Behavioral Health-Works (BH-Works) is a proven web-based system for integrating behavioral health screening, triage and prevention services into medical, school and mental health services settings. The BH-Works Program consists of provider education, web-based screening, and assisting in building a strong behavioral health care environment. The centerpiece of this program is the Behavioral Health Screening tool (BHS). The BH-Works program has been in use at the Children’s Hospital of Philadelphia Emergency Department since 2007, and is currently in use at over 40 primary care offices, crisis centers, and student health centers across the state of Pennsylvania. A proven solution for screening, prevention, and treatment of mental health issues for numerous healthcare settings, BH-Works can be rapidly deployed into primary care, emergency departments, colleges/universities and schools across the United States, as well as internationally.

Behavioral Health-Works: A systems change approach to health care integration

For the past ten years our team has programmatically developed and studied clinical and informatics solutions integrating behavioral health into primary care. Rather than study a single strategy or component (e.g., screening), we take a “systems change” approach consistent with implementation science models that encourage the simultaneously targeting of structural (e.g. policy), organizational (e.g. leadership) provider, patient and the intended innovation (Caudoir, Dugan & Barr, 2013). Therefore, BH-Works integrates a set of procedures, trainings and resources to change the culture of medical environment:

1. Provider Training
2. Web-based Screening
3. Family Engagement
4. Building the BH community
5. Information Exchange

Component #1: Medical Provider Training in Suicide Risk Assessment.

It has been well documented that medical staff feel they lack adequate training in suicide risk assessment (Feldman et al., 2006; Mann & Tylee, 1998). Therefore, this model begins with educating medical providers in suicide risk assessment and patient engagement strategies. For this component, we will implement a one-hour, web-based suicide risk training developed by the American Association of Suicide (AAS, 2012).

Component #2: Web-based, standardized assessment of suicidal patients.

Even with education, medical and behavioral health professionals may not have the time or skills to accurately identify a patient’s level of suicidal risk. Therefore, we developed the Behavioral Health Screen (BHS), a brief but comprehensive, web-based screening/assessment tool of the tool takes seven minutes to complete and provides an instant report profiling psychiatric syndromes as well as multiple risk behaviors and experiences (e.g., exposure to violence, history of abuse. etc). This screen is scored automatically and a report is instantly printed and can be integrated into the electronic medical record (EMR) with the data aggregated for quality improvement reporting.

Component #3: Family and Patient Engagement.

A critical challenge for medical staff is what to say to patients and parents once they have completed the suicide risk assessment and indicated a course of treatment (Spirito et al., 2002). To address this challenge, we borrow procedures from the first session of Attachment-Based Family Therapy (Diamond et al., 2010). These clinical strategies are purposefully designed to engage teens and parents as well as to motivate them to engage in treatment.

Component #4: Enhanced Information Exchange between Emergency Department, Primary Care, Mental Health Providers and Psychiatric Hospitals.

Medical providers consistently complain that once a patient is identified, finding referral options (outpatient or inpatient) is the most time-consuming and frustrating part of the discharge planning process (Rhodes et al., 2005; Rhodes et al., 2009; Miller & Druss, 2001). This grant will thus concentrate our informatics efforts to address these challenges. These efforts include an electronic resource guide, searchable by insurance and zip code and populated electronically by participating mental health providers. The BH-Works will then enable the emergency department staff to a) send the BHS report to registered mental health providers through a HIPPA protected portal, b) send family members automated e-mail, phone or text reminders about appointment times, and c) allow the mental health provider to respond back when the patient has attended or not. These functions exist in other MDLogix products and will be integrated into the BH-Works system. This component will also have a daily census of available inpatient psychiatric beds, updated by participating psychiatric hospitals.

Component #5: Increased collaboration between the medical and mental health communities.

The medical and behavioral health communities typically have minimal communication (Knesper, 2010; Ballard et al., 2008). To narrow this gap, we will use procedures identified in the Suicide Screening in Primary Care Tool Kit and the mental health tool kit, developed by the American Association of Pediatrics (AAP, 2012). These tools kits offer several strategies for relationship development including: collaborative problem solving meetings, assigned specific liaisons between the systems and joint in-services, which are some of the strategies we have found successful (Diamond et al., under review). Ongoing cross-discipline stakeholder meetings will also assist with closing the communication gap.

Behavioral Health Screen (BHS)

The Behavioral Health Screen (BHS) was developed by the Center of Family Intervention Science through collaboration between clinical investigators at the Children’s Hospital of Philadelphia (“CHOP”) and University of Pennsylvania and the Baltimore-based Medical Decision Logic, Inc. (“mdlogix”), a leading provider of health informatics solutions and services, to address the need for comprehensive behavioral health screening in primary care.

The BHS was designed for an adolescent and young adult patient population and consists of psychiatric symptom scales and risk behaviors that cover all the psychosocial areas suggested by best practice guidelines. The items were reviewed by a team of 20 national experts and by several physician focus groups. The BHS contains 61 core items with an additional 48 embedded items that are presented when certain items are positively endorsed. In addition to primary care, the BHS can be utilized for adults and in emergency departments and schools. Depending on the number of problems endorsed, it takes about 5 to 10 minutes to complete the BHS.

Typically, a patient or student will complete this screen before an in-person meeting with a medical provider. The system will score the report instantaneously and generate a report that the provider reviews before meeting with the patient or student. The BHS can be administered when a patient/student is identified as “at-risk” or as part of regular universal screening for all patient/students.