Date of Award

January 2014

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

A. D. Paltiel


Background: The integration of behavioral health care into primary care is being promoted as a means to treat more people with behavioral health problems where they are most likely to be seen. Clinics with traditional behavioral health services may open slots among scheduled appointments to see these "warm-hand off" (WHO) patients identified by primary care providers (PCPs). The effects of giving priority for behavioral health appointments to either scheduled or WHO patients and of the number of appointments left open for WHO patients are investigated in this project.

Methods: A discrete event simulation model was built of a moderately integrated clinic. WHO patients arrive randomly, on average 4 per day per PCP, and wait to see behavioral health providers (BHPs) who also see scheduled patients. Simulations of four clinic sizes, with PCP to BHP ratios of 1:1, were run. Effects of queue discipline (priority is given to scheduled or WHO patients) and the number of open WHO slots (3 or 5) are analyzed. Outcomes include the percent of scheduled patients served, the percent of WHO patients served, and the percent of BHP utilization.

Results: In clinics with 1 PCP and 1 BHP, for 3 and 5 open slots respectively, giving priority to WHO patients resulted in 80.6% and 81.0% of WHO patients served and 84.4% and 86.6% of scheduled patients served, however, giving priority to scheduled patients resulted in 97.8% and 98.1% of scheduled patients served, but 32.0% and 47.9% of WHO patients served. A similar pattern was seen for larger clinics, though the percent of WHO patients served increased for both 3 and 5 open slots with clinic size. Having 3 or 5 open slots led to few differences when WHO patients were given priority, but when scheduled patients were given priority, choosing 5 open slots rather than 3 open slots, increased the percent of WHO patients served by 15-20 percentage points across the clinic sizes. In either queue discipline, changing from 3 to 5 open slots reduced the percent of BHP utilization by approximately 8 percentage points for all clinic sizes. When WHO patients were given priority, the average wait time for scheduled patients increased from approximately 2-5 minutes to 13-19 minutes across clinic sizes.

Conclusion: These results might suggest to some clinics attempting to integrate primary care and traditional behavioral health services to choose to give WHO patients priority. However, it is recognized that there are costs associated with not seeing both scheduled and WHO patients, and clinics making this decision will have to weigh these tradeoffs. The analysis of these results provides one framework to assist in choosing between different arrangements for integration.


This is an Open Access Thesis.