title: The Implementation of Integrated Behavioral Health Protocols In Primary Care Settings in Project Care.
abstract: OBJECTIVE
  The majority of adults with mental health (MH) and substance use (SU) disorders in the United States do not receive treatment. The Affordable Care Act will create incentives for primary care centers to begin providing behavioral health (MH and SU) services, thus promising to address the MH and SU treatment gaps. This paper examines the implementation of integrated care protocols by three primary care organizations.
  
  
  METHODS
  The Behavioral Health Integration in Medical Care (BHIMC) tool was used to evaluate the integrated care capacity of primary care organizations that chose to participate in the Kern County (California) Mental Health Department's Project Care annually for 3years. For a subsample of clinics, change over time was measured. Informed by the Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors, inner and outer contextual factors impacting implementation were identified and analyzed using multiple data sources and qualitative analytic methods.
  
  
  RESULTS
  The primary care organizations all offered partially integrated (PI) services throughout the study period. At baseline, organizations offered minimally integrated/partially integrated (MI/PI) services in the Program Milieu, Clinical Process - Treatment, and Staffing domains of the BHIMC, and scores on all domains were at the partially integrated (PI) level or higher in the first and second follow-ups. Integrated care services emphasized the identification and management of MH more than SU in 52.2% of evaluated domains, but did not emphasize SU more than MH in any of them. Many of the gaps between MH and SU emphases were associated with limited capacities related to SU medications. Several outer (socio-political context, funding, leadership) and inner (organizational characteristics, individual adopter characteristics, leadership, innovation-values fit) contextual factors impacted the development of integrated care capacity.
  
  
  CONCLUSIONS
  This study of a small sample of primary care organizations showed that it is possible to improve their integrated care capacity as measured by the BHIMC, though it may be difficult or unfeasible for them to provide fully integrated behavioral health services. Integrated services emphasized MH more than SU, and enhancing primary care clinic capacities related to SU medications may help close this gap. Both inner and outer contextual factors may impact integrated service capacity development in primary care clinics. Study findings may be used to inform future research on integrated care and inform the implementation of efforts to enhance integrated care capacity in primary care clinics.
authors.affiliation: University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA, 90025. Electronic address: hpadwa@ucla.edu.
authors.forename: Howard
authors.initials: H
authors.lastname: Padwa
authors.affiliation: University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA, 90025. Electronic address: cteruya@ucla.edu.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Teruya
authors.affiliation: University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA, 90025. Electronic address: elisetr@ucla.edu.
authors.forename: Elise
authors.initials: E
authors.lastname: Tran
authors.affiliation: University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA, 90025. Electronic address: klovinger@ucla.edu.
authors.forename: Katherine
authors.initials: K
authors.lastname: Lovinger
authors.affiliation: University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA, 90025. Electronic address: vjpearce@ucla.edu.
authors.forename: Valerie P
authors.initials: VP
authors.lastname: Antonini
authors.affiliation: Kings View Behavioral Health, 4900 California Avenue, Tower B, Office #3, Bakersfield, CA 93309. Electronic address: colleenoverholt@att.net.
authors.forename: Colleen
authors.initials: C
authors.lastname: Overholt
authors.affiliation: University of California, Los Angeles, Integrated Substance Abuse Programs, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA, 90025. Electronic address: durada@ucla.edu.
authors.forename: Darren
authors.initials: D
authors.lastname: Urada
mesh_terms: D002140:California; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D006284:Health Plan Implementation / Q000379:methods*; D006801:Humans; D008605:Mental Health Services / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D019966:Substance-Related Disorders / Q000628:therapy*
keywords: Behavioral Health in Medical Care (BHIMC) assessments; Behavioral health/primary care integration; Implementation science; Mental health services; Primary care clinics; Substance use disorder services