Our findings build on prior research illustrating that IBH in primary care not only leads to increased provider satisfaction [8, 9] but also increases access to behavioral health treatment for patients and care coordination [11, 13, 14], providing additional insight into the factors that contribute to, or impede, satisfaction. This study demonstrates important aspects of IBH that contribute to provider satisfaction, demonstrating that IBH services in primary care settings require attending to both organizational and relational aspects of IBH. Both organizational and relational components had an influence on provider satisfaction, and the odds of referral for IBH clinics were higher than non-IBH sites, underscoring the increase in mental and behavioral health care access for typically medically underserved populations. In addition, results indicated significant reductions in days to an BHP appointment in the post-integration timeframe compared to pre-integration. Analysis of the open-ended question revealed two main themes that provided greater context and insight into the process of IBH service delivery: 1) positive regard for the value of IBH and 2) organizational barriers to IBH.
Organizational drivers of provider satisfaction included the immediate availability of BHP; however, open-ended responses revealed major frustrations when BHP were not available or accessible. This issue is not unique to this particular healthcare system and may impact provider satisfaction with IBH. Shortages of behavioral health specialists have been a long-standing concern nationally [23, 24], with major shortages estimated to continue through 2025 [25]. This need has increased since the onset COVID-19 pandemic [23, 26]. BHP face a high rate of burnout which may lead to poor morale, reduced commitment to the organization, depersonalization, intent to leave, and ultimately higher rates of turnover [23, 27], which may be contributing to staffing challenges raised by survey respondents. Without systems to ensure accessible and equitable mental health care, these services continually fail to meet the needs of the most vulnerable, under-resourced patients. Given the well-documented success of IBH implementation [28], including both patient outcomes and satisfaction with behavioral health integration into primary care, access to providers is imperative. Healthcare systems must recruit and retain talent by addressing burnout, offering student loan repayment, signing bonuses, and incentives offered to physicians.
The Health Resources and Services Administration recently funded several rounds of the Behavioral Health Workforce Education and Training (BHWET) Program for Professionals in the United States. As of 2018, 3,523 new behavioral health social workers entered the field and has undoubtedly increased since the years that additional BHWET funding was awarded [29]. This presents an opportunity for health practitioners such as social workers, licensed professional clinical counselors, psychologists, and primary care providers to be adequately and competently trained to address clients’ and patients’ complex needs, integrating knowledge from human behavior, psychology, and medicine, among other fields, to develop an appropriate and effective intervention or treatment plan in collaboration with colleagues.
Our quantitative and qualitative findings indicate that relational drivers of provider satisfaction include an established workflow that supports care continuity. These findings are consistent with previous research on successful IBH that demonstrates key facilitators of a supportive clinical environment included primary care and BHP collaborations [6, 15, 30]. These partnerships should be established from the onset of implementing IBH to help ease any early provider dissatisfaction during the early phases of IBH implementation [31]. As the present study’s open-ended responses suggest, continuity and care coordination must be maintained to manage potential frustrations. These findings are supported by prior research highlighting that care coordination is a central organizational factor for successful IBH, which can be achieved through shared notes, communication via emails, phone, video conferencing, and in-person [10, 31, 32].
Limitations and Future Research
Several key limitations must be noted. First, the demographic data of survey respondents was not collected to protect the confidentiality of a small survey pool of healthcare providers. Consequently, we could not determine the influence of respondents’ social identities or positions on their experiences and satisfaction with IBH. Future research should also explore the relationships between provider and patient satisfaction, considering individual characteristics of patients and providers and site-level characteristics. In addition, because behavioral health visits were limited to one year from the referral order, truncation bias may be present; analyses with a larger window may yield larger effects. Variations in IBH rollout processes could not be accounted for, as such, further research is needed to understand the pre- and post-IBH implementation implications on provider satisfaction and patient outcomes. While a structured pre-integration IBH protocol was provided to clinics, open-ended questions indicated that knowledge of systems in place and logistics of IBH care needs improvement. There are several intensive pre-assessment and training protocols, but a brief, targeted rollout process to create a best practice may improve outcomes.