• Melinda M Davis, Bijal A Balasubramanian, Maribel Cifuentes, Jennifer Hall, Rose Gunn, Douglas Fernald, Emma Gilchrist, Benjamin F Miller, Frank DeGruy, and Deborah J Cohen.
• 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.
• J Am Board Fam Med. 2015 Sep 1; 28 Suppl 1: S32-40.

PurposeTo examine the interrelationship among behavioral health clinician (BHC) staffing, scheduling, and a primary care practice's approach to delivering integrated care.MethodsObservational 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.ResultsAcross 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.ConclusionPractices' 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.© Copyright 2015 by the American Board of Family Medicine.

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