This document discusses integrating behavioral health care into the patient-centered medical home model. It provides an overview of the American Academy of Family Physicians, their strategic goals including practice advancement and health of the public. It describes the "Joint Principles" published in 2014 that outline seven principles for integrating behavioral health care into the PCMH. Barriers to integration include issues with payment, time, knowledge and effective referral processes, while opportunities include promoting the PCMH model and medical neighborhood approach to integrate primary care and public health.

1. Integration of Policy, Practice
and Partnership
Julie K. Wood, MD, FAAFP
National Conference on Tobacco and Behavioral
Health
May 20, 2014

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Family Physicians
• The AAFP Represents 115,900 members—
active, residents, and students.
• Approximately one in four of all office visits
are made to family physicians. That is 240
million office visits each year– nearly 87
million more than the next largest
medical specialty.

3. Strategic Goals of AAFP
• Advocacy
• Education
• Practice Advancement
• Health of the Public
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4. Practice Advancement
• Patient Centered Medical Home (PCMH) is a
focus.
• Medical Neighborhood
• “Joint Principles: Integrating Behavioral
Health Care Into the Patient-Centered Medical
Home”
• Published in the March/April 2014 Annals of
Family Medicine
• http://www.annfammed.org/content/12/2/183.2
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5. Integrating Behavioral Health Care Into
the Patient Centered Medical Home
• Adjunct to original Joint Principles of the Medical Home
AUTHORING ORGANIZATIONS:
• American Academy of Family Physicians
• American Board of Family Medicine
• Association of Departments of Family Medicine
• Association of Family Medicine Residency Directors
• North American Primary Care Research Group
• Society of Teachers of Family Medicine
ENDORSED BY:
• American Academy of Pediatrics
• American Psychological Association
• Collaborative Family Healthcare Association
• AAFP Foundation
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6. Integrating Behavioral Health Care Into
the Patient Centered Medical Home
• Set of seven principles describes the characteristics of a
PCMH in which behavioral health care is a part.
Personal physician
Physician-directed medical practice
Whole-person orientation
Coordination of care
Quality and safety
Enhanced access
Payment
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7. Integrating Behavioral Health Care Into
the Patient Centered Medical Home
• Agreement on clear and consistent language
across disciplines.
• Understanding of the central role of the patient
and family in articulating needs and developing a
care plan.
• Defining the different roles and skill sets required
for physicians, behavioral health clinicians, and
other members of the health-care team to provide
whole-person care.
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8. Integrating Behavioral Health Care Into
the Patient Centered Medical Home
• Interdisciplinary training for practicing clinicians &
other team members, faculty, fellows, residents,
and students, for the roles that behavioral health
clinicians as well as primary care clinicians will
assume in the PCMH.
• Research to better define the optimal provision of
whole-person health services in the PCMH, with
attention to patient, practice, training, and
financing issues.
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9. Integrating Behavioral Health Care Into
the Patient Centered Medical Home
• Recognition of local adaptations of integrated,
whole-person care so as to include all persons
and to take advantage of the differing
requirements and resources of different
communities across the entire country.
• Assurance that behavioral health services, as
described in the Mental Health Parity and
Addiction Equity Act of 2008, are included in all
benefit plans.
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10. AAFP Health of the Public Resources
• Ask and Act Program
• www.askandact.org
• Evidence-based strategy
• Provides the opportunity for every member
of the practice team to intervene at each
visit.
• Materials for both physician and patient
education and practice improvement.
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12. AAFP Health of the Public Resources
• Office Champions Program
• Integrates systems changes into clinic workflow.
• A quality improvement systems change model
built on team-based care.
• www.askandact.org/officechampions
• FQHC report:
• http://www.aafp.org/dam/AAFP/documents/patient_care/to
bacco/office-champions-final-report-2013.pdf
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13. Best Practices
• Behavioral health coordinator in office
and/or behavioral health professional
embedded in office to address cessation
needs at the point of care.
• Creating a medical neighborhood to support
patients with behavioral health concerns
and that desire cessation.
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14. Best Practices
• Partner with external behavioral health professionals,
support groups, quitlines, and faith-based groups to create
a successful medical neighborhood.
• Consider brief referral forms with release of information
form as appropriate to facilitate communication and
optimize patient care.
• Team-based efforts—the physician doesn’t have to do it
all. Have staff trained to intervene and follow up, be well
trained in motivational interviewing.
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15. Barriers
• Payment
• Time
• Knowledge deficits
• Transportation
• Lack of effective internal flow when at-risk
patient is identified
• Lack of effective referral process
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16. Opportunities
• Integration of primary care of public health
• PCMH and medical neighborhood
• Promotion of PCMH and integrated mental health
• Continue to advocate for access to care and
appropriate cessation benefits
• Education
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17. Questions?
• Julie K. Wood, MD, FAAFP
Vice President for Health of the
Public & Interprofessional Activities
• Email: jwood@aafp.org
• Twitter: @juliekwoodmd
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