Across Medicare, Medicaid, and commercial contracts, performance now depends on outcomes that behavioral health directly influences. Medication adherence, chronic disease management, avoidable utilization, and total cost of care all move in the wrong direction when depression, anxiety, substance use, or serious mental illness go unaddressed. While many practices recognize this, few have found a model of behavioral health integration that works in real life.
Why Behavioral Health Integrations Matter in VBC
Patients with untreated behavioral health conditions:
- Miss appointments more often
- Struggle to manage chronic conditions
- Experience higher rates of ED visits and hospitalizations
- Have lower medication adherence
- Report lower satisfaction and trust in care
In a fee-for-service world, these issues were frustrating but often invisible. In value-based models, they directly affect quality scores, shared savings, and financial performance. Integration is no longer optional; it is foundational to success in risk-based contracts.
What’s Working
- Embedding Behavioral Health into Primary Care Workflows: Practices that succeed treat behavioral health as part of routine care. They consistently screen patients for depression, anxiety, and substance use during annual wellness visits and chronic care visits. They normalize the conversation and use validated tools (PHQ-9 and GAD-7) as part of standard intake and follow-up. Most importantly, they act on results in the same visit. When a patient screens positive, someone intervenes, whether that is a behavioral health provider, a care manager, or a trained nurse. This reduces the gap between identification and treatment, where many patients fall through the cracks.
- Using Care Management as the Bridge: If practices lack the volume or resources to hire a full-time behavioral health clinician, they can train case managers and nurses to address mild to moderate behavioral health needs and coordinate care for more complex cases. This model aligns well with Chronic Care Management, Principal Care Management, and other value-based care infrastructure that practices already use.
- Leveraging AWVs and Preventive Care: AWVs provide a structured opportunity to assess behavioral health risk in a setting designed for prevention. Practices that use AWVs effectively to prevent behavioral health issues from growing into utilization problems in the future:
- Identify depression and cognitive concerns early
- Review medication lists for interactions that affect mood and cognition
- Identify social isolation and safety risks
- Establish trust that makes patients more open to discussing mental health
- Tight Coordination with Community Resources: To close the loop and prevent referrals from becoming dead ends:
- Share information when appropriate
- Track whether the patient completed the visit
- Follow up after outside appointments
- Coordinate treatment plans
- Build strong relationships with local behavioral health providers, social services, and substance use programs
- Data-driven Identification At-risk Patients: Value-based organizations are using data to identify patients with patterns that suggest underlying behavioral health issues, such as medication nonadherence, repeated no-shows, poor chronic disease control, and/or frequent ED use without a clear medial cause. These patients are flagged for outreach and screening, even if they have never discussed mental health concerns.
What is NOT Working
- Relying Only on Referrals to External Behavioral Health Providers: The traditional workflow of handing a patient a referral often fails. Patients face long wait times, transportation issues, stigma, and confusion about where to go. Many never schedule that appointment or attend once and never return. Without active follow-up from the primary care practice, the referral rarely translates into meaningful engagement.
- Treating Behavioral Health as a Separate Program: Some practices create behavioral health initiatives that live outside daily workflows. Staff see it as an extra task rather than part of routine care. Screenings are skipped when the clinic is busy, results are documented but not addressed, and follow-up depends on individual initiative rather than a defined process. True integration only works when it is embedded into how the practice already operates.
- Lack of Training Among Staff: Many clinical and non-clinical staff feel unqualified to talk about behavioral health. They worry about saying the wrong thing or opening a conversation they cannot manage. Without training and clear protocols, staff avoid the topic or rush through screenings without meaningful engagement. This leads to underreporting and missed opportunities for intervention.
- Understanding the Impact on Value-based Care: Some practices still view behavioral health as a secondary concern rather than a driver of quality and cost outcomes. As a result, they invest time and resources into coding, documentation, and reporting, but not into the patient factors that influence those metrics the most.
How Providers Can Move Forward
Successful practices:
- Make behavioral health screening a standard part of preventive and chronic care visits.
- Train care managers and nursing staff to address mild to moderate needs and coordinate care.
- Define clear workflows for positive screenings and referrals.
- Use data to identify patients who may need intervention.
- Treat behavioral health conversations as routine.
Behavioral health integration is one of the most effective levers providers have to improve outcomes, reduce avoidable utilization, and succeed in value-based models. What works is consistent processes, trained staff, and follow-through.