Unpacking Sustainability: An Examination of Factors Influencing Integrated Behavioral Health in Federally Qualified Health Centers (FQHCs)

This dissertation examines the key factors influencing the sustainability of integrated behavioral health (IBH) services in Federally Qualified Health Centers (FQHCs). As IBH models gain prominence for improving holistic patient care, understanding their long-term viability is important. Behavioral health conditions affect over 58 million U.S. adults, yet more than half do not receive adequate treatment (Newton, 2020; Reinert et al., 2021). Given the well-documented links between mental and physical health, integrating behavioral health with primary care offers significant benefits, including improved treatment outcomes, reduced healthcare costs, decreased emergency department utilization, and enhanced patient quality of life (Asarnow et al., 2015; Butler et al., 2008; Gerrity, 2015; Thapa et al., 2021). Despite these advantages, IBH programs face sustainability challenges due to workforce shortages, inconsistent funding, and regulatory constraints. This study investigates the internal and external factors that influence IBH sustainability within FQHCs and explores similarities and differences across diverse settings.

Using an explanatory, sequential mixed-methods approach, including surveys, semi-structured interviews, and facilitated discussion, this research identifies critical determinants of IBH success. Internally, leadership support, workforce stability, staff training, and effective communication emerged as key factors. Strong interdisciplinary leadership facilitated collaboration and ensured that IBH remained an organizational priority. Workforce retention strategies and proactive recruitment efforts were essential to addressing provider shortages, while comprehensive staff training improved competencies and closed cultural and operational gaps. Effective communication strategies, including shared tools and team-based approaches, reinforced collaboration and care coordination. Summary (continued)

Externally, partnerships, funding mechanisms, and policy frameworks played significant roles. Collaborations with local organizations and academic institutions enhanced resource sharing and addressed social determinants of health. However, funding sustainability remained a challenge due to reimbursement complexities and reliance on short-term grants. Policy frameworks, such as Medicaid expansions and telehealth provisions, were important enablers, though regulatory misalignments sometimes hindered progress. Community engagement, cultural responsiveness, and stigma reduction efforts were also important for improving IBH accessibility and effectiveness.

The study’s findings inform recommended practices for sustaining IBH, including comprehensive training programs, strategic collaborations, and leadership commitment to fostering a culture of innovation. Financial sustainability through value-based payment models and diversified funding streams was emphasized as essential. Integrating community health workers proved effective in improving patient outcomes and reducing costs. Ongoing professional development, needs assessments, and patient feedback mechanisms were recognized as important for ensuring adaptability and continuous improvement.

These insights offer practical strategies for strengthening IBH sustainability within FQHCs and beyond, contributing to improved healthcare access and outcomes in diverse primary care settings.