Date of Award

Summer 2022

Document Type

Open Access Dissertation



First Advisor

Mark D. Weist


The integration of behavioral health and primary care is a best practice to improve patient outcomes and achieve health equity. However, the process of integrating is opaque, requiring organizational change and sometimes a complete system overhaul. Implementation science offers useful ideas for helping healthcare organizations to implement care. This field has identified potential environmental conditions and determinants of successful implementation; however, much is still unknown about how these factors may be relevant for organizations seeking to integrate care. To address the limited existing knowledge in this area, this dissertation gathers practice-based evidence using exploratory methods. Results are translated into an implementation support tool for integrating care. The Active Implementation Frameworks (AIF) form the theoretical basis of this work, and the R=MC2 framework of organizational readiness is used for operationalizing determinants. This multiphase study explores unknown process components for integrating behavioral health and primary care, including (1) when each determinant is most important in the process, and (2) whether technical assistance could be a helpful strategy for improving determinants of integrated care implementation.

In Phase I, a participatory action approach (a systematic Delphi study) was designed and conducted to gather the lived experiences of ten knowledgeable practitioners, researchers, and technical assistance providers with proficiency in integrated care. This study interviewed and surveyed participants over four data collection rounds, collecting qualitative and quantitative data on 11 determinants and eight contextual factors affecting implementation for primary care behavioral health integration. Results show most determinants are important over the lifespan of implementation – except the perceived Simplicity of integrating care – and that determinant strength is most critical during active implementation stages. Most relevant are Leadership, Priority, a Champion, Supportive Climate, Culture, Innovativeness, and Staff Capacities. Results also indicate technical assistance is not perceived as helpful for improving organizational strength for most determinants, except perceived Observability.

In Phase II, study results were translated into an integrated care implementation support tool using an evidence-informed template. The tool includes directions, self-assessment, and worksheets. It was designed as a supplement for existing integrated care models rather than a standalone implementation guide. A survey was administered to assess the potential utility of this tool by integrated care practitioners, administrators, and technical assistance providers (N = 33). Results showed adequate perceived acceptability and appropriateness of the tool. TA providers are the best audience for executing this tool. This tool would be strengthened by demonstrating synergy with existing logistics-driven integrated care guides and piloting the tool in practice. Proposals are made for enhancing the rigor and quality of typical TA practices. This work is a promising step towards bridging implementation science methodologies into integrated primary care behavioral health.


© 2022, Ariel Michelle Domlyn