Integration as Both Standard of Care and Standard of Training

We appreciate the recognition of our work by Drs Peter Cronholm and Benjamin Wolk, and their desire to start a discussion on strategies for accelerating workforce development in integrated behavioral health. Our team believes that integration (ie, interdisciplinary and team-based) should be the standard of care in the United States and the standard of training for graduate medical education (GME) in primary care.

The realities of patients with mental and behavioral health concerns seeking treatment, largely in primary care settings, are well documented.^1-3 While recommendations for GME training in primary care have been promoted, no unifying standard exists.⁴ Additionally, while the Accreditation Council for Graduate Medical Education (ACGME) requires family medicine residents to receive training in the diagnosis and intervention of mental health concerns, no requirements or standards have been set related to working on or leading integrated teams.⁵ Although there are no required standards for integrated care training in family medicine, family medicine residencies appear to be on the forefront among primary care specialties in focusing on team-based holistic care. Thus, while we took a beginning step for training future FM residents in integrated care, much work is still needed to assess how the 21 competencies we identified apply to other specialties within the realm of primary care (eg, pediatrics, internal medicine, etc.)

We agree with the excellent points Drs Cronholm and Wolk made about the vital role that accreditation bodies like the ACGME play in this discussion. The ACGME should provide clear direction on the skills that residents need to successfully work within interdisciplinary care teams. To date, that has not happened. Training programs also need easy access to a central repository of high-quality, competency-based modules as well as technical assistance for practice transformation that supports integration. We believe that such training and technical assistance should be financially supported by federal entities like Health Resources and Services Administration and the Substance Abuse and Mental Health Services Administration, not by the ACGME.

In addition to the next steps recommended by Drs Cronholm and Wolk, we propose four steps to accelerate workforce development for integrated care. First, develop a competency-based curriculum that residency training programs can adapt and use for their own needs. Our team has developed such a curriculum and preliminary data suggests that residents value the training and report higher knowledge and confidence in working in integrated behavioral health teams. Second, develop a validated measure of medical provider self-efficacy in behavioral health integration as a tool for developing personalized learning pathways and assessing performance. Third, determine the fit of our competencies with other primary care disciplines (eg, pediatrics, internal medicine, advanced practice providers). Our team is actively working on steps two and three. Fourth, involve national accreditation and workforce development bodies in making integrated care the standard of graduate medical training in primary care.