title: Understanding Care Integration from the Ground Up: Five Organizing Constructs that Shape Integrated Practices.
abstract: OBJECTIVE
  To provide empirical evidence on key organizing constructs shaping practical, real-world integration of behavior health and primary care to comprehensively address patients' medical, emotional, and behavioral health needs.
  
  
  METHODS
  In a comparative case study using an immersion-crystallization approach, a multidisciplinary team analyzed data from observations of practice operations, interviews, and surveys of practice members, and implementation diaries. Practices were drawn from 2 studies of practices attempting to integrate behavioral health and primary care: Advancing Care Together, a demonstration project of 11 practices located in Colorado, and the Integration Workforce Study, a study of 8 practices across the United States.
  
  
  RESULTS
  We identified 5 key organizing constructs influencing integration of primary care and behavioral health: 1) Integration REACH (the extent to which the integration program was delivered to the identified target population), 2) establishment of continuum of care pathways addressing the location of care across the range of patient's severity of illness, 3) approach to patient transitions: referrals or warm handoffs, 4) location of the integration workforce, and 5) participants' mental model for integration. These constructs intertwine within an organization's historic and social context to produce locally adapted approaches to integrating care. Contextual factors, particularly practice type, influenced whether specialty mental health and substance use services were colocated within an organization.
  
  
  CONCLUSIONS
  Interaction among 5 organizing constructs and practice context produces diverse expressions of integrated care. These constructs provide a framework for understanding how primary care and behavioral health services can be integrated in routine practice.
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE) cohendj@ohsu.edu.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cohen
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Bijal A
authors.initials: BA
authors.lastname: Balasubramanian
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Melinda
authors.initials: M
authors.lastname: Davis
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hall
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Rose
authors.initials: R
authors.lastname: Gunn
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Kurt C
authors.initials: KC
authors.lastname: Stange
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Larry A
authors.initials: LA
authors.lastname: Green
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: William L
authors.initials: WL
authors.lastname: Miller
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Benjamin F
authors.initials: BF
authors.lastname: Crabtree
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Mary Jane
authors.initials: MJ
authors.lastname: England
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Khaya
authors.initials: K
authors.lastname: Clark
authors.affiliation: From the Departments of Family Medicine and of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, Houston School of Public Health (BAB); Harold Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX (BAB); Oregon, Rural Practice-Based Research Network (MD); Department of Family Medicine, Oregon Health & Science University, Portland (MD, JH, RG, KC); Department of Epidemiology & Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH (KCS); Department of Family Medicine, University of Colorado School of Medicine, Aurora (LAG, BFM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, Somerset, NJ (BFC); Department of Health Policy and Management, Boston University School of Public, Health, Boston, MA (MJE).
authors.forename: Benjamin F
authors.initials: BF
authors.lastname: Miller
mesh_terms: D003155:Community Mental Health Centers; D003156:Community Mental Health Services / Q000458:organization & administration*; D019091:Critical Pathways; D003430:Cross-Sectional Studies; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D006801:Humans; D008137:Longitudinal Studies; D001523:Mental Disorders / Q000628:therapy*; D011216:Practice Management, Medical / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D012017:Referral and Consultation; D014481:United States
keywords: Delivery of Health Care; Integrated; Practice-based Research; Primary Health Care