Introduction

More than 1.5 million adults in North Carolina experi­ence mental illness annually, with another 132,000 young people suffering from a major depressive episode.¹ Unfortunately, more than half of adults and youths fac­ing behavioral health challenges go without needed treat­ment due to lack of access to care.¹ Integrated behavioral health (IBH) seeks to transform traditional care deliv­ery to comprehensively address medical and behavioral health conditions in primary care settings.^2,3 Primary care settings are critical entryways for behavioral health care that can increase access for many North Carolinians.^3,4 This is especially important in North Carolina, which is ranked 38th among states for access to mental health care¹ and is experiencing a mental health professional short­age in 93 of 100 counties.⁵

What is Integrated Behavioral Health?

Integrated care models were developed to address unmet patient needs, especially complicating behavioral health con­ditions that are often overlooked within a fragmented health care delivery system. Team-based care is the cornerstone of integrated approaches as it allows professionals with differ­ent expertise to collaborate with patients to plan and deliver comprehensive and cost-effective services.⁶ Commonly adopted integrated care models include Collaborative Care Management (CoCM) and Primary Care Behavioral Health (PCBH).² Both address behavioral health concerns within primary care settings but are slightly different in terms of focus and collaborative structure. CoCM utilizes systematic screening for concerns (i.e., depression, anxiety) as a mech­anism for identifying behavioral health needs, and treatment is delivered by a team of behavioral health specialists, pri­mary care providers, and care coordinators. PCBH addresses a broader scope of behavioral health concerns and empha­sizes co-location of behavioral health and primary care providers to facilitate timely access to services.² Health systems have embraced different models based on system priorities, payor considerations, and provider preferences. In 2018, North Carolina launched primary care reimbursement codes that support CoCM delivery; rates were increased in 2022, leading to expansion of this model across the state.⁷

The Role of Behavioral Health Social Workers in Integrated Care

Integrated care models rely on behavioral health pro­fessionals to have a broad knowledge of behavioral health concerns, conduct universal screenings, and provide brief interventions to a wide range of patient populations. Professional social work competencies are well aligned with these integrated care practice skills.^8,9 Master of Social Work (MSW) programs focused on IBH provide unique training in delivering behavioral health services, as well as in addressing social drivers of health and providing culturally responsive services. Historically, behavioral health social workers have addressed mental health and substance use disorder, providing insurance-reimbursable services within private practice settings. Research suggests organizations utilizing CoCM and affiliate billing codes prefer to hire behavioral health social workers for psychotherapy billing purposes,¹⁰ and utilization of social workers in integrated care models is cost-effective.¹¹ Further, integrated care teams that include social workers demonstrate significantly improved mental health outcomes.¹² Through dedicated federal funding, behavioral health workforce development in social work education has evolved as it seeks to prepare MSW students to be responsive to patient needs and prac­tice settings.^13,14

Interprofessional education (IPE) is an essential aspect of training behavioral health social workers to deliver effective team-based care.^15,16 Strong IPE training supports learn­ers in mastering core competencies needed for interprofes­sional collaborative practice.¹⁷ IPE experiences should focus on developing students’ expertise and skills for effec­tive communication, conflict resolution, and leadership—all key ingredients for quality integrated care. IPE also provides opportunities to learn about, from, and with students from other health professions who will be collaborative partners in primary care settings.

Integrated Behavioral Health Training Programs Making a Difference

University of North Carolina at Charlotte

The UNC-Charlotte School of Social Work began its IBH program in 2017 with funding from the Health Resources and Services Administation Behavioral Health Workforce Education and Training Program. This IBH program strength­ens the pipeline of MSW graduates trained to deliver behav­ioral health interventions as part of team-based care, thereby increasing behavioral health care access at the population level. IBH scholars are MSW students in their advanced year of study who apply and are accepted into the program. They receive 50–60 hours of specialized training that includes: 1) screening and brief interventions to address issues such as suicidality, depression, anxiety, substance use, and chronic illnesses; 2) role of social workers within team-based-care models; 3) social drivers of health; and 4) interprofessional collaboration. Over time, the program has been responsive to evolving community needs by developing targeted train­ing in the areas of telehealth and behavioral health interven­tions for youth. IBH scholars implement their specialized training while completing 480 supervised practicum hours within various settings, including primary care, federally qualified health centers, outpatient specialty care, and com­munity clinics. These academic–community partnerships increase access to behavioral health services for many in the Charlotte region.

IPE is essential in preparing students to fully participate as team members in their practicum settings and as future professionals, and several initiatives were created to prepare MSW students for interprofessional collaborative practice. An IPE course, Interprofessional Collaboration in Healthcare, was created in partnership with the UNC-Charlotte School of Nursing. Since 2018, it has been taken by over 350 gradu­ate students in social work, nursing, public health, health psychology, and exercise physiology. Enrolled students work together as small interprofessional teams. They meet online and in video conferencing platforms to complete learning modules on client-centered care, team member roles, effec­tive communication, conflict resolution, team leadership, and continuous quality improvement. Teams then complete case-based learning assignments in which they collaborate to create interprofessional care plans in response to realistic scenarios. Evaluation data have revealed statistically signifi­cant improvement on measures of interprofessional social­ization and valuing, as well as interprofessional collaborative competencies. Qualitative data indicated that students ben­efited from the opportunity to practice communication and teamwork with learners from other professions, and that they believed the experience would enhance their profes­sional practice. An MSW student stated, “I have a lot more evidence-based strategies to pull from in my future interprofes­sional interactions and I am much more motivated to ensure that interprofessional collaboration is done correctly now that I know how much it affects the patient”.¹⁸

Experiential IPE provides opportunities for students to apply their knowledge and skills to patient care. One example is interprofessional student hot-spotting. In this six-month program, MSW students collaborated with medicine, phar­macy, nursing, and health psychology students from regional universities. In teams, they worked with medically and socially complex patients in the local community to identify their health needs and design interventions, with the goal of reducing emergency room visits and costs. Students received mentorship from faculty from each profession and presen­tations enhanced knowledge of social drivers of health, barriers to care, motivational interviewing, and medication adherence. Evaluation data indicated students gained valu­able collaborative care skills, such as leveraging their unique roles and practicing effective communication. Students were able to observe the benefits of interprofessional collabora­tion and learn approaches to care for complex patients.¹⁹

To date, IBH scholars have completed practicums in over 40 health settings. The program works closely with community partners to ensure students possess requisite knowledge and skills to holistically meet patients’ behav­ioral health needs and that practicum sites create a positive learning environment. IBH scholars offer therapeutic inter­ventions that patients may otherwise not have received, including psychoeducation, relaxation training, cognitive interventions, and support for health behavior change. Health providers working with IBH scholars are over­whelmingly positive when rating the quality of behavioral health services provided. All partnering health providers who completed the 2023 IBH program evaluation survey (N = 43) strongly recommended their colleagues offer IBH services and strongly agreed that the IBH schol­ars increased access to behavioral health services.¹⁹ Provider comments were similarly positive: “It is helpful to have someone to explore resources in the community to help patients and to provide counseling and SDOH resources for families” and “This has opened our patients up to a new way of care - the TLC, community benefits, and engagement the social work intern has been able to add to our team and patients has been incredible”.¹⁹ In patient satisfaction surveys, 90% to 100% of responding patients (N = 78) reported feeling respected and cared about, listened to, more knowledgeable about resources, and likely to recommend social work services to someone they knew.¹⁹

East Carolina University

IPE has a long history at East Carolina University that continues to expand. Among these efforts are the Interprofessional Task Force, an annual Developing Future Interprofessional Healthcare Leaders event sponsored by Truist Leadership Center, and the Office of Interprofessional Education and Practice. Only recently has the School of Social Work at ECU been added to the list of programs representing the behavioral health field in these activities.

As a 2023 pilot project, the School of Social Work launched an IPE course for graduate students: Interprofessional Education for Clinical Decision Making. The course included classroom presentations and discussions, video-based learning, and cross-campus experiential train­ing. For example, students participated in a bus tour of eco­nomically disadvantaged communities impacted by health disparities, shadowed social workers at the ECU Center for Telepsychiatry and e-Behavioral Health, participated as behavioral health providers at Brody School of Medicine simulations, and partook in a case study seminar with ECU School of Dental Medicine students. Feedback from partici­pating students has been overwhelmingly positive. Students in the social work IPE class completed surveys before and after class participation, including the SPICE-R2, which eval­uates perceptions of IPE and interprofessional collaborative practice. The MSW students (n = 13) agreed or strongly agreed that Participating in education experiences with stu­dents from different disciplines enhances my ability to work on an interprofessional team.

A joint case study between MSW and second-year dental students was a component of the IPE course. The aim was for students in each field to explore the benefits of hav­ing a behavioral health professional work in dental clinics. MSW students learned the oral signs of abuse, child neglect, drug addiction, and alcoholism. Dental students became educated about how past and current abuse—along with current mental health diagnoses, financial hardship, and everyday unmet needs—could affect a patient’s behavior and adherence to treatment plans. Examples of student reflections were: “Utilize each other and continue to learn and approach care from different perspectives to provide compre­hensive care” and “Very interesting to see the differences in perspective. We picked up on dental and medical issues and the social work students focused on the psychological and social history of the patient.” Of the dental and social work students who participated, 23 SPICER-R2 surveys were completed, revealing that they unanimously very strongly agreed that Patient/client satisfaction is improved when care is delivered by an interprofessional team. Belief in this partnership led the ECU School of Dental Medicine and School of Social Work to apply for a grant, which was awarded and will lead to estab­lishment of social work internships in dentistry.

Another IPE event involving MSW students as behavioral health providers allowed students from different disciplines to gain practice working with LGBTQ+ patients. This was a pilot Objective Structured Clinical Examination (OSCE) in which MSW students were evaluated on interprofessional collaborative competencies¹⁷ cross-walked with Council on Social Work Education (CSWE) competencies. MSW students participated with physician and nursing students. Of eight completed post-event surveys, all students strongly agreed that competent, interprofessional care is important for LGBTQ+ patients. An MSW student remarked, “It was good exposure both to interdisciplinary care and to the unique needs LGBTQ+ patients may face.” The experiential IPE learn­ing grew student appreciation for the value of interprofes­sional care in promoting patient well-being, and all students agreed or strongly agreed that the OSCE increased confi­dence in their ability to provide interprofessional care.

Conclusion/Recommendations

Social work can play a valuable role within integrated health care models, thereby improving access to behav­ioral health services and mental health outcomes in North Carolina. IBH programs work to ensure MSW students can practice effective interprofessional collaborative care by threading IPE through curricula.^6,15,18 Expanded invest­ments—including development and support for quality practicum sites—and increasing IPE exposure are important for IBH training programs to respond to patient behavioral health and workforce needs statewide.

Acknowledgments

This work was supported by the Health Resources and Services Administration (HRSA), an operating division of the U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Health Resources and Services Administration or the U.S. Department of Health and Human Services.

All authors report no conflicts of interest.