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Behavioral Health Integration in Primary Care @ Brigham & Women's Hospital - South Huntington

Keywords: Behavioral Health, Mental Health, PCMH, Primary Care


Integration of behavioral health capabilities into primary care at a patient-centered medical home


  • Stuart Pollack MD
  • Jane Erb MD
  • Janna Levi LICSW
  • Debra Aponte


Festus Ojo


South Huntington Primary Care Associates, Brigham Health, Boston, MA

Organizational Context

  • South Huntington Primary Care Associates is a Level 3 Patient Centered Medical Home in Jamaica Plain, MA. It is a primary care affiliate of Brigham and Women’s Hospital, an academic medical center.
  • Clinic was founded in 2011 to test a team-based care approach.  
    • Staff is organized into three care teams, each with multiple attending physicians, one or two residents, a nurse, a social worker, a physician assistant, and two medical assistants. 
    • A staff pharmacist, RN care manager, nutritionist, and community resource specialist provide support to all teams.
  • BWH and South Huntington leadership were aware of successful models of behavioral health integration into primary care and concerned about a shortage of mental health providers for their patients. 
  • They thus deemed behavioral health integration a priority for the clinic at the time of its founding.
  • South Huntington had already adopted the Collaborative Care Model, with multidisciplinary teams of doctors, physician assistants, nurses, social workers, and medical assistants providing team-based care to patients on a daily basis.

    • This created a more natural setting into which to bring a behavioral health focused multidisciplinary team consisting of a social worker, health support specialist, PCP, and consulting psychiatrist.

Population Served

  • The clinic currently sees over 7000 patients with a variety of insurance types (Medicaid, Medicare, commercial) in an urban environment. 

Project Research & Planning

Workflow Development

  • PCPs, a psychiatrist, & social workers developed workflows and materials for the intervention, adapted to some degree from the IMPACT model and Intermountain Health’s behavioral screening tool.
  • Developed proprietary tools where existing tools did not meet needs.

Question selection

  • PHQ-2 and GAD-2 are used as screening tools. PHQ-9 (depression screening questionnaire) and GAD-7 (anxiety screening questionnaire) are administered to patients who screen positive on the above. Other screens are available as appropriate (AUDIT-C for ETOH).
  • Any patient who receives a PHQ-9 or GAD-7 will also receive a behavioral health “packet” collated by the South Huntington behavioral health team. This includes more in-depth questions about problems with sleep, OCD, eating disorders, psychosis and mania, history of self-harm, family history of psychiatric disturbances, alcohol or other substance abuse, and the patient’s support system. 

Project Tools & Components

  • Paper copies of the PHQ-2, GAD-2, PHQ-9, GAD-7, and behavioral health packet are available for in-clinic visits.
  • Epic was programmed to include a place to record patient’s questionnaire answers. An Epic smartphrase was created to pull in PHQ-9 or GAD-7 answers into a standard visit note.
  • Epic was also programmed to include PHQ and GAD surveys that could be sent to patients via Patient Gateway (Epic’s patient portal) so that patients could complete surveys electronically and remotely as part of standard follow-up.




  • All staff involved in the program are trained how to use scales as part of their onboarding. They also receive ongoing in-service training dedicated to evaluation and management of psychiatric disorders.
  • New social workers are trained by veteran social workers.

Tech Involved


Team Members

  • Physicians (PCP, Psychiatrist)
  • Social Workers
  • Health Support Specialist

Daily Workflow Steps

  • At each visit, patient receives PHQ-2 and a GAD-2 questionnaires. If appropriate, the patient will also receive an AUDIT questionnaire.
  • If the patients’ answers to the above screening tools lead to a "positive screen," the primary care physician will direct the patient to complete a full PHQ-9 and/or GAD-7 questionnaire. These patients also receive a behavioral health packet to complete.
  • Patients who have a ‘positive screen’ in these extended questionnaires are either started on treatment by a primary care physician if their presentation is uncomplicated, or they can be referred for review at weekly Behavioral Health Rounds if their case is more complex (ex. depression with history of PTSD, refractory depression).
    • During Behavioral Health Rounds, patients with more complex cases are discussed with the program’s Psychiatrist, Dr. Jane Erb. 
    • Dr. Erb makes treatment recommendations for the primary care physicians. These recommendations are documented in the electronic medical record.
    • For those patients whose behavioral health needs are deemed too complex to manage in primary care alone (ex. coexisting substance abuse), they are referred to BWH Psychiatry.
  • Patients are co-managed by primary care physicians, social workers, and the health support specialist.
    • Patients can be referred to each team’s social worker (often through a warm-handoff at a relevant visit) for connection to resources or in-practice services.
      •  South Huntington’s social workers maintain their own schedule. They provide supportive counseling, short behavioral health interventions such as Cognitive Behavioral therapy, motivational counseling, and crisis interventions.
      • Many patients choose to have an outside therapist, and the practice’s social workers often help them with locating this resource.
  • The practice’s health support specialist maintains a registry of all patients who are part of the behavioral health program.
    • They contact patients every 2 weeks and administer the PHQ-9 and GAD-7 (either via phone or via Patient Gateway) to track treatment progress.
    • They inquire about medication adherence and side effects. They also engage patients in dialogue about their situation, assess what patients want to work on (personal/social), oversee an internet-based cognitive behavioral therapy program, and engage patients in behavioral activation which involves patients problem-solving around their condition.
    • Patients whose questionnaire scores are rising are flagged so that PCPs are aware they may need for therapy adjustment or in-person assessment.



  • Each social worker’s salary is about $102,000 per year including fringe benefits while the population health manager receives $77,500 per year including benefits.
  • Social workers are part of the collaborative care team at South Huntington, however, so their salary cannot be completely attributed to the behavioral health integration program.


  • The program is part of established, ongoing care at South Huntington.


  • Thousands have been treated by the program since its inception, with about 50 patients treated at any one time.


  • Patients with behavioral health needs have a wider support network and are able to receive psychiatric input for their care much more quickly than if referred to psychiatry.
  • Treatment of behavioral health issues is thought to improve population and high risk care management.
  • Psychiatric referrals from South Huntington are now more limited to those involving patients who are truly beyond the scope of primary care practice.
  • Discontinuity of care has been lessened. Additionally, it is less likely that patients will get psychiatric care at an outside facility with a completely different EHR, resulting in lower risk of medication errors and other adverse events.
  • Primary care physicians are supported in their treatment of behavioral health needs, both through case review at weekly behavioral health rounds and through collaborative, longitudinal management of patients with behavioral health needs by a social worker and health support specialist.

Unique Challenges

  • In initial years, South Huntington’s reimbursement was predominantly fee-for-service, which did not provide as clear of a financial structure in which to run such a program.
  • Certain integral portions of the program - i.e. telephone calls - were not billable even though they were more efficient than an in-person appointment which would have been reimbursed.

Personnel Challenges

  • The program’s health support specialist is only supported for this work part-time and often feels stretched thin in her ability to follow-up with patients as the program’s caseload has grown.
  • It has been difficult to bring this program to practices with long traditions of providing traditionally organized rather than collaborative care, in which most patients needing psychiatric care are referred directly to psychiatry.

Relevant Metrics

2018 MIPS Quality Payment Program (QPP) Measures:

Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Providers may be able to improve their performance on a number of these metrics by integrating behavioral health programs into primary care. Sample metrics include:

  • Depression Remission at Twelve Months
    • The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit
  • Screening for Clinical Depression and Follow-Up Plan
    • Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

More details about measures included in the QPP set can be found here.

Medicare Shared Savings Program (MSSP) ACOs:

Clinics associated with an MSSP ACO are required to report their performance on measures for Depression Remission at Twelve Months and Screening for Clinical Depression and Follow-Up Plan. More information about these measures and requirements can be found here.


Integrating a behavioral health program such as Collaborative Care for Depression into primary care may help practices meet a number of NCQA Patient Centered Medical Home 2017 Standards. Potential opportunities include:

  • KM-03- Conducts depression screenings using a standardized tool
  • KM-04- Conducts behavioral health screenings or assessments for at least 2 of the following: anxiety, alcohol use disorder, substance use disorder, pediatric BH screening, post-traumatic stress disorder, ADHD, postpartum depression
  • CM-04- A person-centered care plan is established for care management patients.
  • CC-10- A behavioral health provider is integrated into the practice’s delivery system

More information can be found here.

HEDIS Depression-Related Measures:

Related HEDIS measures for 2018 include:

  • Depression Screening and Follow-up for Adolescents and Adults 
  • Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
  • Depression Remission or Response for Adolescents and Adults
  • Unhealthy Alcohol Use Screening and Follow-Up

More information can be found here for depression measures and here for the alcohol use measure.

Direct Billing:

Providers may be able to directly bill for many of the services provided through Collaborative Care for Depression programs. For example, as of 2017, providers can bill CMS for counseling and care management services using BHI-specific codes (more information available here).

South Huntington’s Behavioral Health Workflow (Majzoub-Perez et al. Healthcare 2015)

South Huntington’s Behavioral Health Workflow (Majzoub-Perez et al. Healthcare 2015)

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