Configuring health care for systematic behavioral screening and intervention.

The United States Preventive Services Task Force recommends universal screening and intervention for tobacco use, excessive drinking, and depression. These services improve health outcomes, decrease health care costs, enhance public safety, and generate substantial return on investment. Given the prevalence rates of these behavioral conditions and the time necessary for evidence-based interventions, it will be challenging to integrate behavioral screening and intervention (BSI) into busy health care settings. Therefore, consistent with the principles of the medical home and the chronic care model, the health care team must be expanded to systematically provide BSI. A 2-tiered, stepped-care model is proposed. The first tier of services-consisting of assessment, intervention, and follow-up services-would address most mild-to-moderate behavioral risks or conditions. The second tier would include various specialty-based resources, which would be conserved for patients with greatest need and potential to benefit. With slight enhancement of their training, health educators would be excellent candidates to serve as cost-efficient providers of first-tier services. The proposed model would help the United States realize improved health outcomes and cost savings as health care benefits are expanded to a greater proportion of its population.