as possible.

For the lessons from this research tobe put into practice, there must beinterdisciplinary training andretraining opportunities throughouteach team member’s professionaleducation and career. Whether ina classroom or in a practice-basedenvironment, team-based trainingwill allow care members to betterunderstand each other’s roles andlearn how to address workflowproblems that may arise. In 2011,a number of health professioneducation associations came togetherthrough the InterprofessionalEducational Collaborative to setstandards for interdisciplinarylearning.43 This collaboration offersa promising framework to developthese trainings, although involvementof behavioral health associations,which was not seen in the 2011collaborative report, is essential asthese standards develop.42,43 To bestfoster teamwork, these trainingsshould encourage clear definition ofteam roles, shared decision-making

TABLE 2 Sample Standards From the 2014 NCQA PCMH Recognition Program35 and the AHRQ Integrated Behavioral Health Care Measure Atlas36

2014 NCQA PCMH Recognition Program

Standard, Element, and Factor Factor Text

Standard 2: Team-Based Care The practice has a process for informing patients/families about the role of themedical home and gives patients/families materials that contain the following information:

Element B: Medical Home Responsibilities The practice is responsible for coordinating patient care across multiple settings.Factor 1 Explanation: The practice coordinates care across settings (ie, specialists, hospitals,

rehab centers and other facilities), including for behavioral health.Standard 2: Team-Based Care The practice uses a team to provide a range of patient care services by:Element D: The Practice Team Training and assigning members of the care team to support patients/families/caregivers

in self-management, self-efficacy and behavior change.Factor 6Standard 5: Care Coordination & Care Transitions The practice:Element B: Referral Tracking & Follow-Up Maintains agreements with behavioral health care providers.Factors 3 and 4 Integrates behavioral health care providers within the practice site.

AHRQ Integrated Behavioral Health Care Measure Atlas

Core Measure Relevant SubmeasuresC4. Consumer Assessment of Healthcare Providers and

Systems: Clinician & Group Measurese. Provider’s (doctor’s) attention to your child’s growth and developmentf. Patient-centered medical home items set1. Providers pay attention to your mental or emotional health (adult only)

C6. Level of Integration Measure 3. The BHSs share access to the electronic medical record/patient chart with the PCPs.17. PCPs and BHSs do warm handoffs according to patient needs.21. PCPs and BHSs collaborate in making decisions about mutual patients in the clinic.

C9. Young Adult Health Care Survey Measures 15. In the last 12 mo, did you and a doctor or other health provider talk about whetheryou ever felt sad or hopeless almost every day?

24. In the last 12 mo, did you and a doctor or other health provider talk about alcohol use?

BHS, behavioral health service; PCP, primary care provider.

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and accountability in patient care,and opportunities for teamdebriefing. To measure the impact ofthese training programs, evaluationsmay assess clinician turnover andsatisfaction, a variety of careprocesses, team communication, andpatient outcomes.42 Last, thesetrainings must integrate patients andfamilies or caregivers as well aspossible, so that in addition toreceiving training themselves,patients and families or caregiverscan teach students and clinicians howto best engage future patients andfamilies or caregivers in the team.

IMPROVE POPULATION HEALTH BYIMPLEMENTING POPULATION-BASEDPRACTICES AND ESTABLISHINGLINKAGES WITH COMMUNITYRESOURCES

There are a number of steps thatapproaches across the spectrum ofintegration can take to addresspopulation health. The AmericanAcademy of Pediatrics Taskforce onMental Health recommends thatprimary care clinicians ask patients 2or 3 questions about functioning atevery visit to identify children withbehavioral health problems. Childrenwho are at risk for certain conditionscan receive preventive services, suchas home visits, in which clinicianswork with families to address socialdeterminants.44 Children identifiedwith behavioral health conditions canreceive evidence-based, cost-effectivetherapies such as psychosocial,behavioral, and family-basedinterventions, with the goal ofpreventing serious problems beforethey develop fully.45 For adults, primarycare practices use a practice known asscreening and brief intervention toquickly screen for depression by usingthe standardized Patient HealthQuestionnaire and then provide briefevidence-based treatments.3

Most existing research evaluatesdisease-specific treatments in well-defined, specific populations(eg, depression treatment for older

adults).40 However, the PCMH mustbe able to provide treatments that areeffective across a wide range ofconditions and populations. Forexample, the Common Factorsapproach developed by Wissowet al46 demonstrates the potential ofprimary care approaches to benefita range of patients who may havesimilar symptoms but are not definedby a specific diagnosis. Additionalresearch is needed to identify moretreatments that can be similarlyapplied across a broad population ofpatients. Furthermore, it is importantto determine how these differentnon–disease-specific treatmentsmight be integrated within thevarious PCMH approaches.

Next, there is great potential forbehavioral health providers tocontribute to patients’ physicalhealth, beyond providing treatmentsfor specific behavioral healthproblems. For example, medicalproblems are often influenced bypsychosocial problems, and effectivetreatments may involve behavioralchanges to address diet, exercise, andtobacco or other substance use.40 Wemust determine whether behavioralhealth providers, through practicessuch as motivational interviewing andcognitive behavioral therapy, canaddress these issues and improveoverall health outcomes.17

It will also be important to integratebehavioral health metrics intocondition-specific programs typicallyaddressing chronic health careproblems. Condition-specificprograms have demonstrated use ofmetrics to drive improvement of care.For example, diabetes programs trackthe health of their patients throughfrequent hemoglobin A1Cmeasurements, and coronary arterydisease programs carefully monitortheir patients’ blood pressure. Giventhe prevalence of behavioral healthproblems among people with chronicconditions, there is an opportunity forthese programs to measure andaddress process and outcome metrics

for behavioral health (eg, percentageof patients with behavioral healthproblems identified, percentagetreated).4,21 It will be important todetermine whether clinicians incondition-specific programs can usethese measures alongside those forchronic conditions to identify, refer,and treat patients with behavioralhealth problems and to improveoverall population health.

Last, to support behavioral healthinterventions on a population-basedlevel, PCMH models must forge strongrelationships with communityresources.47 For example, thereshould be significant collaborationbetween the juvenile justice andadolescent behavioral health systemsand between schools and pediatricpractices. Such relationships offer thepotential for the primary care andbehavioral health systems to worktogether with community resourcesto identify patients with behavioralhealth problems and to help managetreatments. In addition to developingrelationships with the justice systemand with schools, the integratedPCMH could form connections withworkplace wellness and employeeassistance programs. Suchrelationships could be very valuablein improving the treatment andreducing the prevalence of behavioralhealth problems across thepopulation. Furthermore, they couldhave tremendous value to theeducation system, justice system, andworkplace.47 It will thus be veryimportant to determine whichadditional community resourceswould best support the PCMH, toidentify best practices in establishingthese linkages, and finally to evaluatethe impact of such relationships onsociety as a whole.

ELIMINATE BEHAVIORAL HEALTH CARVE-OUTS AND ALIGN AND TEST INNOVATIVEPAYMENT STRATEGIES WITHINTEGRATED APPROACHES

The administration of physical andbehavioral health is often based in

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multiple state agencies, whichcomplicates coordinated state actionon issues ranging from theelimination of carve-outs to thepromotion of innovative paymentsystems. To ensure coordinatedaction to improve health and advanceinnovations, state governmentsshould consolidate physical andmental health agencies, as wasrecently completed in California.States that are unable to take this stepshould consider consolidating keyadministrative roles, such asbehavioral and physical healthpayment administration. Finally, evenbefore states take these steps,Medicaid agencies around thecountry, which account for 26% ofbehavioral health care spending, havean important opportunity to take thelead in eliminating mental healthcarve-outs by integrating behavioraland physical health payments.48

The widespread presence ofbehavioral health carve-outs, theadministration of behavioral healthreimbursements throughindependent payment systems, hassignificantly impeded the delivery ofintegrated behavioral health care.Because of carve-outs, primary careclinicians often are not reimbursedfor mental health diagnoses and areunable to bring onsite behavioralhealth clinicians.19,49 This lack ofreimbursement severely limitsprimary care clinicians’ ability toprovide prevention and earlytreatment, and as a result, conditionsare identified at a much later, moredifficult to treat point in the course ofthe illness. A number of studies havedemonstrated how carve-outs lead tofragmented and uncoordinatedcare.19,48,50–53 To ensure that allpatients benefit from the integratedPCMH, carve-outs must be eliminated,and care for both behavioral andphysical problems must beadequately reimbursed.

Across the country a number ofpayment models are being developed,which specifically aim to increase the

integration of behavioral health andprimary care. In Massachusetts, forexample, Medicaid has started toprovide bundled payments fora specific set of behavioral healthand primary care services.54 InColorado, there are progressivepilots and Medicaid programsthat use alternative paymentmethods to better support primarycare and behavioral health.49 Thisbreadth of innovation offers animportant opportunity to pilotvarious payment strategies as partof integrated demonstrationprojects.

To fully support integration ofbehavioral health and primary care,these payment strategies mustaddress a number of key issues.First, payment systems mustencourage coordination of carebetween primary care andbehavioral health and must supportall members of the care team. In theshort-term, this need could beaddressed through billingmechanisms that support warmhandoffs or through per-member-per-month care coordinationinfrastructure payments, which area key part of many PCMHdemonstration projects.26,27 Next,payment changes must help achievetrue behavioral health parity, suchthat patients have access toappropriate behavioral healthservices when they need them. Thiswill require the elimination offinancial barriers to appropriatebehavioral health services and theremoval of other payment featuresthat restrict patient choice ofservices. Last, for the integratedPCMH to successfully achieve the keygoal of the PCMH, it must improvethe physical and behavioral health ofthe population. This integrationmight be achieved through paymentsystems that consider keyperformance metrics and account fordifferences in patients’ baselinehealth statuses. Policymakers mustdetermine the ability of existingmodels to achieve these goals and

develop innovative payment designswhere there are opportunities forimprovement.

DEVELOP A NEW GENERATION OFMEASURES THAT ARE POPULATION-FOCUSED AND ATTUNED TO DETECTINGTHE SOCIETAL IMPACT OF BEHAVIORALHEALTH INTEGRATION

Currently, both the administration ofthe Children’s Health InsuranceProgram Reauthorization Act and theNational Quality Forum publish a setof measures of behavioral health,which are rigorous and widelyused.55,56 However, largely because ofthe low prevalence of specificconditions in the population, thesemeasures do not adequately capturehealth on a population level. Themeasures tend to focus on specificdisease states rather than overallhealth and on process rather thanoutcomes. To effectively evaluate theimpact of the PCMH on populationhealth, researchers must developoutcome measures that reflect globalmeasures of wellness and take intoaccount entire, non–disease-specificpatient populations. These newmeasures should involve data thatcan be generated as a normalconsequence of clinicaldocumentation and should notrequire any additional coding or datainput by members of the clinicalteam. Additionally, measures mustaddress the uniqueness of integratedbehavioral health and assess theinvolvement of different members ofthe care team and the family orcaregiver in patient care. Toincorporate these elements and toensure comparability, these measurescould build off the frameworksestablished in the NCQA PCMHcriteria and AHRQ IntegratedBehavioral Health Care MeasureAtlas.35,36

Given the potential of the PCMH toaffect numerous aspects of patients’and families’ lives, measures toevaluate the impact of the PCMH onoutcomes distal to the health care

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process are needed. For example, byimproving treatment andmanagement of behavioral health andphysical health issues, the PCMH mayhelp increase productivity at workand reduce sick days. Similarly,improved pediatric behavioral andphysical health could improvechildren’s ability to learn while inschool and reduce sick days fromschool. Such a reduction in missedschool days could reduce the numberof days parents take off work to carefor their children. To capture thesepotential societal benefits, newmeasures must be created that reflecta comprehensive notion of populationhealth and that use data from thevarious sectors that the PCMH mightaffect. The World Health OrganizationInternational Classification ofFunctioning, Disability and Healthincludes a number of standardizedmeasures of health and offers an idealframework for the development ofthese measures.57 Finally, given thepotential for the PCMH to have long-term societal impacts, especiallyamong the pediatric population, thesemeasurements must be part ofstudies that track patients over longperiods of time, using a standardizedframework, such as the InternationalClassification of Functioning,Disability and Health, to maximizecomparability.

CONCLUSIONS

The widespread innovation that istaking place to improve theintegration of behavioral health andprimary care offers an importantopportunity to advance policies tospread successful practices and tosupport progress. To take advantageof this opportunity, we offer 5recommendations. First, there mustbe well-funded demonstrationprojects to scale and evaluate themost promising approaches ofbehavioral health integration. Second,we must identify best practices forthe care team and developinterdisciplinary training systems tosupport each member. Third, we must

focus on improving population-levelbehavioral health by identifying andsupporting key practices andstrengthening linkages withcommunity resources. Fourth, wemust eliminate behavioral healthcarve-outs and identify and developpayment designs to encourageintegration. Fifth, we must developnew measures to better evaluate theimpact of the PCMH on populationhealth and society as a whole. Webelieve these recommendations willexpand the state of knowledge aboutthe PCMH and will improve thedelivery of high-quality, population-focused, integrated care.

ACKNOWLEDGMENTS

This paper was developed from the2013 Research Conference, hosted bythe Society of General InternalMedicine, the Society of Teachers ofFamily Medicine and the AcademicPediatric Association, and inpartnership with the Agency forHealthcare Research and Quality, theVeterans Health Administration, USDepartment of Veterans Affairs andthe Commonwealth Fund. The viewsexpressed in the article do notnecessarily reflect the policies orpositions of the organizations withwhich the conference or the authorsare associated.

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