Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care

Abstract

Purpose: This study sought to describe features of the physical space in which practices integrating primary care and behavioral health care work and to identify the arrangements that enable integration of care.

Methods: We conducted an observational study of 19 diverse practices located across the United States. Practice-level data included field notes from 2-4-day site visits, transcripts from semistructured interviews with clinicians and clinical staff, online implementation diary posts, and facility photographs. A multidisciplinary team used a 4-stage, systematic approach to analyze data and identify how physical layout enabled the work of integrated care teams.

Results: Two dominant spatial layouts emerged across practices: type-1 layouts were characterized by having primary care clinicians (PCCs) and behavioral health clinicians (BHCs) located in separate work areas, and type-2 layouts had BHCs and PCCs sharing work space. We describe these layouts and the influence they have on situational awareness, interprofessional "bumpability," and opportunities for on-the-fly communication. We observed BHCs and PCCs engaging in more face-to-face methods for coordinating integrated care for patients in type 2 layouts (41.5% of observed encounters vs 11.7%; P < .05). We show that practices needed to strike a balance between professional proximity and private work areas to accomplish job tasks. Private workspace was needed for focused work, to see patients, and for consults between clinicians and clinical staff. We describe the ways practices modified and built new space and provide 2 recommended layouts for practices integrating care based on study findings.

Conclusion: Physical layout and positioning of professionals' workspace is an important consideration in practices implementing integrated care. Clinicians, researchers, and health-care administrators are encouraged to consider the role of professional proximity and private working space when creating new facilities or redesigning existing space to foster delivery of integrated behavioral health and primary care.

Keywords: Behavioral Medicine; Delivery of Health Care; Integrated; Medical Office Buildings; Primary Health Care; Qualitative Research.

Figure 1.

Observed type 1 layout: primary care and behavioral health clinicians located in separate work areas.

Figure 2.

Observed type 2 layout: primary care and behavioral health clinicians located in shared work areas.

Figure 3.

Recommended floor plan example, open pod arrangement. BHC, behavioral health clinician; Case Mgr, case manager; MA, medical assistant; PCC, primary care clinician; RN, registered nurse; Sched, Scheduler.

Figure 4.

Recommended floor plan example, closed pod arrangement. BHC, behavioral health clinician; Case Mgr, case manager; EVS, environmental services; MA, medical assistant; PCC, primary care clinician; RN, registered nurse; Sched, Scheduler.