What is IBH (Integrated Behavioral Health) and Why Should It Matter to Family Physicians?

“How long is the wait to see a behavioral health provider?  3 MONTHS?!  What am I supposed to do for my child in the meantime?  He’s really suffering.”

     You work in primary care.  You get it.  Sadly, this scenario has become a common occurrence.  You are the trusted, local primary care provider.  For most people, your door is the first one people walk through when entering the U.S. health care system.  Whether it’s a sore throat, a follow-up visit for diabetes or a depressed mood, you are the point person ― the frontline health care worker.  While most of us in family medicine received some formal training in behavioral health conditions, once we stepped out of training and into our practices, many of us found ourselves ill-equipped to manage ― let alone triage ­― all the psychiatric and BH needs that present in primary care. 

     We knew that mental health was a part of primary care, but perhaps we did not anticipate the extent to which we would be needed to help patients navigate the complex health care system.  Sure, many of us would consider depression and anxiety, even ADHD, as bread-and-butter topics in family medicine.  Due to a multitude of factors, such as the global Covid pandemic, increased awareness of mental health conditions, etc., PCPs find themselves facing an increasing quantity and acuity of behavioral health concerns.

     This increase in demand for behavioral health services, combined with the severe shortage of BH providers in most communities, has created a behavioral health care crisis.  Many people, adults and children, cannot find access to mental health care, when and where they need it.  And the fallout can be devastating.  Unmet mental health needs contribute to decreased productivity at work, social isolation, increased risk of substance use/misuse, and increased risk of death by suicide. 

     Family physicians feel this strain on a regular basis.  Sitting with families and seeing their heartbreak when their loved one is suffering, and not being able to deliver the care they need or connect them to specialists who can help, is a terrible feeling.  The moral injury that providers feel when a patient’s mental health care needs go unmet is a major contributing factor to provider burnout.  According to recent data from the AMA, 40% of physicians are seriously considering leaving their current job in the next two years, https://www.ama-assn.org/practice-management/sustainability/40-doctors-eye-exits-what-can-organizations-do-keep-them

     So how do we overcome these bleak realities and sad statistics?  Ask the already overworked PCP to “do more”?  With the strain of productivity demands in fee-for-service models and documentation burden, how can we add more to their already overflowing plates? 

     Instead of demanding more from the individual clinician, we need to call on our health systems and legislators to equip us with additional tools and teammates to meet the needs of our patients. 

      Integrated Behavioral Health (IBH) is a team-based approach the treats the “whole person”, breaking down silos between physical health clinicians and behavioral health providers.  By dismantling these silos and working together, we can achieve better health outcomes, lower health care costs, and deliver a better care experience for our patients, and us, too.  IBH has many different models of care and payment mechanisms that can make this work financially sustainable. While IBH is a relatively “new” field, there is a strong evidence base for IBH models, such as PCBH (Primary Care Behavioral Health) and CoCM (Collaborative Care Model), https://integrationacademy.ahrq.gov/about/integrated-behavioral-health.  Despite the robust evidence, IBH has yet to see widespread adoption in the U.S. health care system.  Many academic centers and FQHCs are leading the way in implementing these innovative models and contributing research on how this succeeds in real world settings.  There is even an entire field of study devoted to this work: D and I Science: Dissemination and Implementation Science.   

     Now we need to focus efforts on bringing this research to the bedside, so that more family physicians can utilize these tools, and more patients can benefit from this integrated care.  The AAFP, along with seven other leading physician organizations, joined the AMA’s BHI Collaborative in 2021, to support the integration of behavioral health into medical practices.  But we still face very real barriers to IBH becoming mainstream, such as cost of implementation and scaling these efforts.  In a fee- for-service environment, time is money.  We need to prioritize IBH adoption and clearly define the value our time brings to our patients and our health systems. 

      As family physicians, we need to support legislation that builds integrated health care teams.  For example, ask your legislators to support Illinois House Bills 5045 and 5046 should they be reintroduced during the upcoming General Assembly session in 2025. These bills would appropriate funds from the General Revenue Fund to the Department of Public Health for Collaborative Care Demonstration Grants. We need to ensure strong mechanisms of payment for IBH care.  This will require advocacy and building partnerships with commercial payers and public insurers.

    With ongoing support, IBH models can become part of our everyday work.  Our legacy as medical clinicians is built on the premise of “know better; do better.”  Applying evidence-based findings to our everyday patient care is fundamental to our work as family physicians.  And working on an IBH team has certainly helped me.  I’ve had the pleasure of working with a BH Care Manager and a Consulting Psychiatrist in my family medicine practice for the past five years.  I can honestly say that working as part of this team has helped me rediscover my joy in practicing medicine and helped me build resilience to combat burnout.   If we can ensure that health care teams willing to reimagine primary care have the support they need, then our pilot IBH programs can take root and thrive.  Then we can envision primary care as the right place to start with a mental health concern.  If we truly embrace the value that mental health IS health, then we can deliver needed care to more people, when and where they need it.

 IAFP Board Member Jennifer Thomas, MD, FASAM is a family medicine and addiction medicine physician and Medical Director for Integrated Behavioral Health at Morris Hospital in Morris, IL. Dr. Thomas is a board member of the Illinois Society of Addiction Medicine and also serves as National Medical Co-Director for Integrated Care at CFHA, the Collaborative Family Healthcare Association. CFHA is a national, non-profit member organization supporting all health care professionals who believe in breaking down health care silos and supporting whole person health.