Health care reform is on the lips of our national dialogue. State and local communities are struggling to design organizational systems for health care reform while securing funding and resources for evidence-based clinical practices. There are multiple stakeholders with competing agendas in health care debates; among them are the advocates, providers, and policy makers who are committed to weaving together our long divorced biomedical and psychosocial systems of care. There are a growing number of vested individuals and teams that are championing the ­development and dissemination of information about the merits of integrated ­behavioral health care models, as evidenced by the proliferation of books and ­articles on integrated and collaborative health care that have mushroomed in the past decade. This explosion of literature, however, has resulted in a cacophony of voices with an array of uniquely designed collaborative approaches to integrated care. We have been inundated with interesting and innovative pilot studies but few unifying themes, cohesive evidence-based factors, or sustainable organizational policies for implementing systems-based integrated behavioral health care initiatives. Consequently, as a community of providers with a shared biopsychosocial mission, we are struggling to find our grounding and a unified language to advance our vision of health care reform. We are limited by our local “dialects” with no overarching concepts or objective templates to evaluate the benefits and limitations of our various models.

The vision for tomorrow’s health care system includes strengthening primary care using the Institute of Medicine’s principles of safety, timeliness, efficiency, efficacy and patient-centeredness. This future vision recognizes the importance of holistic patient care that stands firmly on a biopsychosocial foundation of prevention and primary care. Yet, weaving together the complex factors of biomedical and psychosocial systems, which have been long divided, is a perplexing and challenging enterprise. Even when policy makers, health care administrators, and clinicians have embraced the vision for integrated health care, they often flounder in a web of diverse cultures, different languages, competing values, opposing structures, and conflicting resources (Peek, 2011). These all add layers of complexity and confusion in the advancement towards a new approach to health care.

Integrated behavioral health care principles can be traced to Dr. Engel’s biopsychosocial model outlined in the 1960s, which has been used as a guiding conceptual model for the emerging fields of family medicine, family therapy, and integrated health care. Research and clinical practices using the biopsychosocial framework have emerged in health psychology, social work, alternative and complimentary medicine, and primary care (Doherty, McDaniel, & Baird, 1996; McDaniel, Campbell, & Seaburn, 1991). Some of the seminal work in the 1980s focused on the epidemiology of mental health needs of patients seen in primary care practices. Identifying the prevalence of the problem set the stage for research, such as PRIME-MED to develop reliable and valid ways to identify patients with mental health symptoms in primary care settings (Brody et al., 1998; Spitzer et al., 1994). Out of this empirical base, researchers and providers focused on treatments for targeted patient populations using mental health diagnostic criteria. Depression screening and treatment using the chronic disease model over the past decade has become the most prominent and public practice model that demonstrates the effectiveness of integrated behavioral health care (Von Korff, Gruman, Schaefer, Curry, & Wagner, 1997; Wagner, 1997). Other types of research, such as substance abuse screening and treatment (e.g., SBIRT) or counseling for smoking cessation (e.g., 5 As), have also gained traction for integrated behavioral health care within medical settings and have contributed more empirical support for integrated care (Addo, Maiden, & Ehrenthal, 2011; Babor et al., 2007; Bodenheimer, Wagner, & Grumbach, 2002).

More recently, the Four Quadrant Model has emerged as a robust conceptual model for describing integrated behavioral health care initiatives. Community ­mental health centers and the Department of Defense and the VA have used the Four Quadrant Model to develop a variety of integrated care initiatives. Championed by the National Council and SAMSA, the Four Quadrant Model offers a wide spectrum for depicting a continuum of care between mental health and primary care services. However, this is not an evidence-based approach that validates the effectiveness or efficacy of integrated behavioral health care practices. Currently, the focus of integrated behavioral health care is shifting from more traditional schemes of diagnosing mental health in primary care to the role of behavioral health in enhancing protective factors in patient functioning, promoting healthy behaviors, or preventing poor coping tendencies. The conversations about integrated behavioral health care have expanded from primarily mental health to a host of behavioral health approaches such as motivational interviewing, health behavior coaching, team-­based care, group visits, self-management, health literacy, and patient activation strategies for “whoever comes to see a doctor.” These developments may be forging our future pathway in integrated care and will need a systematic and organized foundation for evaluating this direction.