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.