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Clinical Workflows and the Associated Tasks and Behaviors to Support Delivery of Integrated Behavioral Health and Primary Care

Davis, Melinda M., PhD; Gunn, Rose, MA; Cifuentes, Maribel, BSN, RN; Khatri, Parinda, PhD; Hall, Jennifer, MPH; Gilchrist, Emma, MPH; Peek, C. J., PhD; Klowden, Mindy, MNM; Lazarus, Jeremy A., MD; Miller, Benjamin F., PsyD; Cohen, Deborah J., PhD

The Journal of Ambulatory Care Management: January/March 2019 - Volume 42 - Issue 1 - p 51–65
doi: 10.1097/JAC.0000000000000257
Original Articles

Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors—guided by protocols or scripts—to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery.

Departments of Family Medicine (Drs Davis and Cohen and Ms Hall) and Medical Informatics and Clinical Epidemiology (Dr Cohen) and Oregon Rural Practice-based Research Network (Dr Davis and Ms Gunn), Oregon Health & Science University, Portland; OHSU-PSU School of Public Health, Oregon Health & Science University, Portland (Dr Davis); The Colorado Health Foundation, Denver (Ms Cifuentes); Cherokee Health Systems, Knoxville, Tennessee (Dr Khatri); Departments of Family Medicine (Ms Gilchrist) and Psychiatry (Dr Lazarus), University of Colorado School of Medicine, Aurora; Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis (Dr Peek); Jefferson Center for Mental Health, Lakewood, Colorado (Ms Klowden); and Well Being Trust, Oakland, California (Dr Miller).

Correspondence: Melinda M. Davis, PhD, Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L222, Portland, OR 97239 (

Portions of this work were presented during the 2014 Practice-based Research Network (PBRN) Annual Meeting in Bethesda, Maryland.

The authors are thankful to the 19 participating practices. Larry A. Green, MD and Frank deGruy III, MD, provided helpful comments preparing this manuscript. This research was supported by grants from the Colorado Health Foundation (CHF-3848), Agency for Healthcare Research and Quality—8846.01-S01. Tides Foundation/CalMHSA Integrated Behavioral Health Project-AWD-131237. Maine Health Access Foundation—2012FI-0009. Dr Davis is supported in part by a Cancer Prevention, Control, Behavioral Sciences, and Populations Sciences Career Development Award from the National Cancer Institute (K07CA211971).

The Oregon Health & Science University and The University of Texas Health Science Center at Houston Institutional Review Boards approved this study.

The authors report no conflicts of interest.

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