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Focusing on integration

February 1, 2007
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CARF plans to start offering accreditation to integrated behavioral health/primary care settings in July

Discussion around the need for integration of behavioral health and primary care, while certainly becoming more prevalent, is definitely not new. But within the past couple years the dialogue has become universal. The Institute of Medicine's Crossing the Quality Chasm reports and the National Association of State Mental Health Program Directors’ compilation of state studies clearly support the need to adequately assess and respond to the holistic needs of persons with behavioral health concerns.

CARF, International, which develops standards in response to needs identified “by the field,” began its internal discussion around the possibility of accreditation for integrated behavioral health and primary care (IBH/PC) settings in early 2003. While communication was occurring with representatives of some federally qualified health centers (FQHCs), the Veterans Health Administration (VHA), and national associations such as the National Council for Community Behavioral Healthcare (NCCBH), it was important to assess the market potential and desire for distinct pro-gram accreditation in this area. After significant national dialogue, a Leadership Panel convened in December 2005 to confirm the need for national IBH/PC standards and to identify themes critical to include.

In response to the Leadership Panel's confirmation of the growing importance and recognition of integrated treatment settings, CARF convened an International Standards Review Committee (CARF ISRC) in August 2006, comprised of consumers, national association representatives (including members of the CARF International Advisory Council), integrated service providers, state and federal funding authorities, and other national experts. This group was charged with developing a progressive and state-of-the-art set of standards to be presented to the field.

In addition to developing the draft standards, the CARF ISRC identified descriptions of IBH/PC settings the standards would cover:

  • contractual, where two separate legal entities en- ter into an agreement to staff and operate a single program;

  • a distinct, integrated program located within a large entity such as a VHA campus;

  • the colocation of complementary disciplines such as behavioral staff in a primary care setting (as in an FQHC) or primary care staff in a community mental health center (as described by NCCBH in the December 2006 issue of Behavioral Healthcare); or

  • a single organization that incorporates both behavioral health and primary care services in an integrated model.

One of the ISRC participants was Morna Pederson-Rambo, executive director of DaySpring Behavioral Health Services, Inc., which operates integrated programs in Oklahoma and Arkansas. She offered the following as support for the importance and value of the new CARF standards:

“To launch standards that guide the integration of primary care and behavioral health services, CARF has opened the door for another method of ensuring access to care and greater potential for positive outcomes to persons served. Many who see their medical doctor have complaints related to depression, extreme or acute life situations that cause distress, or ongoing relationship issues that interfere with medical conditions. The physician who has behavioral health specialists on-site can ask them to become acquainted with the patient at the time the complaint is raised. By introducing or giving a warm handoff to a behavioral specialist, the physician indicates his/her confidence in this provider to attend to yet another facet of the symptoms or stresses that are contributing to disease. Working as a team, the physician and behavioral health specialist provide for a better opportunity to achieve changes in the patient's behavior that positively affect his/her functioning. These changes also promote greater physical health.

“The simple availability of the behavioral health specialist makes it more likely that the patient will follow through with a recommendation for needed behavioral health services. Secondly, the nature of integrated service delivery supports short-term, solution-focused interventions, which can be accessed multiple times if necessary, and can support progressive work toward greater mental and physical health care. In addition, the overview of medications from both the medical and behavioral health sides of care lead to the potential for quicker assessment and introduction of positive pharmaceutical regimes. Because of integration, the individual has the attention of several providers working together to ensure a positive outcome of the treatment plan.”

The draft standards were posted on the CARF Web site ( in December, and although specific notice was sent to providers who have CARF accreditation, CARF-affiliated associations, and state mental health directors, all interested individuals were invited to participate. Initial review indicated a strong response. The field review was analyzed in January 2007 and changes made where necessary.

Programs seeking accreditation under the IBH/PC standards would need to meet existing CARF Business Practice and General Behavioral Health program standards, as well as areas such as:

  • identification of parameters of populations served and services provided;

  • colocation requirements;

  • coverage requirements;

  • staffing requirements;

  • requirements for education on wellness and recovery;

  • processes ensuring consent for treatment;

  • written procedures for communication and collaboration; and

  • clearly identified performance measurement indicators that include both medical and behavioral healthcare.