title: Clinician Staffing, Scheduling, and Engagement Strategies Among Primary Care Practices Delivering Integrated Care.
abstract: OBJECTIVE
  To examine the interrelationship among behavioral health clinician (BHC) staffing, scheduling, and a primary care practice's approach to delivering integrated care.
  
  
  METHODS
  Observational cross-case comparative analysis of 17 primary care practices in the United States focused on implementation of integrated care. Practices varied in size, ownership, geographic location, and integrated care experience. A multidisciplinary team analyzed documents, practice surveys, field notes from observation visits, implementation diaries, and semistructured interviews using a grounded theory approach.
  
  
  RESULTS
  Across the 17 practices, staffing ratios ranged from 1 BHC covering 0.3 to 36.5 primary care clinicians (PCCs). BHC scheduling varied from 50-minute prescheduled appointments to open, flexible schedules slotted in 15-minute increments. However, staffing and scheduling patterns generally clustered in 2 ways and enabled BHCs to be engaged by referral or warm handoff. Five practices predominantly used warm handoffs to engage BHCs and had higher BHC-to-PCC staffing ratios; multiple BHCs on staff; and shorter, more flexible BHC appointment schedules. Staffing and scheduling structures that enabled warm handoffs supported BHC engagement with patients concurrent with the identification of behavioral health needs. Twelve practices primarily used referrals to engage BHCs and had lower BHC-to-PCC staffing ratios and BHC schedules prefilled with visits. This enabled some BHCs to bill for services, but also made them less accessible to PCCs in when patients presented with behavioral health needs during a clinical encounter. Three of these practices were experimenting with open scheduling and briefer BHC visits to enable real-time access while managing resources.
  
  
  CONCLUSIONS
  Practices' approaches to PCC-BHC staffing, scheduling, and delivery of integrated care mutually influenced each other and were shaped by the local context. Practice leaders, educators, clinicians, funders, researchers, and policy makers must consider these factors as they seek to optimize integrated systems of care.
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland davismel@ohsu.edu.
authors.forename: Melinda M
authors.initials: MM
authors.lastname: Davis
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Bijal A
authors.initials: BA
authors.lastname: Balasubramanian
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Maribel
authors.initials: M
authors.lastname: Cifuentes
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hall
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Rose
authors.initials: R
authors.lastname: Gunn
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Douglas
authors.initials: D
authors.lastname: Fernald
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Emma
authors.initials: E
authors.lastname: Gilchrist
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Benjamin F
authors.initials: BF
authors.lastname: Miller
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Frank
authors.initials: F
authors.lastname: DeGruy
authors.affiliation: From the Department of Family Medicine (MD), Oregon Health & Science University and Oregon Rural Practice-based Research Network, Portland; Department of Epidemiology, Human Genetics, and Environmental Sciences (BAB), University of Texas Health Science Center Houston School of Public Health, Dallas; Department of Family Medicine (MC, DF, EG, BFM, FD), University of Colorado School of Medicine, Aurora; Department of Family Med-icine (JH, RG), Oregon Health & Science University, Portland; Department of Family Medicine and the Department of Medical Informatics and Clinical Epidemiology (DJC), Oregon Health & Science University, Portland.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Cohen
mesh_terms: D003156:Community Mental Health Services / Q000458:organization & administration*; D003430:Cross-Sectional Studies; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D066296:Grounded Theory; D006801:Humans; D001523:Mental Disorders / Q000628:therapy*; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; 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; Mental Health; Primary Health Care; Qualitative Research