Integrated primary care: why you should care and how to get started.
In the U.S., mental health and substance use (MH/SU) services have traditionally been organized in mental health treatment centers and private practices. Although this system is well-developed and provides quality services, many individuals in need of MH/SU services are never recognized, do not seek, or are not adequately maintained in this model. This realization is the starting point for examining alternative treatment models.
THE CHALLENGES AND OPPORTUNITIES OF PRIMARY CARE
The primary care (PC) setting has been described as the de facto mental health care system. Of the 18-25% of people in the United States that meet the criteria for mental health disorders every year, only half seek treatment (Kessler et al., 2005). For those who do receive MH treatment, 70% of that care will be provided solely by the primary care physician (PCP; Regier et al., 1993). In primary care clinics serving low-income populations, mood and anxiety problems can approach 50% (Wang et al., 2005). PCPs typically under-identify MH/SU problems (Young, Klap, Sherbourne, & Wells, 2001), and when patients are identified and referred for specialty MH/SU services, 30-50% never make the first appointment (Fisher & Ransom, 1997). For low-income and ethnic minority patients, delivery of MH/ SU in the PC setting is even more challenging (see, e.g., Gonzalez et al., 2010).
Patients with psychosocial concerns typically present with physical complaints (e.g., chest pain, fatigue, dizziness, headache, insomnia) for which a biological etiology cannot be identified (Kroenke & Mangelsdortf, 1989). Moreover, the culture of some racial/ethnic minority groups (e.g., Native Hawaiians or Pacific Islanders) shapes emotional distress to present somatically (Sanchez, Chapa, Ybarra, & Martinez, 2012). Distressed patients consume more medical resources in the form of extra physician visits, frequent visits to the emergency department, and unnecessary tests and procedures (deGruy, 1996). Compared to those with chronic medical illness alone, patients with comorbid depression or anxiety report significantly more medical symptoms (Katon, Lin, & Kroenke, 2007) and cost more to treat (Petterson et al., 2008). Modifiable behavioral factors and unhealthy lifestyles are among the leading factors in the top 10 causes of mortality and morbidity in the U.S. (Mokdad, Marks, Stroup, & Gerberding, 2004).
More is needed than simply heightening use of the current MH/SU system because it cannot accommodate the volume of services needed, many patients will not seek specialty services, and the costs would be prohibitive (Strosahl, 2001). One tested solution is integration of behavioral health (BH) services into primary care, which is known as Integrated Primary Care (IPC).
Integrated Primary Care
IPC increases collaboration and coordination between PCPs and BH clinicians (BHCs). The degree of integration can vary from minimal to fully integrated (see Table 1). At a basic level, there is increased provider and case coordination. When co-located, the BHC and PCP may share a physical structure, though treatment plans and records remain separate. When fully integrated, the BHC becomes part of the PC team and collaboration and interaction are extensive. Within integrated care, different health care delivery models have been tested, among them care/disease management (CM) and primary care behavioral health (PCBH; Robinson & Reiter, 2007). The population-based CM model uses vertical integration to target discrete and often chronic conditions (typically high-frequency and high-cost conditions, such as depression or diabetes) with specific treatment protocols (see Figure 1). The PCBH model is generally nontargeted (open to a variety of presenting problems); nonspecific (treatment based on provider decision); and addresses population health through horizontal integration; BHCs are available during the PC visit to assess patients and initiate brief treatment protocols. Treatment is provided in the clinic in relatively short sessions (15-25 minutes) for one to four sessions, with interventions targeted to rapid reduction of symptoms. Follow-up care is coordinated with PCP visits. At the end of a treatment episode, care is returned to the PCP. The goal of PCBH is to make behavioral health care a routine part of PC services (Strosahl, 1998). Common BHC interventions are acceptance-based strategies, problem-solving, mindfulness training, relaxation training, cognitive thought reframing worksheets, behavioral activation, stimulus control/sleep hygiene, motivational interviewing, and psychoeducation. (For excellent reviews of techniques, see Hunter, Goodie, Oordt, and Dobmeyer, 2009, or Robinson and Reiter, 2007.)
A critical element of IPC is same-day referral--the "warm handoff"--where the PCP begins the assessment and introduces the BHC to the patient as a member of the PC team. With patient assent, the PCP then briefly communicates the referral need and background to the BHC, moving on to the next patient while the BHC continues the assessment. Afterwards, the BHC and PCP collaborate on the treatment plan and follow-up recommendations (PCP, BHC, or referral to a specialist). The BHC then completes the service with brief documentation in the medical record to facilitate collaboration within the primary care team (PCPs, care managers, nurses, and the BHC).
Before IPC can be widely adopted, its effectiveness must be considered. Currently, IPC research is in its infancy, although numerous program types, populations, interventions, and outcomes have been examined (Blount, 2003). While a variety of outcomes can be used to evaluate IPC services (Blount, 2003), this article examines four elements: (a) improved access, (b) patient adherence to treatment regimens, (c) improved clinical outcomes, and (d) financial viability. It also outlines research into the effectiveness of these services with culturally diverse populations.
Access to Care and Patient Adherence
Minority patients may not seek mental health services from traditional mental health centers. The Office of Minority Health (OMH, 2011) reports that only 4% of African Americans seek services from a mental health provider, while the majority seek help from physicians. Access to care, accuracy in diagnosis, culturally competent care, and location of services are factors that impact health care disparities (OMH, 2011; Sanchez et al., 2012). IPC has been demonstrated as one means of addressing disparities and increasing access to care (Arean et al., 2008; Sanchez et al., 2012). A recent study found that in IPC over half of PC patients referred to a BHC were seen the same day or within two weeks, a significantly shorter time than in specialty mental health systems (Barber, Frantsve, Capelli, & Sanders, 2011). With reduced wait-times, patient adherence increases (Valleley et al., 2007). Wait-times may be a larger factor in attendance to BHC services than co-location: Guck, Guck, Brack, and Frey (2007) found similar attendance rates between in- and out-of-office locations when patients were scheduled within 24 hours; both sites had significantly higher than standard attendance rates. Interestingly, they also reported that patients with Medicaid showed a significant improvement in attendance with the co-located model.
Clinical Improvement Following IPC
Studies on introduction of IPC services reflect a range of clinical conditions and behavioral concerns, with depression and anxiety being typical reasons for referral (Barber et al., 2011; Funderburk et al., 2011). A significant number of studies are concerned with vertical aspects of integrated treatment, typically for specific conditions (e.g., depression, anxiety, and substance use). Multiple randomized studies support the benefits of IPC for depression (see Bower, Gilbody, Richards, Fletcher, & Sutton, 2006, for review). Support for the findings of Katon et al. (1995), a seminal study that demonstrated improved clinical outcomes for integrated care for depression, has been evidenced in similar other studies such as those on Improving Mood-Promoting Access to Collaborative Treatment (IMPACT; Uniitzer et al., 2002) and Depression Improvement Across Minnesota: Offering a New Direction (DIAMOND; Solberg et al., 2010). The IMPACT study covered 18 primary care clinics and 1,801 participants aged 60 or older who had been diagnosed with depression. Participants were randomly assigned to either the IMPACT intervention or a standard care group. The former were educated on late-life depression and offered a depression care manager for 12 months who helped them with treatment options, typically including an antidepressant or brief psychotherapy. The standard care group pursued usual care in specialty mental health services or primary care. The intervention group was found to be significantly more likely to engage in psychotherapy or use antidepressant treatment, were more satisfied with treatment, and became less depressed as measured by the SCL-20 (Unutzer et al., 2002).
DIAMOND drew upon findings from the IMPACT study, such as use of care managers, a tracking system for patients, and use of PHQ-9 for symptom recognition and monitoring, with a psychiatrist available for consultation and case review (Solberg et al., 2010). The care manager helps the patient to coordinate treatment, assessment, and education. The early results found that depressive symptoms were remitted for five times more patients in the DIAMOND project than those receiving standard care (Solberg et al., 2010). For the majority of patients symptoms remained improved at 12-month follow-up. (See https://www.icsi.org for additional information on the DIAMOND program, including locations, study findings, and patient information.)
Vera et al. (2010) completed a study of 179 patients in a PC setting randomly assigned to collaborative or usual care. The collaborative care group was offered treatment by PCP, BHC, and a care manager that included medication or cognitive behavioral treatment (CBT) at no cost. The usual care group was offered treatment options available through their insurance. At six months, 97% of patients in the collaborative care group had been treated for depression compared to 57% in the standard care group; the former also showed greater reductions in depression.
Studies have also suggested support for specific treatment of anxiety in primary care settings (Roy-Byrne et al., 2010) as well as co-morbid anxiety and depression (Lang, 2003). Roy-Byrne et al. (2010) examined 1,004 patients of 17 PC clinics with symptoms of one or more anxiety disorders; patients were not excluded if they presented with comorbid depression. Patients were then randomized into a usual care or a Coordinated Anxiety Learning and Management (CALM) treatment group. Patients in the CALM group were provided treatment of their choice (CBT, medication, or both). Their outcomes were significantly better. A review by the Agency for Health Care Research had earlier concluded that IPC demonstrated superior outcomes for depression and anxiety than usual care (Butler et al., 2008).
Whitlock et al. (2004) reviewed the literature on brief interventions in PC settings that targeted alcohol use. One well-documented strategy is the use of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) protocol, in which the BHC and other members of the primary care team identify and manage problem substance use (Babor et al., 2007).
In other horizontal integration models that address multiple behavioral health complaints, reasons for referral include coping with illness, sleep disturbances, bereavement, PTSD, and other mood concerns (Barber et al., 2011). This is consistent with Funderburk et al. (2011), who found substance abuse, adjustment, anxiety, and depression to be typical reasons for referral. Assessing integrated services for children in a rural community, Valleley et al. (2007) found typical referrals to BHCs to be for behavioral disorders, school problems, sleep, and mental retardation. Others have found support for the reduction of "general psychological distress" when patients are referred for "mental health needs" or psychosocial concerns and receive brief treatment (Bryan, Morrow, & Appolonio, 2009; Cigrang, Dobmeyer, Becknell, Roa-Navarrete, & Yerian, 2006). IPC services have also been indicated for patients presenting with more severe symptoms (Bryan et al., 2012).
Regarding longitudinal outcomes of IPC, Ray-Sannerud et al. (2012) completed a study of well-being and symptom outcomes in an IPC setting with baseline and outcome measures 1.5 to 3 years after BHC interventions for depression, stress/anxiety, and insomnia. Follow-up reflected sustained symptom reduction, with greatest effect among patients whose initial symptoms were severe.
In another area, Kroenke et al. (2009) found support for intervention with PC patients presenting with musculoskeletal pain and depression. Treatment included antidepressant intervention by a physician depression specialist and a nurse care manager providing a pain self-management program (p. 2101). Significant improvements were found in both depression and pain symptoms.
IPC Financial Viability
Without a clear financial model to support IPC, its increased adoption and long-term sustainability seem uncertain. Several factors have been posited as methods to demonstrate its financial benefits: improved clinician efficiency, improved health outcomes (as noted above), direct revenue generation, and medical cost offset (Monson, Sheldon, Ivey, Kinman, & Beacham, 2012). Clinician efficiency is realized when the PCP can hand off time-consuming and less reimbursable behavioral health issues to the BHC and move on to medical cases with greater reimbursement potential (Cummings, O'Donohue, & Cummings, 2009; Monson et al., 2012). Improved health outcomes are related to both symptom reduction and the prevention of more serious illness by increased access, early detection, and rapid treatment. Direct revenue generation of BH services in PC settings is, however, challenging (e.g., limitations of PC and BH same-day billing and use of health and behavior codes) but continues to have potential as a source of increased revenue (O'Donnell, Williams, & Kilbourne, 2013). Finally, medical cost offset (e.g., decreased emergency department visits and improved primary utilization) has long been held as an outcome of mental health interventions (Chiles, Lambert, & Hatch, 1999), but IPC-specific evidence is limited. As reimbursement models move to more capitated and bundled payment systems, the financial benefits of an integrated approach can be more fully realized.
Culturally Tailored Research
The benefit of integrated services for racial and ethnic minorities and other underserved populations has not been well-documented (Butler et al., 2008), or well understood (Sanchez et al., 2012; Vera et al., 2010). Many have called for greater integration of services for all underserved communities (Auxier, Farley, & Seifert, 2011; Cabassa & Hansen, 2007; Sanchez et al., 2012); for instance, Manoleas (2008) proposed the need for and benefit of 1PC for Latinos. Although the approach was primarily theoretical, Manoleas outlined a plan for how to make integrated services culturally sensitive.
In 2012 the U.S. Department of Health and Human Services OMH and the Hogg Foundation for Mental Health reported on a review of the literature on eliminating disparities by integrating BH and PC care services (Sanchez et al., 2012). However, the review lacked outcome information. This may be partly explained by a scarcity both of data and analyses related to culturally diverse populations and of culturally competent researchers and providers (Manoleas, 2008; Sanchez et al., 2012). However, several notable studies have begun the work in this area. For example, Miranda, Schoenbaum, Sherbourne, Duan, and Wells (2004) demonstrated that when compared to usual care interventions implemented within PC clinics, BH integration reduced the probability of major depression for minority as well as nonminority patients.
Auxier et al., (2011) explored the benefit of integration for medically indigent migrant workers and un- and underinsured populations. Describing BHC services as population-based services, which include evidence-based interventions, they demonstrated how their model of integration contributed to the number of patient contacts by providers and the identification of mental health needs. Cabassa and Hansen (2007) reviewed six randomized controlled studies of depression programs within the PC setting and demonstrated that the collaborative care/ culturally adapted models were more effective than usual care in reducing depressive symptom distress and improving functioning.
One example of culturally tailored research was a randomized control trial by Ell et al. (2010) comparing enhanced usual care with a culturally adapted collaborative care model to address psychosocial stressors for Latinos with diabetes and depression. They used Spanish-speaking recruiters and interviewers, adapted materials, and covered transportation costs. Training for all staff increased participant access to community resources, supplemental patient support, and care managers. Ell and colleagues reported significant improvements related to depression and other sociodemographic variables. Intervention group patients demonstrated high rates of participation in problem-solving therapy, increased adherence to antidepressant medications, and greater satisfaction with depression care than did enhanced usual care patients. Similarly, Ayalon, Arean, Linkins, Lynch, and Estes (2007) hypothesized that compared to White patients, Black patients would utilize the integrated model more than an enhanced referral model (which increased connection to specific off-site specialty BHC). Indeed Black patients in the integrated model were significantly more likely to have at least one MH/SU visit (77.5%) than those in the enhanced referral arm (22%), but the same was not found for Whites. They also found that there were no ethnic group differences in total number of MH/SU visits in the integrated model; however, the Black patients utilized the enhanced referral model less than White patients. Finally, Ell et al. (2011) examined outcomes of a collaborative care model for Latinas with cancer and depression. Their intervention, adapted from the IMPACT model, was culturally modified for low-income, predominantly Hispanic women. In their one-year follow-up, collaborative care participants demonstrated reduced depression and enhanced quality of life compared to those with enhanced usual care. These studies begin to demonstrate the efficacy of culturally tailored research and practice within an IPC environment.
Limitations of Current Research and Barriers
Empirical support for the effectiveness of models addressing multiple comorbid conditions in diverse communities, which is typical of PC practice, is incomplete (Carey et al., 2010; Petterson et al., 2008; Sanchez et al., 2012). Likewise, the value added by each component individually and synergistically has not been clearly determined (Carey et al., 2010).
IPC is not a panacea, as Arean et al. (2008) pointed out. When examining care for ethnically diverse older adults in multiple settings (community mental health, VA, outpatient), integrated care increased the likelihood of access to mental health and substance abuse services but treatment outcomes after six months were not significantly better. Seal et al. (2011) also found that while integrated services for veterans may have improved initial first contact with a mental health professional, it did not lead to sustained contact after the initial appointment.
IPC research has been conducted in a wide variety of treatment settings, including private sector, family health care, government-sponsored plans (e.g., Veterans Health Administration, Military/Department of Defense, Federally Qualified Health Centers), and large managed care plans. Among the populations studied have been children and adolescents, older adults, and underserved communities. However, the impact of integrated care is not fully understood for rural populations and for those with serious and persistent mental health conditions (Carey et al., 2010).
IMPLICATIONS FOR COUNSELORS
Culturally Tailored Practice
For practices that are either currently integrated or are drafting an action plan to become integrated, it is imperative to understand the needs of the community being served. Culturally tailored practices relate not only to racial/ ethnic minority groups but also to such groups as those of low socioeconomic status, limited English proficiency, diverse religious/spiritual belief systems, ability status, and sexual orientation. BHCs can support the PC environment by encouraging and modeling patient-centered communication, which can address those that have specific worldviews on mental health care in general.
Culturally tailored practices must match the values and norms of the community they serve. For example, some groups, such as Latinos, prefer an emphasis on the relationship during therapy (Manoleas, 2008), while Asian Americans, Native Hawaiians, and Pacific Islanders often express their distress through physical symptoms; if mental illness is considered shameful in a community, members of that community may not seek treatment (Sanchez et al., 2012). In African-American communities, patients often delay seeking mental health treatment, and the lack of culturally sensitive or minority providers is another barrier (Sanchez et al., 2012). Furthermore, groups differ in their preferences for use of psychotropic medications (Cooper et al., 2003).
To increase cultural competence in design and delivery of services it is useful for all providers to review the National Standards for Culturally and Linguistically Appropriate Services in Health Care issued by OMH (2001). Training for IPC staff that is culturally and linguistically appropriate to the population being served is integral to the management of mental health distress. This requires a systematic approach by all IPC participants (i.e., physician identification of mental health concerns, connection with the BHC, mental health interventions provided, case management, and general commitment to proactively meet the needs of the community). When care is congruent with the worldview, values, literacy level, and culture of patients, they participate more actively in treatment and that helps to improve outcomes (Ell et al., 2010; Sanchez et al., 2012).
Preparing for IPC Practice
Before embarking on an IPC endeavor, the first step for providers is a self-assessment of whether primary care is a good fit for them. The work is fast-paced and team-based. Those who do well in this setting are flexible, tolerant, and accommodating of a practice environment that is often not conducive to comfort, quiet, and privacy (Nash, McKay, Vogel, & Masters, 2012). Although providing IPC services draws upon many skill sets, integrated care requires adopting elements from the PC culture, such as a primary care focus, a symptom-reduction-based approach, and efficient methods of managing referrals and documentation (see McDaniel et al., 2013). IPC is about doing intervention differently, not faster. If practice is to be competent, skills unique to IPC may require additional training and supervised experiences.
The next step is to identify one or more PC practice partners. These could be private practices (solo or group), university or hospital PC clinics, clinics designed for health professional training (e.g., a family medicine residency), or specialized (e.g., HIV) primary care clinics. When approaching a practice or clinic to enter into an integrated relationship, it is useful to observe how prepared the practice is to add a provider. What is central here is identifying stakeholders who may facilitate or may challenge new ventures (Auxier et al., 2011). This often includes the PCP, the office manager, and perhaps a hospital-owner of the practice.
When negotiating possible relationships with PCPs, one of the first decisions is how much integration is possible within a given setting (see Table 1). A common progression begins with closer coordination of BH and PC services and working toward a co-located and eventually a fully integrated model (Vogel, Kirkpatrick, Codings, Cederna-Meko, & Grey, 2012). A related decision is the model of care that will be provided. As illustrated in Figure 1, advantages have been demonstrated for both vertical integration (targeting one condition and using a specific clinical pathway with all patients that present with this condition) and horizontal integration (providing focused behavioral services for a wide variety of conditions, e.g., PCBH). Clearly, the type of services potential partners are most familiar with may also guide whether counselors interested in more integrated services approach a disease-specific practice or one offering more generalized horizontal services.
Before beginning formal collaboration with a PCP, it is critical that the relationship agreement be clear. Contractual issues may cover space, length of relationship, how patient referrals will be arranged, insurance coverage, confidentiality of records, access to office resources, and marketing and professional independence (Coons & Gabis, 2010).While close proximity is often recommended to increase the degree of integration, space is often at a premium. BHCs new to IPC might initially work out of a group office and see patients in its examination rooms or settle for space on a different floor in the same building. The ability of leadership to commit resources to the IPC project is an important indicator of eventual success (see Monson et al., 2012, for an excellent review of these issues).
Beginning IPC Practice
It is often best to begin small; two half-days a week in a practice provides frequent face-time and also allows multiple options to schedule patients for follow-up. Initial buy-in to the IPC model by stakeholders is necessary, followed by training in evidence-based culturally tailored practices for everyone, including PCPs, medical assistants, office staff, and BHCs (Auxier et al., 2011).
To be considered part of the team, counselors need to both understand the team members and find ways to participate in the group structure. This may be as simple as lunching with the PCP, medical assistants, and other professionals on the health care team. Involvement may also be more extensive, such as participation in a quality or practice improvement project. Shadowing a PCP during lean referral times will help the BHC understand the primary care culture and offer opportunities to suggest ways the BHC can assist the PCP. As MH professionals find ways to contribute to the team structure, they become more fully integrated into care delivery and viewed as valued, effective, and productive PC team members (Nash, McKay, Vogel, & Masters, 2012).
Critical to the success of the IPC endeavor is ensuring financial viability and sustainability (Monson et al., 2012). One financial opportunity comes from increased medical provider efficiency via improved patient flow when BHCs can assist with difficult and time-consuming patients. IPC practices may also originate in a recognition that the traditional ways of providing services are inadequate for reaching desired health outcomes. It is important For BHCs to track their success in helping achieve health outcomes (e.g., depression remission), success in meeting quality guidelines (e.g., HbA1c reductions in diabetic patients), and use of fewer unnecessary or expensive medical services (e.g., reduction in hospital admissions and emergency room use). Practices that become Patient-Centered Medical Homes (and reach level three recognition of the National Committee for Quality Assurance) also earn higher reimbursement rates. Since substantial BH integration is a requirement for this level of certification, a portion of the reimbursement can be attributed to BH integration. Finally, psychological assessments and short-term psychotherapy may be billable services, depending on the clinic type and the patient's situation. In some areas, and with some insurance plans, health and behavior codes can be billed for behavior interventions for a medical diagnosis. This kind of billing requires knowledge of BHC procedures and rules that may limit billing practices. Robinson & Reiter (2007) provided suggestions for successful billing practices and O'Donnell, Williams, & Kilbourne (2013) gave methods to dismantle reimbursement roadblocks.
Learning More about IPC
Opportunities to pursue education and training in IPC range from specialized training programs to additional readings. BHCs vary widely in initial training. In graduate psychology education, increasing numbers of doctoral programs are providing exposure to IPC through course work and practicum experiences. Many psychology internship programs and post-doctoral fellowships also incorporate experiences, emphases, and a major focus on this material (see listing published by the American Psychological Association Education Directorate and the web-based directory published by the Association of Psychology Postdoctoral and Internship Centers). Other formalized training includes workshops and certificate programs, such as those offered by the University of Massachusetts, Fairleigh Dickinson University, and the University of Michigan School of Social Work. Most of these combine onsite, distance, and experiential learning. There are also excellent step-by-step guides for providers who want to learn more about this practice option (Hunter et al., 2009; Robinson & Reiter, 2007).
IPC holds great promise for better treatment of behavioral health problems in a primary care setting and is consistent with current public and private health reform efforts. While there remains a need for more empirical support for various aspects of successful IPC execution, the current knowledge base supports continued development and implementation. This article is an introductory guide for those considering applying IPC principles in practice. While the promise of closer integration of mind and body care has been debated for many years, current efforts at efficient use of BHC in PC settings have moved the model toward long-term sustainability. Yet IPC challenges the views and practices of both mental health providers and physicians. With increased understanding by all parties (clinicians, administrators, policy experts) of what the model does and does not entail, the move toward improved research, clinical applications, and patient care looks promising.
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All authors are affiliated with Genesys Regional Medical Center. Grand Blanc, MI. Correspondence should be sent to Mark E. Vogel, Ph D.. ABPP Genesys Regional Medical Center, Family Health Center, 1460 N Center Rd., Burton, MI 48509. Email: email@example.com.
Table 1. Continuum of Behavioral Health Integration Coordinated Key Element: Communication Level Level 1 Level 2 Description Minimal Basic at a distance Systems Separate Separate Facilities Separate Separate Communication Rare Periodic; driven by specific patient issues Roles/Culture Little View each appreciation other as of each resources other's roles Co-Located Key Element: Physical Proximity Level Level 3 Level 4 Description Basic onsite Close collaboration onsite with some systems integration Systems Separate Some shared, like scheduling or records Facilities Same facility Same space but not within facility necessarily same offices Communication Regular, about In person, shared patients; driven by need driven by for consultation need for each and other's services coordination and reliable plans for referral difficult patients Roles/Culture Feel part of Basic larger yet understanding ill-defined of roles and team culture Integrated Key Element: Practice Change Level Level 5 Level 6 Description Close Fully collaboration transformed/ approaching merged integrated integrated practice practice Systems Shared Integrated Facilities Same space- Same space- some shared all shared Communication Frequent in Consistent at person, driven system, team, by desire to be and individual a member of level; shared care team concept of team care Roles/Culture In-depth Roles and understanding cultures blur of roles and and blend culture Adapted from Heath, Wise, Romero, & Reynolds, 2013.