title: Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care.
abstract: OBJECTIVE
  This study sought to describe features of the physical space in which practices integrating primary care and behavioral health care work and to identify the arrangements that enable integration of care.
  
  
  METHODS
  We conducted an observational study of 19 diverse practices located across the United States. Practice-level data included field notes from 2-4-day site visits, transcripts from semistructured interviews with clinicians and clinical staff, online implementation diary posts, and facility photographs. A multidisciplinary team used a 4-stage, systematic approach to analyze data and identify how physical layout enabled the work of integrated care teams.
  
  
  RESULTS
  Two dominant spatial layouts emerged across practices: type-1 layouts were characterized by having primary care clinicians (PCCs) and behavioral health clinicians (BHCs) located in separate work areas, and type-2 layouts had BHCs and PCCs sharing work space. We describe these layouts and the influence they have on situational awareness, interprofessional "bumpability," and opportunities for on-the-fly communication. We observed BHCs and PCCs engaging in more face-to-face methods for coordinating integrated care for patients in type 2 layouts (41.5% of observed encounters vs 11.7%; P < .05). We show that practices needed to strike a balance between professional proximity and private work areas to accomplish job tasks. Private workspace was needed for focused work, to see patients, and for consults between clinicians and clinical staff. We describe the ways practices modified and built new space and provide 2 recommended layouts for practices integrating care based on study findings.
  
  
  CONCLUSIONS
  Physical layout and positioning of professionals' workspace is an important consideration in practices implementing integrated care. Clinicians, researchers, and health-care administrators are encouraged to consider the role of professional proximity and private working space when creating new facilities or redesigning existing space to foster delivery of integrated behavioral health and primary care.
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.) gunnr@ohsu.edu.
authors.forename: Rose
authors.initials: R
authors.lastname: Gunn
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Melinda M
authors.initials: MM
authors.lastname: Davis
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hall
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: John
authors.initials: J
authors.lastname: Heintzman
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: John
authors.initials: J
authors.lastname: Muench
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Brianna
authors.initials: B
authors.lastname: Smeds
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Benjamin F
authors.initials: BF
authors.lastname: Miller
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: William L
authors.initials: WL
authors.lastname: Miller
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Emma
authors.initials: E
authors.lastname: Gilchrist
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Shandra
authors.initials: S
authors.lastname: Brown Levey
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Brown
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Pam
authors.initials: P
authors.lastname: Wise Romero
authors.affiliation: From the Department of Family Medicine, Oregon Health & Science University, Portland (R.G., M.D., J.Ha., J.He., J.M., D.J.C.); Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland (M.D.); PKA Architects, P.C., Portland, OR (M.D., B.S.); Department of Family Medicine, University of Colorado School of Medicine, Aurora (B.F.M., E.G., S.B.L.); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (W.L.M.); Southeast Mental Health Group, La Junta, CO (J.B.); Axis Health Systems, Durango, CO (P.W.R.); Department of Medical Informatics and Clinical Epidemiology, Oregon Health &; Science University, Portland (D.J.C.).
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D003156:Community Mental Health Services / Q000458:organization & administration*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005160:Facility Design and Construction / Q000379:methods*; D006801:Humans; D001523:Mental Disorders / Q000628:therapy; D011216:Practice Management, Medical / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D014481:United States
keywords: Behavioral Medicine; Delivery of Health Care; Integrated; Medical Office Buildings; Primary Health Care; Qualitative Research