Primary Care Behavioral Health Model Research Articles

Integrating Behavioral Health and Primary Care

Osteopathic family physicians embody the philosophy of whole-person care, including using a biopsychosocial approach to incorporate mental health into patient care. The creation of the Behavioral Health Integration Collaborative increased support for a system-level adoption of whole-person care in primary care settings. With the increase in both mental health symptoms and diagnoses among Americans, and the increasing support for integrated physical and behavioral healthcare in the primary care setting, this paper shares various approaches, as well as challenges to, adapting integrated care in the primary care office. This includes reviewing best practices for implementing this care approach. The two leading models for integrated care are the Primary Care Behavioral Health (PCBH) model and Collaborative Care model (CoCM). Both models include clinically embedding licensed mental health professionals into the primary care setting, thus increasing access to colleagues with this specialized approach. The PCBH model utilizes a warm hand-off approach, resulting in a collaboration between physician and mental health provider in the care of the patient. The CoCM focuses on a registry of patients who are overseen by a behavioral health manager with treatment decisions guided by a consulting psychiatrist. Blended models are also emerging to better suit the needs for different practices and the patient populations they serve. Challenges to full implementation include acquiring buy-in from practice leadership, hiring appropriately trained mental health providers, and defining billing and coding procedures.

Embedding Counselors in Student Health Centers: Exploring Challenges to Implementing the Primary Care Behavioral Health Model

ABSTRACT Embedding counselors in various campus locations has been one strategy to address the student mental health crisis. The aim of this study was to evaluate challenges to implementing the primary care behavioral health (PCBH) model, in which behavioral health counselors (BHCs) are embedded within the college health center, and to explore characteristics associated with differing levels of PCBH fidelity. Seventy-one BHCs working in college health centers completed the online fidelity survey. Most respondent scores denoted moderate or strong fidelity to the PCBH model. Psychologists showed better adherence to autonomous clinical aspects of PCBH while social workers/counselors showed better adherence to collaborative aspects of PCBH. Overall findings suggest fidelity to PCBH by BHCs in college health is driven by independent clinical activity more than interdisciplinary collaboration. Strategies for developing and evaluating a PCBH program that complements the specialty mental health services offered through counseling centers are discussed.

Can the electronic medical record provide reliable indicators of primary care behavioral health fidelity? Comparison of accessibility and productivity indicators assessed through observational coding.

The primary care behavioral health (PCBH) model is one of the most widely implemented integrated care approaches. However, research on the model has been limited by inconsistent measurement and reporting of model fidelity. One way of making measurement of PCBH model fidelity more routine is to incorporate fidelity indicators into the electronic medical record (EMR), though research regarding the accuracy of EMR data is mixed. In this study, we aimed to assess the reliability of EMR data as a PCBH fidelity measurement tool by comparing key EMR indicators of PCBH fidelity to those recorded by an observational coder. Over an 8-month period (October 2021-May 2022), 12 behavioral health consultants (BHCs; 92% White, 75% female) across five primary care clinics recorded indicators of PCBH fidelity in the EMR as part of their routine charting of behavioral health visits. During that same period, one observational coder completed seven 4-hr visits per clinic to obtain multiple samples of data from each over time and recorded the same variables (i.e., percentage of visits prompted by warm handoffs, number of warm handoffs, and number of patient visits). We used bivariate correlations to test the associations between the EMR variables and the observer-coded variables. Correlations between EMR and observer-coded variables were moderate to strong, ranging from r = .46 to r = .97. Leveraging EMR data appears to be a fairly reliable approach to capturing indicators of PCBH model fidelity in the key domains of accessibility and high productivity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Leveraging the electronic medical record to measure fidelity to the primary care behavioral health model: Implications for clinical and research pursuits.

The primary care behavioral health (PCBH) model of integration has been widely implemented across a number of noteworthy health care systems. However, lack of consistent measurement and reporting of the degree to which the PCBH model has been implemented as developers intended has resulted in two disadvantages in the field. First, clinical quality improvement efforts are hampered by lack of clear guidance on what elements are central to PCBH implementation. Second, the dearth of empirical studies reporting model fidelity impedes cross-study comparisons and limits the rigor of PCBH-focused research. Efforts to expand measurement of PCBH model fidelity would benefit from identification of accessible, unbiased metrics that could complement existing self-report measures. In this article, we describe how we partnered with our clinical informatics team to incorporate PCBH fidelity metrics into the electronic medical record (EMR), allowing for monthly extraction and review of these data. Next, we describe how we have used monthly fidelity monitoring to inform clinical quality improvement efforts in the context of a developing integrated care program and provide an example of how PCBH fidelity data might be reported in a research article. Leveraging EMR data to support PCBH fidelity measurement has the potential to strengthen clinical quality improvement efforts and enable more consistent measurement and reporting of PCBH fidelity data in research. Future efforts should aim to parse out the relative contribution of different variables to the success of PCBH integration and evaluate the effectiveness of implementation strategies at supporting high fidelity. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient Acceptance of Primary Care Behavioral Health in a Resident Obstetrics and Gynecology Clinic.

Primary care behavioral health (PCBH) is a patient care model in which a behavioral health consultant (BHC) works alongside the primary care provider to address behavioral components of health conditions. PCBH is well received in the primary care setting; however, little is known about acceptability of the service among prenatal patients. The study was designed to explore the acceptability of PCBH among pregnant patients in a resident obstetrics and gynecology clinic. A survey designed to assess different components of acceptability was administered to eligible pregnant patients who received prenatal care at the resident obstetrics and gynecology clinic. The majority of patients wanted to receive education on pregnancy-relevant topics from the BHC: healthy weight gain (68.4%), healthy eating (70.4%), healthy exercise (73.5%), and mood disorders (63.3%). The majority of participants wanted help from the BHC in managing coexisting conditions affecting pregnancy: stress (63.3%), depression (75.5%), or anxiety (73%). The majority of patients (55.6%) preferred to work with a BHC for mental health concerns rather than an outside psychiatrist or counselor. PCBH service was perceived to be easy to understand (78%). Barriers to engaging in the PCBH service included time (41.4%), lack of perceived need (13.8%), unavailability (6.9%), and others (13.8%). Despite the perceived benefit, there was an implication of stigma among prenatal patients seeking PCBH or mental health care. Overall, the PCBH model had high acceptability among a prenatal care population in a resident obstetrics and gynecology clinic and offers potential to improve prenatal outcomes.

Brief, modular, transdiagnostic, cognitive-behavioral intervention for anxiety in veteran primary care: Development, provider feedback, and open trial.

Anxiety is undertreated in primary care, and most treatment provided is pharmacological rather than behavioral. Integrating behavioral health providers (BHPs) using the Primary Care Behavioral Health (PCBH) model can help address this treatment gap, but brief interventions suitable for use in PCBH practice are needed. We developed a modular, cognitive-behavioral anxiety intervention, Modular Anxiety Skills Training (MAST), that is evidence-based, transdiagnostic, feasible for PCBH, and patient-centered. MAST comprises up to six 30-min sessions emphasizing skills training. This article describes the rationale for and development of MAST as well as pilot work in the Veterans Health Administration (VA) to tailor and refine MAST for delivery to Veterans in VA primary care (MAST-V) to improve feasibility for VA BHPs and acceptability to Veterans. We used a convergent mixed-methods design with concurrent data collection. In phase one, we interviewed five BHPs to obtain feedback on the treatment manual. BHPs assessed MAST-V to be highly compatible with PCBH and provided suggestions to enhance feasibility. In phase two, we conducted an open trial in which six Veterans experiencing clinically significant anxiety received and provided feedback on all nine possible modules; we also assessed changes in mental health symptoms and functioning as well as treatment satisfaction and credibility. Veterans found MAST-V to be highly acceptable, and pre-post clinical outcomes were very promising with large effect sizes. Findings from this initial pilot provide preliminary support for the feasibility, acceptability, and efficacy of MAST-V and suggest further research with a randomized clinical trial is warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Using a Delphi Technique to Define Primary Care Behavioral Health Clinical Supervision Competencies.

There is an increasing need for Primary Care Behavioral Health (PCBH) workforce development (i.e., increase in well-trained PCBH providers) given the growth of behavioral health (BH) integration into primary care, specifically at a time when behavioral health needs are increasing because of the COVID-19 pandemic (Kanzler and Ogbeide in Psychol Trauma 12(S1):S177-S179, https://doi.org/10.1037/tra0000761 , 2020). Therefore, it is imperative to provide current and future behavioral health clinical supervisors in primary care settings specific competencies, given there are no current competencies specific to clinical supervision within the PCBH Model. Using a Delphi process, the authors identified and reached expert consensus on competencies for BH clinical supervisors in primary care. A purposive sample (in: Patton, Qualitative evaluation and research methods, Sage, Newbury Park, 1990) of fifteen experts (n = 15) in PCBH clinical training and education evaluated quantitative and qualitative domains and specific competencies associated with PCBH supervision gathered during an initial in-depth qualitative interview. This was followed by two subsequent rounds of quantitative Delphi surveys to reach consensus. The response rates from our panel of experts were 100% (15/15) for all stages (interviews, round one and round two surveys). Three domains (Primary Care Knowledge, Clinical Supervisor Development, and Clinical Supervision Skills) were rated as essential for providing clinical supervision with PCBH for pre-licensure level learners. The development of competencies will further support BH clinical supervisor needs, professional development, and provide a concrete way to evaluate progress towards teaching and training excellence. This will also have a great impact on the development of the future BH workforce within primary care.

Clinical supervision within the primary care behavioral health model: What we know and where we need to go.

Community-based primary care settings play an important role in the provision of health care to vulnerable populations, as well as in primary care education. Much attention has been given to medical education in community-based primary care and as the need for workforce development grows for behavioral health in primary care, clinical supervision of prelicensure psychology learners in primary care will also need greater attention. Clinical supervision not only impacts learner professional development but also impacts the patient care learners provide. The purpose of this article is to give attention to clinical supervision within the primary care behavioral health (PCBH) model in the context of community-based primary care. The intersection of supervision approaches in specialty mental health care and medical education will be presented, as well as how these approaches can be combined when working with learners within PCBH. Additionally, challenges to clinical supervision in primary care will be discussed as well as solutions to improve not only workforce development in PCBH but also professional development for clinical supervisors in primary care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Introduction to the special section: Supervision in publicly funded settings: Best practices.

Supervision of trainee and early career psychologists is the epitome of clinical skill cultivation and mentorship of knowledge passed from an experienced professional supervisor to supervisee. However, supervision is not only a "one-way street" as it has been traditionally regarded. Rather, the supervisor-supervisee dynamic is variable, ranging from didactic, to symbiotic, to everything in between. Our collection of articles explores the various forms of clinical supervision in publicly funded settings. They include integrating three low burden multicomponent supervision approaches, a Primary Care Behavioral Health (PCBH) model (Ogbeide et al., 2023), metacognitive reflection and insight therapy, use of an Adlerian-informed supervision method that integrates the Respectfully Curious Inquiry/Therapeutic Encouragement (RCI/TE) framework, and Heron's Six Category Intervention Framework (Hamm et al., 2023; McCarty et al., 2023; McMahon et al., 2023; Schriger et al., 2023). Furthermore, this special section applies to various demographics of supervisees, clients, and supervisee-client dyads including the military culture setting, youth with publicly funded insurance, clients with psychosis, trainees with disabilities, and frontline staff at nonprofit organizations (Dawson & Chunga, 2023; Hamm et al., 2023; Reddy et al., 2023; Schriger et al., 2023; Wilbur et al., 2023). Barriers tackled include administrative and fiscal challenges, reduced availability of supervisors, and burnout in highly traumatized environments (Dawson & Chunga, 2023; McCarty et al., 2023; Schriger et al., 2023). Finally, these diverse clinical frameworks of distinct supervisor-supervisee-client pairings foster increasing feelings of connection, clinical competence, disability-affirmative training environments, supervisee self-awareness and self-efficacy, and increased antiracism in supervision (McCarty et al., 2023; McDonald et al., 2023; Wilbur et al., 2023). (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Integrating Behavioral Health and Primary Care: Turning a Duet Into a Trio.

Family physicians are at the front lines of mental health concerns and distress, yet often feel stymied in their attempts to fully support patients' biopsychosocial needs within the barriers of a fragmented health care system. This article describes a practice transformation designed to facilitate more empowered care experiences. We reflect on our interdisciplinary work as a family physician and a behavioral health consultant working closely together in a Primary Care Behavioral Health model within a university setting. We describe our collaborative approach to a composite character from clinical practice: a college student with symptoms of psychomotor depression who screened negative for mood and anxiety concerns. Akin to a musical ensemble, wherein the inclusion of each voice turns a solo into a symphony, we describe key details of interdisciplinary collaboration which promotes holistic care for patients and fulfilling biopsychosocial practice for us as colleagues.

Cardiac behavioral medicine following heart transplant: A novel integrated care clinic model.

Life after transplant is often accompanied by a myriad of psychosocial and behavioral factors, such as medication adherence and depression, that impact quality of life and outcomes, including mortality. The current project sought to expand the breadth of psychosocial and behavioral care provided to heart transplant recipients during routine follow-up care within a heart transplant clinic housed within an urban academic medical center. A weekly half-day model of Cardiac Behavioral Medicine clinic integration (CBM-CI) was developed and implemented within an ongoing heart transplant clinic based off the primary care behavioral health (PCBH) model. After meetings with key leadership, the model was developed during a 3-week pilot, after which, clinic providers' expectations for integration were assessed. After the development phase, the CBM-CI was implemented into the weekly heart transplant clinic and a quality improvement (QI) process was engaged for the first 6 weeks. Across 6 weeks of clinic implementation, 19 patients engaged with a behavioral medicine provider during routine transplant follow-up, with a wide range of psychosocial/behavioral issues. Overall, the CBM-CI was well-received, the integration was in many ways feasible, and the QI process allowed for iterative improvement that addressed issues related to space, scheduling, selection of patient served, and communication. The CBM-CI for heart transplant enhances opportunity to address psychosocial and behavioral factors that negatively impact outcomes in all stages after heart transplant and highlights the unique role and contributions of clinical health psychologists in cardiology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up.

This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.

The Impact of Brief Interventions on Functioning Among those Demonstrating Anxiety, Depressive, and Adjustment Disorder Symptoms in Primary Care: The Effectiveness of the Primary Care Behavioral Health (PCBH) Model.

Limited scalability combined with limited opportunities for patients to receive evidence-based interventions in traditional behavioral health treatment models for anxiety and depression creates a gap in access to adequate care. Primary Care Behavioral Health (PCBH) is one model of treatment in which behavioral health consultants (BHC) work directly within primary care settings, but there is limited evidence regarding the effectiveness of this model of care. The functional outcomes and appointment characteristics of Beneficiaries (N = 5402) within the military healthcare system were assessed. The study sample was predominately Caucasian, female, military dependents seen for 2 to 4 appointments. A reliable change index revealed that 17.2% showed reliable improvement and 2.4% showed reliable deterioration (p < .05). Of individuals with a severe Behavioral Health Measure-20 score at baseline, 81.5% showed some improvement at their final appointment, with 33% demonstrating reliable improvement. A mixed model analysis was used to determine the predictive value of appointment characteristics. All relations were significant (p < .001), except the between-subjects effect of appointment duration. Appointment duration revealed individuals reported worse functioning at the start of atypically long appointments. Individuals with generally longer intervals between appointments reported worse functioning, but an atypically long interval predicted better functioning at the following appointment. As it relates to number of appointments, individuals with more total appointments reported worse functioning outcomes, with generally better functioning across appointments. Overall, these data support the effectiveness of time-limited care provided through the PCBH model.

The primary care behavioral health model (PCBH) and medication for opioid use disorder (MOUD): Integrated models for primary care

ABSTRACT Recent decades have witnessed increases in (a) integrated physical and behavioral health services and (b) the treatment of opioid use disorders (OUD) in primary care settings – also known as office-based opioid treatments (OBOT) – using a combination of medication and psychosocial support. Providing these services requires a workforce trained to address addiction’s psychosocial components and interventions addressing addiction’s biological and neurological mechanisms. This paper examines the implementation factors, clinic workflow and roles, and administrative considerations of two models of integrated care in order to identify ways of increasing treatment capacity and expanding OUD treatment uptake in integrated primary care settings.

Measuring Productivity in Primary Care Behavioral Health: A Delphi Study.

High productivity by behavioral health consultants (BHC) is a defining aspect of the primary care behavioral health (PCBH) model to maximize access to care and is often measured by patient volume. Studies of productivity in health care settings suggest a single productivity target may not be optimal. We used a Delphi method to obtain expert consensus on an operational definition of high productivity by BHCs in the PCBH model. Clinicians, managers, and researchers in PCBH were recruited to participate in a multi-round survey using a modified Delphi technique and develop consensus on PCBH productivity metrics. Ten participants completed all three survey rounds and rated 28 metrics. After three rounds, two direct metrics (average number of billable BHC visits each day; number of patients seen per day) received at least 80% consensus as "Essential", two received at least 50%, and five received less than 50%. One influencer (level of integration at the practice) received at least 80% consensus as "Very Much" influential, 19 received at least 50%, and eight items received less than 50%. Several themes arose from participant comments. PCBH productivity can be interpreted as being high volume. Numerous practice factors influence how productive a BHC may be. Future studies should determine the feasibility of our metrics in clinical practice, establish productivity expectations based on patient needs and clinic resources, and identify patient-, clinician-, or practice-level moderators of productivity.

Patients' perspectives of brief cognitive behavioral therapy for chronic pain: Treatment satisfaction, perceived utility, and global assessment of change.

Introduction: Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP) is a biopsychosocial treatment designed to improve access to nonpharmacological pain care in primary care. Results from a clinical demonstration project in Veterans Health Administration (VHA) clinics showed rapid improvement in pain outcomes following Brief CBT-CP treatment in Primary Care Behavioral Health (PCBH). As part of this larger project, the current work aimed to understand patients' perspectives of Brief CBT-CP via a self-report survey completed posttreatment. Method: Thirty-four primary care patients received Brief CBT-CP as part of their usual VHA care and subsequently completed an anonymous survey that included questions regarding treatment modality, intervention content, utility, and satisfaction, as well as global assessment of change in pain-related functioning. Results: Participants reported that Brief CBT-CP content was useful (91%) and that they were satisfied with the intervention overall (89%), including appointment length, frequency of encounters, and comprehensibility of content. On average (M = 4.50, SD = 1.71), participants reported "somewhat better" to "moderately better" pain-related functioning following treatment. Exploratory descriptive analysis indicated that self-reported change in function following treatment may vary by patient characteristics, including gender and opioid use history. Discussion: Patients were receptive to Brief CBT-CP, were satisfied with their experience during treatment, and reported benefit in pain-related functioning after treatment. Further development and evaluation of Brief CBT-CP as a feasible biopsychosocial treatment option for pain in primary care clinics using the PCBH model of integration is warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The primary care behavioral health model (PCBH) and medication for opioid use disorder (MOUD): integrated models for primary care

ABSTRACT Recent decades have witnessed increases in (a) integrated physical and behavioral health services and (b) the treatment of opioid use disorders (OUD) in primary care settings – also known as office-based opioid treatments (OBOT) – using a combination of medication and psychosocial support. Providing these services requires a workforce trained to address addiction’s psychosocial components and interventions addressing addiction’s biological and neurological mechanisms. This paper examines the implementation factors, clinic workflow and roles, and administrative considerations of two models of integrated care in order to identify ways of increasing treatment capacity and expanding OUD treatment uptake in integrated primary care settings.

How COVID-19 has impacted integrated care practice: lessons from the frontlines

ABSTRACT Primary care systems are a mainstay for how many Americans seek health and behavioral health care. It is estimated that almost a quarter of behavioral health conditions are diagnosed and/or treated in primary care. Many clinics treat the whole person through integrated models of care such as the Primary Care Behavioral Health (PCBH) model. COVID-19 has disrupted integrated care delivery and traditional PCBH workflows requiring swift adaptations. This paper synthesizes how COVID-19 has impacted clinical services at one federally qualified health center and describes how care has continued despite the challenges experienced by frontline behavioral health providers.

Treating Post-traumatic Stress Disorder with a Prolonged Exposure Protocol Within Primary Care Behavioral Health: A Case Example.

Posttraumatic stress disorder (PTSD) is a debilitating condition that impacts anywhere from 2 to 39% of primary care patients. Research suggests overall health, instances of hospitalizations, emergency room visits, and utilization of primary care services are impacted by a diagnosis of PTSD. Evidenced based treatments such as cognitive process therapy and prolonged exposure (PE) are available in specialty mental health but pose many barriers to treatment and implementation into primary care. This case study serves as the first known case example with an ethnic minority civilian, examining the treatment of PTSD within the Primary Care Behavioral Health Model using the brief (5 visits), PE protocol for primary care (PE-PC). PTSD was assessed using the PCL-5. Additional variables were assessed and tracked with the following tools: PHQ-9 (depressive symptoms), GAD-7 (anxiety symptoms), QLES-SF (quality of life), and the AAQ-2 (psychological flexibility) pre/post treatment, 6months post-treatment and 9months post-treatment. The patient reported clinically significant decreases in symptoms of PTSD, depression, and anxiety symptoms. Additionally, the patient's scores on quality of life and psychological flexibility improved. Brief, exposure-based treatment for PTSD can be delivered within the PCBH model. This treatment may result in improved quality of life and has the potential to reduce health care costs. This case encourages the treatment of PTSD within primary care, increasing access to care for patients. Future research is needed to further investigate this protocol in primary care with underserved, civilian populations and to explore patient attitudes toward brief treatment for PTSD in a primary care setting.

Brief Cognitive Behavioral Therapy For Chronic Pain: Results From a Clinical Demonstration Project in Primary Care Behavioral Health.

Although cognitive behavioral therapy is an effective intervention for chronic pain, it is a lengthy treatment typically applied only in specialty care settings. The aim of this project was to collect preliminary effectiveness data for Brief Cognitive Behavioral Therapy for Chronic Pain (Brief CBT-CP), an abbreviated, modular form of treatment designed for use in primary care. A clinical demonstration project was conducted in which Brief CBT-CP was delivered to primary care patients by 22 integrated care providers practicing in the Primary Care Behavioral Health model of Veterans Health Administration primary care clinics. Brief measures were used at each appointment to collect patient-reported clinical outcomes. One hundred eighteen patients provided sufficient data for analysis (male, 75%; mean age, 51.4 y). Multilevel modeling suggested that a composite measure of pain intensity and functional limitations showed statistically significant improvements by the third appointment (Cohen's d=0.65). Pain-related self-efficacy outcomes showed a similar pattern of results but of smaller effect size (Cohen's d=0.22). The exploratory analysis identified that Brief CBT-CP modules addressing psychoeducation and goal setting, pacing, and relaxation training were associated with the most significant gains in treatment outcomes. These findings provide early support for the effectiveness of Brief CBT-CP when delivered by providers in every day Primary Care Behavioral Health settings. Results are discussed in relation to the need for additional research regarding the potential value of employing safe, population-based, nonpharmacological approaches to pain management in primary care.