With the recent implementation of the Affordable Care Act, health care reform has encouraged the integration of health care systems and acknowledged the value of complimentary/alternative medicine. This has created a window of opportunity for the CCUIH to develop and establish sustainable models that integrate primary care with behavioral health, while asserting the need for cultural integrity valued by American Indians, through our Traditions of Health Project.
As part of our Traditions of Health Project, CCUIH adapted SAMHSA’s Six Levels of Integration Tool to incorporate cultural perspectives and introduce traditional healing into primary care and behavioral health integration. This page displays this adapted tool, starting with the Core Descriptions of the Six Levels of Collaboration/Integration. The second table details the Key Differentiators of the Six Levels of Collaboration/Integration: Clinical Delivery, Patient Experience, Organization, Traditional Healing, Business Model, and Traditional Health Sustainability. These characteristics help differentiate the levels and incorporate some functional categories that are important to consumer and staff experiential perspectives of the levels of integration. The last table describes the Advantages and Weaknesses at Each Level of Collaboration/Integration, so that these can be built upon or addressed.
Based on this adapted SAMHSA tool, CCUIH has also devised a survey to assess the integration of primary care, behavioral health, and traditional healing for our member UIHOs. The results of this survey will inform CCUIH’s development of a culturally relevant Integration Model and will be used by CCUIH to provide our member UIHOs with technical assistance to implement this model. While we have received many responses to the survey, we are still collecting data to improve our breadth of knowledge, so if you are a CEO, Medical Director, Behavioral Health Director, or Chief Operating Officer of a CCUIH member UIHO who has not completed the survey yet, please to complete this survey at your earliest convenience, which you can find here.
Core Descriptions of the Six Levels of Collaboration/Integration
| COORDINATED |
CO-LOCATED |
INTEGRATED | |||
| LEVEL 1: Minimal Collaboration | LEVEL 2: Basic Collaboration at a Distance | LEVEL 3: Basic Collaboration Onsite | LEVEL 4: Close Collaboration Onsite with Some System Integration | LEVEL 5: Close Collaboration Approaching an Integrated Practice | LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice |
| Behavioral health, primary care, traditional health, and other healthcare providers work: | |||||
| In separate facilities where they: | In separate facilities where they: | In same facility not necessarily same offices, where they: | In same space within the same facility, where they: | In same space within the same facility (some shared space), where they: | In same space within the same facility, sharing all practice space, where they: |
| > Have separate systems
> Communicate about cases only rarely and under compelling circumstances > Communicate, driven by provider need
> Communicate, driven by patient request
> Communicate, driven by community request
> May never meet in person
> Have limited understanding of each other’s roles
> Have limited understanding of each other’s healing modalities
> Have limited understanding of each other’s capacity
> Skeptical about each other’s effectiveness in practice
> Have no institutional support for collaboration |
> Have separate systems
> Communicate periodically about shared patients > Communicate, driven by specific patient issues
> Communicate, driven by client request
> Communicate, driven by community request
> May meet as part of larger community
> Have a theoretical understanding of each other’s practice
> Appreciate each other’s roles as resources
> Have little-to-no institutional support for collaboration |
> Have separate systems
> Communicate regularly about shared patients, by phone or email
> Collaborate, driven by operational standards > Collaborate, driven by need for each other’s services and more reliable referral
> Meet occasionally to discuss cases due to close proximity
> Feel part of a larger yet non-formal team
> Have basic understanding of each other’s practice
> Have respect for each other’s practice
> Have some support for collaboration
> Lack operational structure
> Lack of formal protocol for collaboration |
> Share some systems, like scheduling or medical records
> Communicate in person as needed > Collaboration, driven by need for consultation and coordinated plans for difficult patients
> Have regular face-to-face interactions about some patients
> Have a basic understanding of roles and culture
> Have respect for each other’s practice
> Have some institutional support for collaboration
> Lack a basic operational structure
> Lack of formal protocol for collaboration |
> Actively seek system solutions together or develop work-a-rounds
> Communicate frequently in person
> Collaborate, driven by desire to be a member of the care team
> Have regular team meeting to discuss overall patient care and specific patient issues
> Have an in-depth understanding of roles and culture
> Have institutional support and encouragement for collaboration
> Have a basic operational structure
> Have general protocol for collaboration, but lack QI structure to ensure collaboration |
> Have resolved most or all system issues, functioning as one integrated system
> Communicate consistently at the system, team and individual levels
> Collaborate, driven by shared concept of team care
> Have formal and informal meetings to support integrated model of care
> Have roles and cultures that blur and blend
> Have institutional support and expectation of collaboration
> Have a comprehensive operation structure
> Have a comprehensive QI structure to ensure continued quality improvement |
Key Differentiators of the Six Levels of Collaboration/Integration
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COORDINATED CO-LOCATED
INTEGRATED LEVEL 1: Minimal Collaboration LEVEL 2: Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice Screening and assessment based on separate PC/BH practice models Screening and assessment based on separate PC/BH practice models, but information may be shared through formal requests PC and BH agree on some specific screenings or other criteria for more effective in-house referral PC and BH agree on some specific screenings, based on ability to respond to results PC and BH have a consistent set of agreed upon screenings across disciplines, which guide treatment interventions All practitioners use standard practice of using population-based PC and BH screenings, with results available to all and response protocols in place Separate treatment plans for BH and PC Separate treatment plans shared based on established relationships between specific providers Separate treatment plans with some shared information that informs them Collaborative treatment planning for specific patients Collaborative treatment planning for all shared patients One collaborative treatment plan for each patient Treatment plans managed by individual providers Some joint plan management in specific issues Providers form a care management team for complex care management – high risk patients only Providers form a care management team for complex care management – high risk patients only Most patients receive integrated panel management All patients receive integrated panel management Evidence-based practices (EBP) implemented separately Separate responsibility for care/EBPs Some shared knowledge of each other’s EBPs, especially for high utilizers Some EBPs and training shared, focused on interest or specific population needs EBPs shared and respected across system with some joint monitoring of health conditions for some patients EBPs are team selected, trained and implemented across disciplines as standard practice CDPs are not considered valid by PC and BH providers Providers have some understanding of CDPs Some use of CDPs , with some shared knowledge, especially for high utilizers Some CDPs and training shared, focused on interest or specific population needs CDPs shared and respected across system with some joint monitoring of health conditions for some patients CDPs are team selected, trained and implemented across disciplines as standard practice -
COORDINATED CO-LOCATED
INTEGRATED LEVEL 1: Minimal Collaboration LEVEL 2: Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice Physical and behavioral health needs are treated as separate issues
Health needs are treated separately, but records are shared, promoting better provider knowledge
Health needs are treated separately at the same location
Patient needs are treated separately at the same site, collaboration might include warm hand-offs to other treatment providers
Patient needs are treated as a team for shared patients and separately for others All patient health needs are effectively treated for all patients by the team
Patient must negotiate referrals with varying degrees of success
Patients may be referred, but variety of barriers may prevent access
Co-location improves success of referrals, although who gets referred may vary by provider
Patients are internally referred with follow-up, with occasional collaboration
One-stop shop; care is responsive to patient needs by a team of providers Unified practice; patients experience a seamless response to all healthcare needs
No care coordination
Care coordination is solely dependent on panel management (No designated care coordinator, case manager, etc.)
Care coordination is solely dependent on panel management (No designated care coordinator, case manager, etc.)
Providers use EHR notes to track referrals
Designated care coordinator or case manager for high-risk patients
Providers use EHR notes to track referrals
At least one full-time dedicated staff focused solely on care coordination for each patient
At least one full-time dedicated staff focused solely on care coordination for each patient
Designated care coordinator tracks access, service, follow up
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COORDINATED CO-LOCATED
INTEGRATED LEVEL 1: Minimal Collaboration LEVEL 2: Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice No coordination or management of collaborative efforts
Some practice leadership in increasing systematic information sharing
Organization leaders supportive of integration, systematic information sharing
Organization leaders support integration through mutual problem-solving of some system barriers
Organization leaders support integration, efforts placed in solving as many system issues as possible, without changing fundamentally how disciplines are practiced
Organizational leaders strongly support integration as practice model with expected change in service delivery, and resources provided for developmen
Little provider buy-in to integration or even collaboration
Some provider buy-in to collaboration and value placed on having needed information
Provider buy-in to making referrals work and appreciation of onsite availability More buy-in to concept of integration but not consistent across providers, not all providers using opportunities for integration or components
Nearly all providers engaged in integrated model. Buy-in may not include change in practice strategy for individual providers
Integrated care and all components embraced by all providers and active involvement in practice change
No care coordination
Care coordination is solely dependent on panel management (No designated care coordinator, case manager, etc.)
Care coordination is solely dependent on panel management (No designated care coordinator, case manager, etc.)
Providers use EHR notes to track referrals
Care coordination only for high-risk patient
Providers use EHR notes to track referrals
At least one full-time dedicated staff focused solely on care coordination for each patient
Full-time dedicated staff focused solely on care coordination for each patient.
Designated care coordinator tracks access, service, follow up
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COORDINATED CO-LOCATED
INTEGRATED LEVEL 1: Minimal Collaboration LEVEL 2: Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice Separate Funding
Separate Funding
Separate Funding
Separate funding, but may share grants
Blending funding based on contracts, grants or agreements
Integrated funding, based on multiple sources of revenu No sharing of resources
May share resources for single projects
May share facility expenses
May share office expenses, staffing costs, or infrastructure
Variety of ways to structure the sharing of all expenses
Resources shared and allocated across whole practice
Separate billing practices
Separate billing practices
Separate billing practices
Separate billing due to system barriers
Billing function combined or agreed upon process
Billing maximized for integrated model and single billing structure
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COORDINATED CO-LOCATED
INTEGRATED LEVEL 1: Minimal Collaboration LEVEL 2: Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice No institutional support for collaboration with Traditional Healers
Have little-to-no institutional support for collaboration with Traditional Healers
Have some institutional support for the use of Traditional Practices
Institutional knowledge and support for Traditional Healing access for patients
Institutional knowledge and support for the integration of Traditional Healing into system of care
Institutional support for the implementation and success of a completely integrated model, where Traditional Healing is treated with the same value as Primary Care and Behavioral Health practices
Separate treatment plans for BH and PC Separate treatment plans shared based on established relationships between specific providers Separate treatment plans with some shared information that informs them Collaborative treatment planning for specific patients Collaborative treatment planning for all shared patients One collaborative treatment plan for each patient Traditional Healers are not validated through licensure/certification or evidence-based practices; therefore, are not acknowledged as practicioners
Traditional Healers are acknowledged as community-defined practitioners that are utilized outside of the clinic setting, and are not acknowledged as ancillary to the continuum of care
Traditional Healers are acknowledged as community-defined practitioners that are utilized outside of the clinic setting, and are acknowledged as ancillary to the continuum of care
Traditional Healing may still be considered an ancillary service, Traditional healing is still treated as a separate service
Traditional Healing is no longer considered an ancillary service
Traditional Healing is no longer considered an ancillary service
Evidence-based practices (EBP) implemented separately Separate responsibility for care/EBPs Some shared knowledge of each other’s EBPs, especially for high utilizers Some EBPs and training shared, focused on interest or specific population needs EBPs shared and respected across system with some joint monitoring of health conditions for some patients EBPs are team selected, trained and implemented across disciplines as standard practice CDPs are not considered valid by PC and BH providers Providers have some understanding of CDPs Some use of CDPs , with some shared knowledge, especially for high utilizers Some CDPs and training shared, focused on interest or specific population needs CDPs shared and respected across system with some joint monitoring of health conditions for some patients CDPs are team selected, trained and implemented across disciplines as standard practice -
COORDINATED CO-LOCATED
INTEGRATED LEVEL 1: Minimal Collaboration LEVEL 2: Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice Separate Funding Separate Funding
Separate Funding
Separate funding, but may be funded by grant for a brief period or for limited contracted services
Traditional healers still typically not considered staff
Blending funding based on contracts, grants or agreements
Integrated funding, based on multiple sources of revenue No sharing of resources
No sharing of resources
No sharing of resources
May share office expenses, but no support for outside space costs or supplies
Traditional Healing is always considered in development plans
Resources shared and allocated across whole practice
Traditional Protocol is followed for payment i.e. tobacco, wood, food, cultural gifts. This is fine, but not sustainable in this time period.
Traditional Protocol is followed for payment i.e. tobacco, wood, food, cultural gifts. This is fine, but not sustainable in this time period.
Traditional Protocol is followed for payment i.e. tobacco, wood, food, cultural gifts. This is fine, but not sustainable in this time period.
Billing for Traditional Healing being considered and planned for the future
Billing function for Traditional Healing being tested through innovative funding options
Billing maximized for integrated model and single billing structure
Traditional Healers will often provide services without payment out of respect for cultural protocol and their commitment to their role in the community.
Often times no payment is provided because the institution views this as a community service
May receive payment for providing a one-time service through grant funding (relate to a specific project) or other institutional means, but payment never includes cost of medicines, travel, preparation, etc.
May receive payment for providing a one-time service through grant funding (relate to a specific project) or other institutional means, but payment never includes cost of medicines, travel, preparation, etc.
Variety of ways to structure the sharing of all expenses
State-level policy change to support billing for complimentary/alternative medicines i.e. Traditional Healing
Advantages and Weaknesses of Traditional Healing at Each level of Collaboration/Integration
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COORDINATED CO-LOCATED
INTEGRATED LEVEL 1: Minimal Collaboration LEVEL 2: Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice ADVANTAGES Each Practice can make timely and autonomous decisions about care Readily understood as a practice model by patients and providers
Maintains each practice’s basic operating structure, so change is not a disruptive factor Provides some coordination and information-sharing that is helpful to both patients and providers
Co-location allows for more direct interaction and communication among professionals to impact patient care Referrals more successful due to proximity
Opportunity to develop closer professional relationships
Removal of some system barriers, like separate records, allows closer collaboration to occur Both behavioral health and medical providers can become more well-informed about what each can provide
Patients are viewed as shared which facilitates more treatment plans
High level of collaboration leads to more responsive patient care, increasing engagement and adherence to treatment plans Provider flexibility increases as system issues and barriers are resolved
Both provider and patient satisfaction may increase
Opportunity to truly treat whole person All or almost all system barriers resolved, allowing providers to practice as a high functioning team
All patient needs addressed as they occur
Shared knowledge base of providers increases and allows each professional to respond more broadly and adequately to any issue
WEAKNESSES Services may overlap, be duplicated or even work against each other Important aspects of care may not be addressed or take a long time to be diagnosed
Sharing information may not be systematic enough to effect overall patient care No guarantee that information will change plan or strategy of each provider
Referrals may fail due to barriers, leading to patient and provider frustration
Proximity may not lead to greater collaboration, limiting value Effort is required to develop relationships
Limited flexibility, if traditional roles are maintained
System issues may limit collaboration Potential for tension and conflicting agendas among providers as practice boundaries loosen
Practice changes may create lack of fit for some established providers Time is needed to collaborate at this high level and may affect practice productivity or cadence of care
Sustainability issues may stress the practice Few models at this level with enough experience to support value
Outcome expectations not yet established
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COORDINATED CO-LOCATED
INTEGRATED LEVEL 1: Minimal Collaboration LEVEL 2: Basic Collaboration at a Distance LEVEL 3: Basic Collaboration Onsite LEVEL 4: Close Collaboration Onsite with Some System Integration LEVEL 5: Close Collaboration Approaching an Integrated Practice LEVEL 6: Full Collaboration in a Transformed/Merged Integrated Practice ADVANTAGES Traditional Healing remains autonomous in decision making and protocol regarding care
Traditional Healing remains a community practice with no over site or input from institutionalized systems
Cultural integrity of practices remains intact and true to traditions and there are no challenges to the intellectual property of such practices
Traditional Healers maintain control over access for community individuals
Operational changes will not be disruptive to cultural protocol
Provides some coordination and information-sharing that is helpful to both patients and providers
Administrative burden for traditional systems will not be heightened
Co-location allows for more direct interaction and communication among professionals to impact patient care
Referrals more successful due to proximity
Opportunity to develop closer professional relationships
Respect for Traditional Healing within care systems becomes more progressive
Sustainability for Traditional Healing becomes more feasible
Removal of some system barriers, like separate records, allows closer collaboration to occur
Institutional leaders, behavioral health and medical providers can become more well-informed about Traditional Healing and what it can provide to the overall system of care and visa versa
Patients are viewed as shared which facilitates more treatment plansFosters movement toward integrated/holistic systems of care
Sustainability for Traditional Healing becomes more feasible
High level of collaboration leads to more responsive patient care, increasing engagement and adherence to treatment plans
Provider flexibility increases as system issues and barriers are resolved
Both provider and patient satisfaction may increase
Fosters movement toward integrated/holistic systems of care
Sustainability for Traditional Healing becomes more feasible
Opportunity to truly treat whole person All or almost all system barriers resolved, allowing providers to practice as a high functioning team
All patient needs addressed as they occur
Shared knowledge base of providers increases and allows each professional to respond more broadly and adequately to any issue
Sustainability for Traditional Healing becomes feasible
A holistic, culturally relevant system of care is operationalized and built to provide individual and community healing
WEAKNESSES Services may overlap, be duplicated or even work against each other Important aspects of care may not be addressed or take a long time to be diagnosed
Access to Traditional Healing and Culturally relevant systems of care become minimized
Sustainability of Traditional Healing is close to impossible
Sharing information may not be systematic enough to effect overall patient care No guarantee that information will change plan or strategy of each providerProvider opinions of one-another may never change
Referrals may fail due to barriers, leading to patient and provider frustrationInstitutional support for culturally relevant services may never change
Sustainability of Traditional Healing is close to impossible
Proximity may not lead to greater collaboration, limiting value
Effort is required to develop relationships
Limited flexibility, if traditional roles are maintained
Respect for space and outside location needs for Traditional Healers may never be considered
Institutional support for culturally relevant services may never change
Sustainability options for Traditional Healing remain limited
System issues may limit collaboration
Potential for tension and conflicting agendas among providers as practice boundaries loosen
Institutional and provider perspectives on Traditional Healing may still not be considered equal, but only as ancillary/secondary options
Administrative burdens may challenge the cultural integrity for the Traditional Healer and their practice
Sustainability options for Traditional Healing remain limited
Practice changes may create lack of fit for some established providers
Time is needed to collaborate at this high level and may affect practice productivity or cadence of care
Institutional and provider perspectives on Traditional Healing may still not be considered equal, but only as ancillary/secondary options
Administrative burdens may challenge the cultural integrity for the Traditional Healer and their practice
Sustainability options for Traditional Healing remain limited
Sustainability issues may stress the practice
There a minimal models at this level with enough experience to support valueOutcome expectations not yet established
Requires high-level systems/policy change to accept and sustain Traditional Healing and create a culturally-relevant holistic system of care
