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Research ArticleOriginal Research

Preparing the Workforce for Behavioral Health and Primary Care Integration

Jennifer Hall, Deborah J. Cohen, Melinda Davis, Rose Gunn, Alexander Blount, David A. Pollack, William L. Miller, Corey Smith, Nancy Valentine and Benjamin F. Miller
The Journal of the American Board of Family Medicine September 2015, 28 (Supplement 1) S41-S51; DOI: https://doi.org/10.3122/jabfm.2015.S1.150054
Jennifer Hall
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
MPH
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Deborah J. Cohen
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
PhD
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Melinda Davis
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
PhD
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Rose Gunn
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
MA
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Alexander Blount
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
EdD
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David A. Pollack
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
MD
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William L. Miller
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
MD, MA
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Corey Smith
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
PsyD
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Nancy Valentine
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
RN, PhD
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Benjamin F. Miller
From the Department of Family Medicine (JH, DJC, MD, RG), and Department of Medical Informatics and Clinical Epidemiology (DJC.), Oregon Health & Science University, Portland; Oregon Rural Practice-Based Research Network (MD), Portland; Department of Family Medicine and Community Health (AB), University of Massachusetts, Worcester; Department of Psychiatry (DAP), Oregon Health & Science University, Portland; Department of Family Medicine (WLM), Lehigh Valley Health Network, Allentown, PA; MidValley Family Practice (CS), Basalt, CO; Department of Health Systems Science (NV), Institute for Healthcare Innovation, Chicago, IL; and Department of Family Medicine (BFM), University of Colorado, Aurora.
PsyD
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    Table 1. Observed Differences between Traditional Mental Health and Integrated Primary Care
    Traditional Mental HealthIntegrated Behavioral Health and Primary Care
    50-min appointmentsBrief, targeted interventions (5 to 30 min)
    Asynchronous communication with other healthcare stakeholders (eg, fax a note, voice message)Immediate communication with other members of the team: directly or within the shared EHR
    Interventions often focused on mental healthInterventions focused on behavioral health: mental health, substance use, life stressors, health behaviors, and adherence to medical regimens
    Clinical involvement often long term, likely to take a reflective approachClinical involvement focused on the moment (eg, problem and/or solution), likely to take a more active and teaching approach
    Patients discharged following completion of carePatients retained in the EHR as long as they are receiving primary care
    Documentation often in narrative form: focused on telling the person's history and storyDocumentation often brief, focused on problem, intervention, and plan, and located either in separate note or imbedded in physicians' notes
    Must document development of thorough knowledge of clientKnowledge of patient developed by PCP in previous relationship
    Assign clinical diagnosis to billDiagnosis often resisted or delayed to try to help the patient without a label
    Individuals referred to as “clients,” “consumers,” or other term designed to reduce stigmaIndividuals referred to as “patients” or “consumers”
    • EHR, electronic health record.

    • View popup
    Table 2. Summary of Observed Skills Clinicians Need to Deliver Integrated Care12
    PCCBHCConsulting Psychiatrist
    Open to sharing care with others: recognizes that other professionals bring specialized expertiseMay proactively review patients to identify potential needs/opportunities for BHC services to PCCViews role as adjunct to PCC and BHC, not as the replacement
    Participates in briefing by listening and asking for clarification when needed
    Reviews screenings, uses clinical discretion, or considers suggestions to identify patients needing BHC servicesIntroduces self as a member of the care team: normalizes behavioral health care delivery as part of “routine” practiceIntroduces self as a member of the care team
    Provides brief assessment of patient's behavioral health needs and establishes foundation for BHC handoff: describing expertise, importance of whole person care, expectations (“selling” resource to patient)Conducts rapid, targeted assessments of patient needs; identifies “feasible” targets for brief interventionProvides psychiatric consultation to the primary care team as needed
    Briefs BHC on perceived patient condition/needs: assessment of situation, depression interventionSets agenda balancing patient/PCC priorities, or negotiates focus of these two stakeholdersAssists PCC: diagnosis, treatment planning, and recommendations
    Available to debrief with BHC during encounter or post-encounter to develop care planApply brief interventions using abbreviated evidence-based treatment strategies: solution-focused therapy, behavioral activation, cognitive behavioral therapy, motivational interviewWilling to treat/consult on some patients without seeing them
    Reinforces care plan and/or BHC intervention during next encounterClinical capacity to address full spectrum of behavioral health needs: common mental health conditions (depression, anxiety), lifestyle behaviors (self-care, social engagement, relaxation, sleep hygiene, diet, exercise)Makes a treatment plan in a short amount of time with limited information
    May develop specialization areas: substance use counseling, biofeedbackFocuses on complex patients who cannot be managed alone by PCP and BHC
    Links efforts to overall patient care: reinforce care plan with PCC and summarize goals/next steps with patient
    Leads group sessions for patients: pain groups, diabetes managementEngages other professionals in patient care plan: BHC, social worker, pharmacist
    Determines care level needed: additional followup with BHC, transition to specialty mental health careCoaches PCCs to manage complex patients; transitions patients back to primary care
    Assists with specialty mental health/other treatment resource transitions (case management)
    Concisely communicates information to the primary care team: verbally, EHR notesConcisely communicates information to the primary care team verbally, EHR notes
    • BHC, behavioral health clinician; EHR, electronic health record; PCC, primary care clinician.

    • View popup
    Table 3. Common Integrated Care Training Manual Components
    Component
    Organizational background
        Organizational history
        Organization mission and vision
        Information on the integration model (current and ideal)
        Description of roles and responsibilities
    Information for all clinicians
        Sample script and handouts for introducing the model and BHCs to patients
        Team meeting descriptions and types
        Smart phrases for the EHR
        Screener forms
        Coding and billing procedures
        Information scheduling, appointment types, and duration
        Health system (internal) and community (external) resources
        Workflow descriptions
        Recommended references (articles, books, and websites)
    Information for BHCs
        Behavioral health interventions and treatment modalities
        Descriptions of the differences between integrated care provided by a BHC and specialty mental health
        Documentation requirements and examples
        Medical vocabulary
    • EHR, electronic health record.

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The Journal of the American Board of Family     Medicine: 28 (Supplement 1)
The Journal of the American Board of Family Medicine
Vol. 28, Issue Supplement 1
September-October 2015
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Preparing the Workforce for Behavioral Health and Primary Care Integration
Jennifer Hall, Deborah J. Cohen, Melinda Davis, Rose Gunn, Alexander Blount, David A. Pollack, William L. Miller, Corey Smith, Nancy Valentine, Benjamin F. Miller
The Journal of the American Board of Family Medicine Sep 2015, 28 (Supplement 1) S41-S51; DOI: 10.3122/jabfm.2015.S1.150054

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Preparing the Workforce for Behavioral Health and Primary Care Integration
Jennifer Hall, Deborah J. Cohen, Melinda Davis, Rose Gunn, Alexander Blount, David A. Pollack, William L. Miller, Corey Smith, Nancy Valentine, Benjamin F. Miller
The Journal of the American Board of Family Medicine Sep 2015, 28 (Supplement 1) S41-S51; DOI: 10.3122/jabfm.2015.S1.150054
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