Preparing the Workforce for Behavioral Health and Primary Care Integration

Recruitment Challenges

Few organizations were able to hire clinicians who already possessed sufficient skills and experience to work in teams delivering care for a shared patient population in an integrated practice. For BHCs, this meant being adaptable to the pace and workflow of primary care clinics, knowing how to work with a PCC team; understanding the health care needs of a primary care population; and knowing how to use brief assessments, counseling, and solution-focused approaches with patients. Table 1 highlights these and other differences between delivering integrated behavioral health and primary care and traditional therapy approaches.

For PCCs, practicing in an integrated setting meant working on a care team with BHCs, consistently identifying patients' behavioral health and emotional needs, knowing when and how to involve BHCs, and being open to incorporating another professional's expertise into patient care. For psychiatrists, working in integrated settings meant consulting with PCCs and BHCs, conducting rapid, minimal assessments with patients directly, or using information from PCCs and other BHCs to inform decision making and treatment advice. Table 2 summarizes additional skills that PCCs, BHCs, and psychiatrists needed to deliver integrated care.

In our interviews with practice leaders and decision makers we heard that when recruiting new employees, most did not find candidates who had developed these competencies and skills either in training or through previous work experience. In our observations of practices going through the hiring process, with few exceptions, most were unable to hire clinicians experienced in integrated care delivery.

Training Challenges for Practices New to Integration

For organizations with little experience in integration, hiring relatively inexperienced health care professionals meant that there were few opportunities to model or train new employees or to orient them to integrated care. Practice leaders also underestimated the time and resources required to train new clinicians: they often did not know what knowledge, skills, or attitudes were essential for new employees. In addition, practice leaders often failed to recognize this as a problem until after unsuccessful implementation. For example, practices might hire BHCs whose prior training and work experiences had only been with traditional mental health concepts or settings. BHCs were unable to effectively handle frequent interruptions by other clinic staff, provide brief assessments or interventions, consult with the primary care team about patient needs and care provided, or concisely document visit notes in the electronic health record (EHR). Practice leaders eventually learned through trial and error, and in some cases from rapid turnover in the BHC position, that specialty mental health clinicians needed relevant training to work effectively with primary care teams. For example, 1 ACT practice, collaborating with a local community mental health center, placed a BHC in their practice. The practice reported the following: As [BHC] writes notes and puts her ideas for treatment together, she has found it extremely difficult to leave the world of behavioral health and integrate patient and medical ideas. As much as I have tried to teach her about what patient centric means, I truly do not think she understands. After much training she still wants to revert to writing old-style behavioral health notes. There are many more examples. Next time around I wonder if I can train better. (Diaries, Practice 9)

Other practices had similar experiences, and some reported frequent turnover with their BHCs, which led to some practices refining their BHC training approaches.

In addition, the loss of multiple BHCs led to the development of reciprocal training for PCCs and staff to learn to work with BHCs. Practices underestimated the time and resources needed to recalibrate and retrain current clinicians and staff to work using an integrated care approach. Training efforts that exclusively targeted BHCs or new employees were incomplete if PCCs and others in the practice lacked experience working with BHCs and delivering integrated care. PCCs needed to learn to make appropriate referrals to BHCs, adjust their workflow to accommodate warm handoffs, and incorporate other clinicians' expertise into patient care.

Practice Strategies for Preparing an Integrated Care Workforce

We observed a variety of approaches to preparing clinical staff to deliver integrated care. These included relying on an internal expert to provide training, sending employees to external training programs, or developing internal postdoctoral or practicum training programs. Once organizations identified the need to prepare everyone in the practice—not just new employees—in delivering integrated care, organizations addressed this training need: And primary care—they think so differently than MH [mental health] people! Even if they say they understand what we're doing, they do not! So I talked with [the practice manager] about doing some training with all the staff—not just clinicians but ALL the staff. I did some training on brief therapy and problem solving. These were small little videos I did. Then I just sat and talked with them and answered questions. Each training was an hour. I went to 3 team meetings every other week—about 3 times overall. Given that the BHC is starting we're going to look at what needs to be done and if she can help with some of the trainings. It was really helpful. Just sitting down and talking with them, answering questions. (Diaries, Practice 10)

When practices lacked the internal experience to train employees in integrated care, they could hire consultants to offer onsite training or send employees to external training programs. Some organizations we studied hosted such trainings with clinicians and organizational leaders, and regularly provided tours to demonstrate how they provide integrated care. However, sending employees to external training programs potentially limits the number of individuals who can attend and can be resource prohibitive in terms of training costs, travel expenses, and loss of revenue-producing work time. The following excerpt from a prefunding interview with an ACT practice describes the perception of the costs of formal training for clinicians in integrated care: The certification took 7 to 8 full days across 4 months. If we elect to use this model it would be exceptionally difficult to cover patient care and maintain revenue with all physicians being trained at the same time. The training for all PCCs and BHCs would cost $80,000, which is financially unrealistic for a private clinic. Currently, some of the previously trained physicians and clinicians in this model will be participating in an update webinar. These are necessary but also time consuming and must either be done on days off or during patient care hours. (Evaluability Assessment Notes, Practice 13)

Another way organizations tried to increase workforce expertise was to offer to be a postgraduate practicum site for medical (eg, primary care or psychiatry) residencies and behavioral health disciplines (eg, psychology or social work) graduates to meet supervised clinical experience requirements for licensure. Program trainees gained hands-on experience working in integrated care teams and received training and supervision from a multidisciplinary team of clinicians. For example, medical residents' clinical encounters were reviewed by BHCs, psychiatrists, and/or pharmacists. Behavioral health students gained consultation skills, confidence, and comfort working directly with PCCs, as well as therapy and intervention skills applicable in primary care settings by working with highly experienced BHCs: One of the biggest things [I teach my behavioral health students] is to not be afraid to go and talk to another provider. Because I think that they are intimidated. I know that I was when I first started in this kind of a setting… You see the medical providers as being way up here. And then coming in as an intern, you know, I am going to walk into the doctors' room and say I need to speak to you? So you need to have a voice and you need to go in there if you have a patient and there's a medication issue, to knock and say, this is who I am. I am working with this patient, and feeling like that is part of your job. You have to be able to do that. (Interview, Practice 1)

Providing postgraduate or practicum training within the practice required experienced personnel to supervise and teach trainees. These programs benefited the organizations by providing affordable options for uninsured patients but also helped with recruitment as it created a pipeline of highly qualified future applicants prepared to work in integrated clinics. Organizations with postgraduate training programs reported hiring a number of their former trainees: With psychologists, we have the American Psychological Association (APA)-approved interns, and there are 4 of those. That has been a real rich tool for us to be able to recruit BHCs. Because when they come here, they get the training to do that, and we get to pick who we would like and make an effort to recruit them. Do not hold me to this, but I'd say over the years we probably recruited half of them into [the organization], maybe more than half. (Interview, Practice 15)

Onboarding Processes for New Employees

Onboarding refers to how organizations socialize employees to the practice's culture, models of care, and workflow. Onboarding helps new staff obtain the knowledge, skills, and behaviors needed to effectively deliver care. Practices with more integrated care experience have developed extensive onboarding processes for new employees.

A key element of this process is the use of training manuals. As detailed in Table 3, training manuals were important reference guides for new employees. Training manuals included information on workflows, protocols, policies, and procedures as well as information on the history, culture, and vision of the organization: It has everything in it from regular employment information like asking for time off and benefit information to information on the integration model, info on the BHC's role, contrast between BHC and integrated care with specialty mental health, visit types, team meeting descriptions and types, standards of practice, interventions and treatment modalities, smart phrases in Epic. (Field Notes, Practice 4)

Practice members identified the process of manual creation as pivotal in their own development, reinforcing their commitment to integration and encouraging reflection and consensus building on vision and values, as well as clinic processes.

Experienced clinics also created rigorous shadowing processes to onboard new employees. Considered an investment by the organizations, shadowing included observing professionals in the role one was hired to do, as well as roles with which new employees would be expected to collaborate. This helped clinicians and staff understand patient resources, the greater continuum of care, and how other positions interfaced with their roles and workflows. BHCs shadowed the PCCs with whom they would later work on care teams. Shadowing began the process of developing rapport and trust between clinicians who would work together: Once they hire someone the new hire will shadow in all the clinics. It can feel cumbersome, but this is the best way to help prepare BHCs. New BHCs shadow the case manager, MA [medical assistant], and PCC so they understand the different workflows. Then they are shadowed by [the lead BHC supervisor] or another supervising BHC to provide feedback and make sure they are operating under their model. BHCs also meet with all new staff to describe and explain their role to new staff and clinicians. (Field Notes, Practice 5) When [BHCs are] onboarded, they have the opportunity to shadow inpatient services and shadow day treatment, so they can see what the continuum of care is for their patients. So if they have a patient who went inpatient, they know what the daily routine is like, who they are going to meet with and what kind of groups they are going to participate in. They understand what day treatment is and what they can expect from that service. So, as you are talking about referring your patient to those services, you can give them a nice picture of what it is going to be like and take away some of the fears. And also understand what you can expect of your colleagues when they are receiving those services. (Field Notes, Practice 4)

The duration of shadowing varied among the practices from a few days to a few weeks. This depended on the practices' routines for onboarding, the type of employee, and the new employee's level of experience. In some practices after shadowing was complete, a supervisor or mentor would observe newly hired BHCs and PCCs before they practiced independently. Following this observation phase, new PCCs and BHCs were often given a lighter schedule to develop new skills, adapt to the team's workflow, and learn to use the EHR: They do a lot of shadowing in their own clinic. New clinicians then see patients independently and get 60-minute appointments. This gives them time to learn the EHR and work with the BHCs and the nutritionists, get used to the flow, and stay on schedule while integrating other components of care. They also troubleshoot if anyone is struggling with any of these components. (Field Notes, Practice 4)

Following the shadowing and observation phases, supervisors remained available to new clinicians for curbside consultations, second opinions, and assistance with challenging patients. Supervisees were encouraged to ask questions and regularly received feedback from their supervisors: We also believe heavily in the value of on-the-fly supervision. We are always available to them, especially initially when they are new to us. There's times early on we're consulting on the fly after every patient they are seeing. And sometimes a couple of times before they let the patient go, because we need to know, what do I need to tell this primary care provider? What should my plan be? What do I need to do with this patient? So we're kind of modeling for them, we're teaching them didactically. We're teaching them in supervision, we're consulting with them during the day. (Interview, Practice 2)

Continuing Education and Support

Organizations provided ongoing development and learning opportunities to existing personnel through the use of multidisciplinary meetings in which clinicians and staff discussed operational issues such as clinic policies or workflow changes. This time was also used for presentations led by various members of the care team. For example, psychiatrists or pharmacists held topic-specific trainings or open question-and-answer sessions for PCCs and BHCs. Presentation topics were based on clinician interests and requests. A psychiatrist who talked about her availability and answered basic questions regarding psychiatric issues led the following meeting: The psychiatrist tells the group she wants to make sure they know she does consults Wednesday with obstetrics. Thursday she is in the telemedicine room ‘embedded’ in the pod there for consults, and then other days she is always available for questions or consults if needed. She wants to open the floor to see if there are any basic questions people have about psychiatry issues. An internist in the primary care practice has his laptop in front of him—he's got some questions prepared. He wonders if there is the Patient Health Questionnaire-2 equivalent for disorders other than depression–thought disorder, bipolar disorder for instance. He is looking for some ‘key questions’ he can ask to try and screen for these types of things. (Field Notes, Practice 2)

Organizations also developed formal, ongoing mentoring opportunities for peers to continuously support and learn from each other. After the onboarding process, various methods of mentoring were available to both new employees and to existing personnel. Mentors were often organization leaders with both administrative and clinical roles who modeled behaviors for integrating care and, by doing so, were not only a source of information and learning but, through their actions and behaviors, reinforced the integration model in the practice: All our administrative folks, heads, who are licensed as clinicians still carry caseloads…. I think that sets a tone, a recognition of if you are going to do the work or if you are going to administer the work, you have got to know what doing the work feels like and stay active with it. (Interview, Practice 2)

Other practices established ongoing meetings that allowed PCCs or BHCs to collaboratively review complex cases. Some practices used this time to engage in continuing education opportunities such as literature reviews on clinical topics. For example, a group of PCCs and BHCs reviewed literature together on physical activity and patients with Alzheimer disease: The meeting continues with someone presenting on a study about physical activity and Alzheimer's. The study found that patients who participated in moderate exercise were 38% less likely to develop Alzheimer's. Another person in the group then reported on other benefits of physical activity. She shared an article from Health and Fitness magazine that explained the health benefits of exercise and strength training—including being good for depression. A PCC asks how this was different from what we already know about physical activity. Here it focused more on the benefits of strength training instead of aerobic activity like most materials tend to address. She thought it would be helpful to share with patients because it suggests that the 30 minutes of activity do not have to be done consecutively. This seems especially important because for some of their patients, starting at 10 minutes at a time is much less overwhelming. (Field Notes, Practice 15)

Opportunities for intra-organizational continuing education were limited and especially challenging for smaller practices without the capacity to provide peer support or educational meetings. This problem was compounded when organization leaders and clinicians in smaller practices lacked experience in integration and were not connected to peers outside of the organization with whom they could consult.