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 Psychological Treatment of
Medical Patients
in Integrated
Primary Care
ANNE C. DOBMEYER

CLINICAL HEALTH PSYCHOLOGY SERIES

ELLEN A. DORNELAS, Series Editor

American Psychological Association • Washington, DC

Psychological Treatment of
Medical Patients
in Integrated
Primary Care
Clinical Health Psychology Series
Psychological Treatment of Medical Patients in Integrated Primary Care
Anne C. Dobmeyer
Psychological Treatment of Patients With Cancer
Ellen A. Dornelas
Copyright © 2018 by the American Psychological Association. All rights reserved. Except
as permitted under the United States Copyright Act of 1976, no part of this publica-
tion may be reproduced or distributed in any form or by any means, including, but not
limited to, the process of scanning and digitization, or stored in a database or retrieval
system, without the prior written permission of the publisher.
The opinions and statements published are the responsibility of the authors, and such
opinions and statements do not necessarily represent the policies of the American
Psychological Association.
Published by
American Psychological Association APA Order Department
750 First Street, NE P.O. Box 92984
Washington, DC 20002 Washington, DC 20090-2984
www.apa.org Phone: (800) 374-2721; Direct: (202) 336-5510
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Typeset in Minion by Circle Graphics, Inc., Columbia, MD
Printer: Edwards Brothers Malloy, Lillington, NC
Cover Designer: Mercury Publishing Services, Inc., Rockville, MD
Library of Congress Cataloging-in-Publication Data
Names: Dobmeyer, Anne C., author. | American Psychological Association, issuing body.
Title: Psychological treatment of medical patients in integrated primary care /
Anne C. Dobmeyer.
Other titles: Clinical health psychology series.
Description: First edition. | Washington, DC : American Psychological Association,
[2018] | Series: Clinical health psychology series | Includes bibliographical references
and index.
Identifiers: LCCN 2017014788 | ISBN 9781433828027 | ISBN 1433828022
Subjects: | MESH: Mental Disorders—therapy | Primary Health Care | Delivery of Health
Care, Integrated | Behavioral Symptoms—therapy
Classification: LCC RC454 | NLM WM 400 | DDC 616.89—dc23
LC record available at https://lccn.loc.gov/2017014788
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition
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10 9 8 7 6 5 4 3 2 1
To Todd, Genevieve, and Julian
 Contents

Series Foreword ix
Acknowledgments xi
Introduction 3
I. A Primer on Integrated Primary Care 11
Chapter 1. Overview of Integrated Primary Care 13
Chapter 2. Fundamentals of Primary Care Behavioral
Health Integration 29
Chapter 3. Conducting the Behavioral Health
Consultation Appointment 41
II. Common Conditions Treated in Primary Care
Behavioral Health 53
Chapter 4. Depression 55
Chapter 5. Anxiety 71
Chapter 6. Insomnia 87
Chapter 7. Diabetes 101
Chapter 8. Chronic Pain 121
Chapter 9. Asthma 141

vii
 contents

III. Future Directions 153

Chapter 10. Future Directions in Training, Funding,
and Research 155
References 169
Index 187
About the Author 197

viii
 Series Foreword

M ental health practitioners working in medicine represent the

vanguard of psychological practice. As scientific discovery and
advancement in medicine has rapidly evolved in recent decades, it has
been a challenge for clinical health psychology practice to keep pace.
In a fast-changing field, and with a paucity of practice-based research,
classroom models of health psychology practice often do not translate
well to clinical care. All too often, health psychologists work in silos, with
little appreciation of how advancement in one area might inform another.
The goal of the Clinical Health Psychology series is to change these trends
and provide a comprehensive yet concise overview of the essential ele-
ments of clinical practice in specific areas of health care. The future of
21st-century health psychology depends on the ability of new practitio-
ners to be innovative and to generalize their knowledge across domains.
To this end, the series focuses on a variety of topics and provides both a
foundation and specific clinical examples for mental health professionals
who are new to the field.
Working with Susan Reynolds, senior acquisitions editor at the Amer-
ican Psychological Association (APA Books), I am very proud to have had
an opportunity to edit this book series. We have chosen authors who are
recognized experts in the field and are rethinking the practice of health
psychology to be aligned with modern drivers of health care, such as pop-
ulation health, cost of care, quality of care, and customer experience.

ix
 SERIES FOREWORD

Anne C. Dobmeyer’s book, Psychological Treatment of Medical Patients

in Integrated Primary Care, is essential reading for the practitioner new
to working in primary care and is informative for clinicians in any area
of clinical health psychology. The number of behavioral health practi-
tioners in primary care has increased exponentially over the past decade.
Dr. Dobmeyer describes the systems level factors that are critical for the
successful integration of behavioral health providers in the primary care
setting, as well as the specific types of assessment and intervention most
often utilized in the primary care behavioral health model. I am tremen-
dously grateful that Dr. Dobmeyer agreed to contribute her expertise to
this series. I believe that readers will find this book to be an exceptionally
valuable resource on the topic of integrated primary care.

—Ellen A. Dornelas, PhD

Series Editor

x
 Acknowledgments

M y work in integrated primary care and clinical health psychology

has been shaped and supported by many colleagues. Kirk Strosahl,
through his training and mentoring in the primary care behavioral health
model, helped launch me on an integrated primary care career path. I’m
also grateful for the excellent clinical health psychology training provided
by Ann Hryshko-Mullen and Alan Peterson, which shaped my ability to
integrate clinical health psychology concepts in the context of integrated
primary care. I would also like to acknowledge colleagues whose collabo-
ration has shaped and improved my work over the years, and from whom
I continue to learn. Particular thanks go to Christopher Hunter, Jeffrey
Goodie, Christine Runyan, Patti Robinson, Jeff Reiter, and Mark Oordt.
Finally, I would like to acknowledge Ellen Dornelas, the series editor for
the Clinical Health Psychology book series, and Susan Reynolds, Andrew
Gifford, and Joe Albrecht at APA Books for their assistance in shaping this
volume.

xi
Psychological Treatment of
Medical Patients
in Integrated
Primary Care
 Introduction

I nterest in the integration of behavioral health and primary care has

been rapidly growing across the United States over the past two decades.
Much attention has focused on how integrated care can lead to better care
in primary care settings for mental health conditions, such as depression
and anxiety. Including a behavioral health provider as an integral part
of the primary care team to assist with treatment of medical conditions
or adverse health behaviors, however, has received less attention (B. F.
Miller, Brown Levey, Payne-Murphy, & Kwan, 2014). Indeed, for many
people, the need for a behavioral health provider to assist with the pri-
mary treatment of diabetes, asthma, chronic pain, or cardiovascular dis-
ease is not always apparent. The patient with low back pain might think,
“Why should I see a mental health provider for my back pain? This pain

The views expressed herein are those of the author and do not necessarily represent the official policy
or position of the United States Public Health Service, Department of Defense, or the United States
Government.
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3
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

is real, not in my head!” The patient with poorly controlled diabetes might
respond, “I don’t know how a counselor will help me. I’m not depressed or
crazy. I know what I’m supposed to do . . . I just need to do it.” The patient
who has just had her third trip to the emergency department for asthma
might state, “I don’t see how a psychologist will help with my breathing.
I really need the treatments in the ER. I’m not having anxiety attacks!”
For many, the ways in which integrated behavioral health providers may
assist medical patients (not just those with mental health disorders) are
not well understood.
This lack of clarity regarding the role and scope of integrated behav-
ioral health providers is not limited to patients. Primary care providers may
rapidly refer patients with relationship problems, depression, or anxiety to
an integrated provider yet rarely include these providers in the treatment
of patients who take their medications irregularly, get little physical activ-
ity, have chronic headaches, or struggle with adhering to a complex diabe-
tes management regimen. Indeed, the literature suggests that integrated
behavioral health providers continue to be used primarily for addressing
mental health conditions (particularly depression and anxiety) rather than
the full range of health behaviors and medical conditions (Funderburk,
Dobmeyer, Hunter, Walsh, & Maisto, 2013; B. F. Miller et al., 2014).
Even experienced behavioral health clinicians may harbor uncertain-
ties about their own value or skill in addressing the needs of a diverse set
of medical patients. Those with limited training or experience in the spe-
cialty of clinical health psychology may be unaware of the wide array of
evidence-based, biopsychosocial interventions targeting various health
conditions and behaviors. Others may be familiar with this literature but
have limited experience in implementing such interventions.
With appropriate training and experience, behavioral health provid-
ers can indeed effectively assist primary care clinics in improving care
for a wide range of chronic medical conditions, behavioral health dis­
orders, subclinical problems, and unhealthy lifestyle behaviors present in
most primary care patients. Most behavioral health providers, however,
have not had advanced training in the specialty of clinical health psychol-
ogy; nor have they had training and experience in providing integrated

4
 INTRODUCTION

primary care services. Integrated behavioral health clinicians must be

able to function effectively as a member of an interdisciplinary medical
team in a fast-paced primary care environment. To achieve population
health outcomes in primary care, strategies must be brief, evidence based,
and available to a large volume of patients with an array of problems.
Reflecting the complex set of skills required for integrated care, several
professional organizations, including the American Psychological Asso-
ciation (APA; 2015) and the Agency for Healthcare Research and Quality
(Kinman, Gilchrist, Payne-Murphy, & Miller, 2015), have recognized that
a distinct set of skills and competencies is necessary to succeed in inte-
grated primary care. These competencies extend beyond the individual
behavioral health clinician to the primary care practice itself because it is
crucial for primary care leaders, providers, and staff to clearly understand,
value, and support the role of integrated behavioral health providers.
This volume, as part of APA Books’ Clinical Health Psychology series,
offers guidance in navigating these patient, clinician, and systems chal-
lenges to providing effective integrated behavioral health care to a wide
range of medical patients in primary care. It provides an overview of inte-
grated primary care and an introduction to the primary care behavioral
health (PCBH) model of service delivery, in which a behavioral health
clinician functions as an integrated team member within the primary care
clinic, providing brief, evidence-based assessment, intervention, and con-
sultation to address a wide range of common mental health and medical
conditions within an integrated primary care setting.

ORGANIZATION OF THE BOOK

This book is organized into three Parts. Part I provides a broad overview
of the integrated primary care arena, focusing on fundamental concepts,
models, and strategies. Chapter 1 discusses the rationale for integrating
behavioral health clinicians into primary care clinics; summarizes the lit-
erature on key integration parameters relevant across different models of
integration; and introduces one prominent approach to integration, the
PCBH model, which is featured throughout the remainder of this volume.

5
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

The chapter ends with a brief overview of the empirical literature evaluat-
ing this model of integration. Chapter 2 delves into more detail regard-
ing fundamental attributes and skills required for successful integration.
Focus is given to both individual provider competencies and practice-level
competencies. Particular emphasis is given to management of behavioral
health workflow and use of clinical pathways to increase the penetration
of behavioral health services to greater numbers of primary care patients.
Chapter 3 provides guidance on specific strategies for conducting initial
and follow-up PCBH appointments, regardless of the referral problem.
A step-by-step outline is provided, along with discussion of strategies for
staying on time within a fast-paced primary care environment. Emphasis
is placed on implementing evidence-based strategies in brief courses of
care using 30-minute consultation appointments.
Part II contains six chapters focused on specific behavioral health
and medical conditions frequently treated in primary care settings. The
section begins with chapters on two of the most common mental health
problems (anxiety, depression), followed by four chapters on medical
conditions frequently presenting in primary care (sleep problems, diabe-
tes, chronic pain, asthma). Each chapter includes an overview of relevant
medical and biological aspects of the problem and a summary of specialty
mental health (or clinical health psychology) interventions. The chapters
continue with guidance on implementation of a PCBH clinical pathway
for each condition, including clinic-level strategies for identifying patients
who would benefit from integrated services, and guidance on focused
assessment, formulation, intervention, and consultation approaches con-
sistent with the PCBH framework. Each chapter includes information on
outcome measurement strategies and ends with a clinical vignette that
highlights some aspect of integrated care for that condition.
Clearly, many more mental health conditions, medical problems, and
adverse health behaviors exist than are covered in these chapters and that
integrated behavioral health providers will encounter in primary care.
The six problem areas selected for inclusion here represent those that fre-
quently present in primary care settings, and particularly those medical
conditions that may be less familiar to many behavioral health providers.

6
 INTRODUCTION

For example, diabetes and asthma were included because behavioral health
providers may have less experience with these conditions (as compared
with obesity or tobacco use, for example). These chapters are intended to
serve as templates for how to approach assessment, intervention, and con-
sultation across different problem areas. Once readers learn the general
PCBH framework and how to address several specific conditions within
this model of service delivery, they should be primed for expanding their
practice into other problem areas and conditions. Additional reading,
training, and preparation will still be needed before treating unfamiliar
conditions; however, the foundations for providing integrated care will
be in place. Interested readers may want to consult the recent volume by
Hunter, Goodie, Oordt, and Dobmeyer (2017), which provides guidance
on PCBH assessment and intervention for a wide range of additional
medical and mental health conditions not covered in this volume (e.g.,
posttraumatic stress disorder, cardiovascular disease, chronic obstructive
pulmonary disorder, irritable bowel syndrome, alcohol misuse, sexual
dysfunctions). Additionally, Robinson and Reiter (2016) provided a com-
prehensive overview of the PCBH model and strategies for successful inte-
gration, including case examples and intervention materials for various
problems.
The book’s final chapter, in Part III, covers future directions for
integrated primary care, relevant to integrated primary care clinicians,
administrators, policymakers, and researchers. Key focus is given to future
directions and recommendations in the areas of integrated primary care
training, funding and policy, and research.

INTENDED AUDIENCE
Any behavioral health clinician or student considering practice in an inte-
grated primary care setting may benefit from the material in this volume,
regardless of whether they are a clinical psychologist, social worker, clini-
cal health psychologist, professional counselor, or graduate student. The
strategies for some of the most common presenting mental health prob-
lems should be helpful to both generalist mental health practitioners as

7
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

well as clinical health psychologists who want to hone their skills in

approaching the management of mental health problems from an inte-
grated, team-based approach. The chapters focused on medical condi-
tions may be particularly useful for clinicians with limited knowledge of
health psychology approaches. However, this content also may prove use-
ful to clinical health psychologists, with its guidance on ways to alter spe-
cialty clinical health psychology approaches to effectively fit within brief,
consultative interactions with patients and medical providers.
This book may also serve as a primer for primary care leaders who are
responsible for the integration of behavioral health services. The informa-
tion will be useful in helping leaders develop a better understanding of the
skills and scope of practice they should expect from their integrated pro-
viders. This information can help guide program development, personnel
selection, and performance evaluations. Primary care leaders will benefit
from the discussions of systems-level factors essential for successful inte-
gration, such as strategies for screening and identifying patients who may
benefit from integrated services, practice workflow, implementation of
clinical pathways, and optimal use of electronic health records and patient
registries for process improvement and program outcome evaluations.
Of course, not all of the potential forms of primary care integration
can be covered in one volume, nor can one book thoroughly review all
the evidence for various models of integration. Nor does this book pro-
vide the comprehensive training necessary to function effectively as an
integrated behavioral health provider or clinical health psychologist. Addi-
tional training to develop such competencies is necessary, and this is
discussed in the final chapter.
In sum, this book serves as an introduction to the practice of inte-
grated primary care for behavioral health providers, students, and pri-
mary care clinic leaders. It places particular emphasis on clinical health
psychology services for medical patients within the PCBH model of ser-
vice delivery. Systems- and clinic-level processes essential for successful
integration are highlighted.
It is hoped that the information presented in this volume will assist
behavioral health providers and graduate students in determining whether

8
 INTRODUCTION

integrated primary care is a good fit for their skills and interests. If it
is, these readers will find introductions to the basic concepts and skills
needed for effectively working in integrated primary care with a range of
medical patients. It is also hoped that the book will stimulate interest and
curiosity, and prompt clinicians to seek additional education and training
to maximize their readiness to effectively work as integrated behavioral
health providers.

9
 one

A Primer on
Integrated
Primary Care
 1

Overview of Integrated
Primary Care

M ental health disorders affect nearly half (47%) of all Americans

at some point during their lifetime (Kessler et al., 2007). Behav-
ioral health problems increase risk of disease and injury, and comorbid
behavioral health problems complicate treatment and influence progno-
sis (Prince et al., 2007). Additionally, substantial numbers of Americans
struggle with modifiable lifestyle behaviors impacting health and well-
being. For example, less than 10% of Americans meet four key health
behavior goals related to physical activity, tobacco use, body weight, and
nutrition (Reeves & Rafferty, 2005).
Despite the high rates of mental health disorders, only 40% of those
with a mental health condition receive any health care for that condition
in a given year (Wang et al., 2005). Of individuals who do receive some
form of behavioral health care, most receive it from a general medical pro-
vider rather than a psychiatrist or other behavioral health provider in a

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13
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

specialty mental health clinic (Wang et al., 2005). Few primary care provid-
ers (PCPs) report having adequate knowledge of behavioral health treat-
ments to use with their patients (Boscarino, Larson, Ladd, Hill, & Paolucci,
2010). Indeed, patients treated solely in general medical settings for mental
health conditions receive fewer appointments (median of 1.7 vs. 7.4 visits)
and are less likely to receive minimally adequate care compared with those
seen in specialty mental health clinics (Wang et al., 2005).
Behavioral health integration brightens the primary care picture.
Individuals are more likely to engage in care when they receive integrated
behavioral health services, compared with those who are referred to a
specialty mental health or substance abuse clinic (Bartels et al., 2004).
Patients who attend a joint consultation with their PCP and an inte-
grated psychologist are more likely to view psychologists’ work as per-
sonally relevant and useful to themselves, helping to decrease the stigma
of behavioral health services (Cordella et al., 2016). And most important,
patient outcomes improve with integrated primary care (see Chapter 2,
this volume).
Increased interest in models of integrated primary care may be par-
tially attributed to broader changes in the way primary care is deliv-
ered. One recent development in the provision of primary care has been
the shift to the patient-centered medical home (PCMH) to achieve the
three primary goals (the “Triple Aim”) of reducing the cost of health
care, improving the patient experience of care, and advancing popula-
tion health (Berwick, Nolan, & Whittington, 2008). The medical home
is the location where patients receive coordinated, comprehensive care
addressing most of their medical needs (American Academy of Fam-
ily Physicians, 2008). With this substantial redesign of care delivery
has come a greater emphasis on integrating behavioral health services
into PCMH to efficiently and effectively address patients’ behavioral
health needs, as well as a recognition of the need for appropriate train-
ing for the interdisciplinary team, innovations in policy and payment
models, and evaluations of various integration approaches (Ader et al.,
2015). The Patient Protection and Affordable Care Act of 2010 fur-
ther increased redesign of care to reduce fragmentation of services

14
 OVERVIEW OF INTEGRATED PRIMARY CARE

and improve care coordination (Kellermann et al., 2012), and the

2014 Joint Principles for the Integration of Behavioral Health Care
Into the Patient-Centered Medical Home underscores the centrality of
integrating behavioral health care as a core part of PCMH redesign
(Baird et al., 2014).
The current chapter provides an introduction to the rapidly evolving
field of integrated primary care. It begins with a look at integration from
a broad perspective. Terminology and definitions related to integrated
primary care are presented, and literature on key parameters relevant for
various forms of integrated primary is summarized. These broad integra-
tion parameters provide a framework for a more focused discussion of
one prominent model of integration, the primary care behavioral health
(PCBH) model of service delivery. This population health approach has
key relevance for behavioral health providers delivering direct psychologi-
cal services in integrated primary care settings. For this reason, the PCBH
model serves as the core model highlighted throughout the remainder of
this book.

DEFINITION OF INTEGRATED PRIMARY CARE

A host of terms have been used to describe approaches to integrated care:
integrated, collaborative, coordinated, and co-located, to name a few. Terms
have been used differently by various authors. To promote greater consis-
tency in integrated care terminology, the Agency for Healthcare Research
and Quality (AHRQ) recently published the Lexicon for Behavioral Health
and Primary Care Integration (hereinafter, AHRQ Lexicon; Peek & The
National Integration Academy Council, 2013), which includes the follow-
ing definition of integrated behavioral health care:

The care that results from a practice team of primary care and behav-
ioral health clinicians, working together with patients and families,
using a systematic and cost-effective approach to provide patient-
centered care for a defined population. This care may address mental
health and substance abuse conditions, health behaviors (including
their contribution to chronic medical illnesses), life stressors and

15
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

crises, stress-related physical symptoms, and ineffective patterns of

health care utilization. (p. 9)

This definition highlights the importance of integrating behavioral health

providers as members of an interdisciplinary primary care team. The care
team may also be defined to include other primary care staff, such as dieti-
tians, clinical pharmacists, and nurses. Working together with patients and
families, the care team may address a broad spectrum of medical and mental
health conditions, as well as adverse health behaviors and life stressors.

KEY PARAMETERS OF INTEGRATED PRIMARY CARE

Many approaches to achieving integrated practices have been developed in
recent years, each with distinct methods and desired outcomes. The PCBH
model of service delivery constitutes one of the prominent models of inte-
gration; other approaches include the collaborative care model, co-located
specialty mental health approaches, medical family therapy, and bidirectional
or reverse integration (see Corso, Hunter, Dahl, Kallenberg, & Manson, 2016,
for a description of various models of integration).
These approaches vary on many major dimensions or parameters of
integration delineated in the AHRQ Lexicon. Several key AHRQ Lexicon
parameters, such as the location of care, the function of the care team,
and the scope of problems targeted in the model, among other factors,
are described here. Review of these integration parameters highlights the
variability that may be found from one integrated primary care practice
to another. Interested readers are encouraged to read the original source
for information on the full set of AHRQ Lexicon parameters.

Location of Care
Integrated practices vary in the spatial arrangements and physical place-
ment of behavioral health care, from separate space, to co-located space,
to fully shared space (Peek & The National Integration Academy Coun-
cil, 2013). In practices using mostly separate space, the behavioral health
provider is located in a separate building and has limited time (if any)

16
 OVERVIEW OF INTEGRATED PRIMARY CARE

practicing in the same space with medical providers. Patients travel from
one building to another to access behavioral health and medical care.
Co-located space involves behavioral health services provided in the same
building, but not the same clinic. Behavioral health and medical providers
spend a relatively small period of time in shared space, and patients travel
from the primary care clinic to the separate behavioral health clinic. Fully
shared space occurs when the behavioral health and medical providers see
patients in the same shared clinic space, often using the same exam rooms.

Care Team Function

Integrated practices may provide care for patient problem areas or needs
that range from more restricted to more expanded, on the basis of the
capabilities and expertise of members of the care team. At one end of the
continuum, some practices may focus on core or “foundational functions”
for the target population, including triage, self-management support,
psychological support, straightforward interventions for mental health
problems, and linking with external resources (Peek & The National Inte-
gration Academy Council, 2013, p. 5). Moving along the continuum of
care team function, integrated practices may use more advanced strat-
egies, such as using a registry for identifying and tracking patients and
coordinating care, and providing more complex mental health and phar-
macologic interventions. Teams with the most advanced functions may
address complex patients through the incorporation of team members
with specialized expertise in particular diseases, populations, or cultures.

Type of Collaboration
The type of collaboration between behavioral health and medical pro-
viders also falls along a continuum. Some integrated care practices have
minimal collaboration, with infrequent communication triggered by
referral of specific patients. Information is shared periodically on referred
patients, but care plans and workflow are typically separate. In other
practices, behavioral health and medical providers communicate more
regularly and may coordinate care plans, although workflows and systems

17
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

(e.g., medical record, registries) are still largely separate. Fully integrated
practices include regular communication between providers, shared care
plans, use of a shared medical record for documentation, and highly coor-
dinated care.

Identification of Patients for Integrated Care

Patients who may benefit from the integration of behavioral health and
medical care may be identified in a nonstandardized fashion. In practices
without a systematic approach to identifying appropriate patients, patients
are identified through self-referral or when the medical provider recog-
nizes a need. Other practices use data from health systems (e.g., patient reg-
istries, claims data, demographic data) to systematically identify patients
with more complex needs. At the far end of the continuum, integrated
practices adopt universal screening for targeted problem areas or popula-
tions to increase the likelihood of identifying patients who would benefit
from integrated behavioral health and medical care.

Targeted or Nontargeted Populations

Some integrated care practices target specific subpopulations or prob-
lems. For example, they may provide a specific integrated care approach
for patients with a particular diagnosis (e.g., depression), condition (e.g.,
pregnancy), or demographic (e.g., age, minority status). Other prac-
tices provide integrated care for nontargeted populations in a “see all
comers” population health approach that may be used with the full range
of patients enrolled in a practice panel (Peek & The National Integration
Academy Council, 2013, p. 8).

PCBH MODEL
This section describes the goals, methods, and outcomes of the PCBH model
through examining a definition of the model, exploring the ways in which
aspects of the PCBH model map onto key integration parameters of the
AHRQ Lexicon, and summarizing select PCBH model outcome literature.

18
 OVERVIEW OF INTEGRATED PRIMARY CARE

PCBH Model Definition

The PCBH model of service delivery integrates behavioral health pro-
viders into primary care clinics to improve the primary care treatment of
a wide range of behavioral health conditions, adverse health behaviors,
and chronic medical problems (Robinson & Reiter, 2016; Strosahl, 1998).
A definition of the PCBH model developed through a consensus process
involving 18 national PCBH model experts (Reiter, Dobmeyer, & Hunter,
in press) offers the following description:

The PCBH model is a team-based primary care approach to man-

aging behavioral health problems and biopsychosocially-influenced
health conditions. The model’s main goal is to enhance the primary
care team’s ability to manage and treat such problems/conditions,
with resulting improvements in primary care services for the entire
clinic population. The model incorporates into the primary care
team a behavioral health consultant (BHC), sometimes referred to
as a behavioral health clinician, to extend and support the primary
care provider (PCP) and team. The BHC works as a generalist and
an educator who provides high volume services that are accessible,
team-based, and a routine part of primary care. Specifically, the BHC
assists in the care of patients of any age and with any health condi-
tion (generalist); strives to intervene with all patients on the day they
are referred (accessible); shares clinic space and resources and assists
the team in various ways (team-based); engages with a large percent-
age of the clinic population (high volume); helps improve the team’s
biopsychosocial assessment and intervention skills and processes
(educator); and is a routine part of biopsychosocial care (routine).
To accomplish these goals, BHCs use focused (15- to 30-minute)
visits to assist with specific symptoms or functional improvement.
Follow-up is based in a consultant approach in which patients are
followed by the BHC and PCP until functioning or symptoms begin
improving; at that point, the PCP resumes sole oversight of care but
re-engages the BHC at any time, as needed. Patients not improving
are referred to a higher intensity of care, though if that is not possible
the BHC may continue to assist until improvements are noted. This

19
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

consultant approach also aims to improve the PCP’s biopsychosocial

management of health conditions in general.

Several aspects of this definition deserve additional elaboration. In

this model, mirroring the pace of primary care, BHCs see a large volume
of patients, meeting with up to 14 patients per day. An episode of care
for a particular problem often ranges from one to four appointments,
although there is no “hard limit” to the number of appointments a patient
may have with the BHC. Utilization data from different settings indicate
that the average number of visits per patient falls between one and three;
a smaller subset of patients is seen for a greater number of appointments
over time (Brawer, Martielli, Pye, Manwaring, & Tierney, 2010; Sadock,
Auerbach, Rybarczyk, & Aggarwal, 2014). The model’s emphasis on brief,
targeted appointments and shorter courses of care enables the BHC to see
a high volume of patients to impact a large portion of the PCPs’ patients,
consistent with a population health model.
In a typical course of care, the patient may work with a BHC over
several appointments to learn and implement self-management strategies;
when symptoms or functioning begin to improve, the BHC recommends
that the patient follow up with the PCP (rather than continuing with the
BHC until full remission of symptoms). In future medical appointments,
the PCP reinforces the strategies that have been helpful and links the
patient back to the BHC if symptoms worsen. In a stepped care approach,
if patients do not adequately improve with a PCBH level of intervention,
they are referred for more intensive care (e.g., psychotherapy in an out­
patient mental health clinic). A smaller percentage of patients with chronic
conditions may receive ongoing consultation with the BHC, although not
at the frequency or intensity found in specialty behavioral health settings.
This “continuity consultation” may be particularly useful for patients
attempting to maintain significant health behavior changes (e.g., patients
with obesity or diabetes) who might benefit from a monthly or quarterly
appointment to promote adherence to the PCP’s care plan.
One of the foundational concepts of the PCBH model is the role of
the BHC as a consultant to the PCP. It is the PCP, rather than the BHC,
who retains primary responsibility for the patient’s care plan. Although

20
 OVERVIEW OF INTEGRATED PRIMARY CARE

the BHC may see the patient for several consultative appointments dur-
ing an episode of care, the PCP continues to provide care to the patient
over time, having many more opportunities to reinforce desired health
behaviors. In subsequent medical visits the PCP asks the patient how the
behavior change plan is going, reinforces the importance of change, and
addresses any barriers that have arisen. To facilitate this process, BHCs
and PCPs communicate frequently to discuss specific strategies and rec-
ommendations for patients. BHCs may also provide training to PCPs and
other staff in strategies such as motivational interviewing or goal setting
for health behavior change.

Key Integrated Service Parameters and PCBH Model

Analyzing the PCBH model in light of several of the key AHRQ Lexicon
parameters of integrated primary care services can help clarify the nature
of this form of integration. In the PCBH model, behavioral health and
primary care medical services share the same medical space (i.e., same
clinic), rather than operating out of separate external clinics or buildings.
This shared location enables the BHC to function as a seamless member of
the primary care team. The BHC can accept warm handoffs from PCPs, in
which the PCP introduces the patient to the BHC during or at the end of
the PCP appointment, and the patient transitions directly from the PCP to
an appointment with the BHC. BHCs also provide on-demand consulta-
tion in an environment in which patients experience behavioral health care
as a normal part of routine primary health care.
Practices using the PCBH model of service delivery may vary on the
range of care team functions employed. Some practices using the PCBH
model may have a narrower range of functions, focused on providing
relatively straightforward interventions for a range of behavioral health
conditions and linking patients with more complex needs to external
resources. As a clinic matures in its implementation of the PCBH model
over time, however, it should also encompass the more advanced care
team functions, such as systematic use of screening, patient registries, and
pathways to identify patients appropriate for integrated behavioral health
care and enhance patient engagement in care over time.

21
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

The nature of the collaboration between BHCs and primary care

team members is highly integrated in the PCBH model. Communication
regarding patient care plans occurs frequently through informal curbside
consultations throughout the day, discussions at provider meetings, and
planning during morning huddles. Practices implementing PCBH use a
shared medical record and care plan, enhancing collaboration and com-
munication regarding patient care. Workflow for the BHC is integrated
into the overall clinic workflow. Patients experience the same check-in and
registration process, and may transition directly from an appointment
with their PCP to the BHC (or vice versa).
BHCs’ practice is a “see all comers” population health approach. In
other words, PCBH services are not restricted to a narrow range of tar-
geted populations. Rather, services are available for patients from a wide
demographic group (i.e., anyone receiving medical services from the
PCMH) with a range of conditions or problematic health behaviors. At
a minimum, patients may be identified for services through a nonstruc-
tured approach, such as identification and referral from the PCP at the
point of care. Ideally, clinics using a PCBH approach also identify patients
through a variety of systematic methods, such as screening for common
behavioral health or medical conditions, use of patient registries or data-
bases, and decision support tools or prompts within the electronic health
records to determine who might benefit from integrated care.

PCBH Model Evidence

The PCBH model outcome literature has focused on implementation
and outcome variables of interest to systems, providers, and patients. Rel-
evant implementation variables include access to care, provider adher-
ence to practice guidelines, patient engagement in care, and patient and
provider satisfaction. Outcome studies have examined changes in patient
symptoms, health-related behaviors, and disease outcomes. As an emerg-
ing practice area, much of the published outcome literature reflects pro-
gram evaluation data rather than research with more methodologically
rigorous designs. Hunter et al. (in press) provided a detailed review of the

22
 OVERVIEW OF INTEGRATED PRIMARY CARE

outcomes, strengths, and limitations of this literature, as well as recom-

mendations for future PCBH model research.

Symptoms and Functioning

Studies examining the effect of PCBH on depression outcomes have
found that symptoms of depression decrease following PCBH inter­
vention (Angantyr, Rimner, Nordén, & Norlander, 2015; Katon et al., 1996;
McFeature & Pierce, 2012; Sadock et al., 2014). Patients receiving PCBH
care for depression have shown a significant decrease in the number of
other medical visits during their period of care from the BHC (McFeature
& Pierce, 2012). In patients with anxiety, care from a BHC is associated
with decreases in symptoms (Angantyr et al., 2015; Sadock et al., 2014).
Promising results for posttraumatic stress disorder have been found
in populations of active duty military personnel receiving an intervention
protocol that includes components of prolonged exposure and cognitive
processing therapy adapted for use in primary care (Cigrang et al., 2011).
The presence of a BHC using routine suicide screening improves detection
of suicidal ideation in primary care compared with PCP assessment alone
(Bryan, Corso, Rudd, & Cordero, 2008). Finally, BHCs integrated into
pediatric well-child appointments (seeing the family for approximately
10 minutes at the conclusion of the pediatrician visit) provided families
with improved anticipatory guidance for behavioral health prevention in
comparison with those randomized to pediatrician alone (Burt, Garbacz,
Kupzyk, Frerichs, & Gathje, 2014).
Other studies have focused on chronic medical conditions and health
behaviors. A randomized controlled trial (RCT) of integrated care for
patients with comorbid depression and diabetes found significantly greater
adherence to medications, improved blood glucose measures, and decreased
depression following three 30-minute appointments and two 15-minute
telephone contacts compared with those receiving usual care (Bogner,
Morales, de Vries, & Cappola, 2012). Another RCT found that brief inter-
vention (one to three 20- to 30-minute visits) with an integrated behavioral
health provider significantly reduced at-risk alcohol use in older adults at
rates similar to those of patients randomized to specialty care (Oslin et al.,

23
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

2006). Although these studies did not incorporate all aspects of the PCBH
model (e.g., seeing patients with a broad range of problem areas), the
interventions provided were nevertheless consistent with core aspects of a
BHC’s work. Finally, patients with insomnia who received brief behavioral
intervention from BHCs showed significant improvements in sleep effi-
ciency compared with baseline (Goodie, Isler, Hunter, & Peterson, 2009),
and tobacco use has been shown to decrease following BHC intervention
(Sadock et al., 2014).
Many studies have reported improvements in functioning, symptoms,
and distress after two or more BHC appointments with heterogeneous
samples of patients, with most showing benefits in four or fewer visits
(Angantyr et al., 2015; Bryan et al., 2012; Cigrang, Dobmeyer, Becknell,
Roa-Navarrete, & Yerian, 2006; Ray-Sannerud et al., 2012; Sadock et al.,
2014). Some evidence suggests that improvements in symptoms from
brief BHC interventions persist over time, with gains being maintained
for several years (Ray-Sannerud et al., 2012).

Access to/Engagement With Care

Timely access to care is a key component of the PCBH model. In a study
of PCBH outcomes with a heterogeneous patient population, nearly
half (48%) of patients referred to the BHC had their first appointment
within 3 days (Angantyr et al., 2015). In another study, patients ran-
domized to integrated care were more likely to have an initial behavioral
health appointment within 2 weeks, compared with patients referred
to a specialty behavioral health clinic (Bartels et al., 2004). PCBH may
also increase patients’ engagement with care. One study found that older
primary care patients randomized to integrated care versus enhanced
referral to an external specialty behavioral health/substance abuse clinic
had significantly greater rates of treatment engagement (71% vs. 49%
completing a first appointment) and completion of a higher number of
appointments (3.04 vs. 1.91; Bartels et al., 2004). Finally, BHCs facilitate
successful linking to a higher level of care when needed. Patients referred
to specialty behavioral health care were more likely to follow through
on these referrals when they were first seen by the BHC (66% vs. 47%

24
 OVERVIEW OF INTEGRATED PRIMARY CARE

completion; Brawer et al., 2010) and were more likely to remain engaged
with that care (Wray, Szymanski, Kearney, & McCarthy, 2012).

Primary Care Provider Practice Patterns

Integrated care can change and improve the practice patterns of PCPs.
Incorporating a BHC in the integrated care of patients has been found to
decrease referrals to specialty mental health clinics, increase PCP adher-
ence to clinical practice guidelines for depression, and lead to more appro-
priate psychotropic prescribing patterns (Brawer et al., 2010; Serrano &
Monden, 2011). A study of PCBH outcomes in a large Veterans Affairs medi-
cal system found that after initiation of the PCBH model, PCPs decreased
their specialty mental health consults by 37%, allowing improved access
for patients with more severe mental illness needing this higher level of
care (Brawer et al., 2010). Finally, PCPs with more frequent interactions
with the BHC report higher levels of comfort discussing behavioral health
concerns with their patients (Torrence et al., 2014).

Patient Satisfaction
Patients report overall satisfaction with PCBH services, a willingness
to meet with BHCs again, satisfaction with the amount of time spent
with the BHC, and a belief that meeting with the BHC was clini-
cally helpful (Angantyr et al., 2015; Funderburk, Fielder, DeMartini,
& Flynn, 2012; Funderburk et al., 2010). High levels of therapeutic
alliance and satisfaction with the BHC after the initial appointment
have been found in samples of both Latino and non-Latino patients
(Bridges et al., 2014). Level of therapeutic alliance with the BHC after
the first appointment has been found to be higher than that with tradi-
tional outpatient specialty mental providers (Corso et al., 2012). Addi-
tionally, older adults receiving integrated care in primary care reported
higher satisfaction than those receiving enhanced specialty care (Chen
et al., 2006).

Provider Satisfaction
PCPs and nurses report that the presence of an integrated BHC improves
patient access to behavioral health services and that BHCs are an integral

25
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

part of the primary care team. Providers perceive that their patients bene-
fit from BHC services, report high levels of communication with the BHC,
and indicate that they would recommend the PCBH service to colleagues
(Funderburk et al., 2010, 2012; Torrence et al., 2014). Notably, PCPs report
significantly improved comfort in treating patients with mental health
conditions, and attribute this increased comfort in large part to the inte-
grated primary care program (Serrano & Monden, 2011).

CONCLUSION
Behavioral health integration in primary care provides opportunities to
improve the care patients receive in primary care settings for a wide range
of behavioral health problems and medical conditions. Integration pro-
motes effective care for problems along a wide severity spectrum, includ-
ing not only chronic conditions but also prevention and early intervention
with subclinical presentations. Access to evidence-based assessment and
intervention is available for patients who might otherwise be unlikely to
receive behavioral health services. A variety of approaches to integration
have been developed, and the integrated primary care field is striving
toward more unified definitions and terminology to help better distin-
guish unique models of service delivery.
The PCBH model, the focus of the remainder of this book, provides
an evidence-based method for delivering collaborative care by integrating
behavioral health providers into primary care clinics using a population
health approach. It addresses many of the problems that exist in tradi-
tional systems of care with separate primary care and behavioral health
services. Primary care patients who would not typically receive a refer-
ral to a behavioral health clinic, but who might benefit from behavioral
health consultation, have access to services. These include patients with
subthreshold problems and those who might benefit from preventive
and early intervention services, as well as those with mental health diag­
noses or chronic medical conditions. Patients reluctant to follow through
on a referral to an external behavioral health clinic, whether their prob-
lems are mild or severe, are more likely to accept and receive behavioral

26
 OVERVIEW OF INTEGRATED PRIMARY CARE

health care from a BHC located in their own primary care clinic. Access
to behavioral health care is improved, with patients often having their
first BHC appointment on the day of referral, rather than waiting weeks
for an intake at a specialty behavioral health clinic. Patients who receive
integrated care but do not significantly improve are referred to higher
levels of care in a stepped care model, promoting efficient use of health
care resources. Systemic screening processes can identify larger numbers
of patients who would benefit from integrated behavioral health services.
This screening is largely made possible by the presence of the integrated
BHC, who is available as a resource for those patients screening posi-
tive. Because BHC workflow mirrors that of primary care (brief, targeted
appointments; concise documentation) and consultation services are
typically short-term (often four or fewer appointments per episode of
care), the BHC has capacity to see a much larger number of patients than
is possible in specialty behavioral health settings. Communication among
members of the health care team is enhanced because PCPs, BHCs, and
other team members share a common medical record and care plan and
have the opportunity for frequent face-to-face consultations. Through
their frequent interactions around specific patient care issues, BHCs may
enhance the PCP’s ability to briefly address relevant psychosocial factors
themselves. And because patients will continue to see their PCP for medi-
cal care after they have completed an episode of care with the BHC, the
BHC provides specific recommendations on how the PCP can reinforce
key self-management strategies.

27
 2

Fundamentals of Primary Care

Behavioral Health Integration

S uccessful integration of behavioral health providers into primary

care clinics does not occur automatically; numerous barriers and
challenges exist. Most behavioral health providers have not had training
focused on providing integrated behavioral health services in medical
settings (McDaniel et al., 2014). They may be unfamiliar with evidence-
based interventions for common medical conditions or health behaviors.
Traditional psychotherapy approaches do not fit with a model in which
patients often are seen for one or two 30-minute appointments. The
cultures, mission, and workflow of primary care and behavioral health
are different. Interdisciplinary functioning does not necessarily improve
when a behavioral health provider joins the primary care team. Primary
care team members may not understand the role of the behavioral health
consultant (BHC) or the scope of primary care behavioral health (PCBH)
services, leading to underutilization or inappropriate utilization. Logistics

http://dx.doi.org/10.1037/0000051-003
Psychological Treatment of Medical Patients in Integrated Primary Care, by A. C. Dobmeyer
Copyright © 2018 by the American Psychological Association. All rights reserved.

29
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

must be addressed, including basic yet important factors like finding

appropriate space for the BHC and ensuring adequate administrative
support. Funding the BHC position may be complex. Support from
clinic leadership is required to initiate systems-level approaches (e.g.,
use of screening, registries, electronic health record [EHR] prompts) to
improve integrated care.
These and other barriers have been encountered and addressed in
many clinics initiating the PCBH model within large and small health
care systems over the past two decades. To address such barriers, specific
competencies for BHCs have been developed to provide benchmarks for
performance, and many authors have discussed key factors for successful
integration (Corso, Hunter, Dahl, Kallenberg, & Manson, 2016; Hunter,
Goodie, Oordt, & Dobmeyer, 2017; Robinson & Reiter, 2016; Strosahl,
2005). Initially, competencies focused primarily on the individual BHC;
more recently, a focus on clinic-level, systems, and team factors has emerged
in the literature (Corso et al., 2016; Kinman, Gilchrist, Payne-Murphy, &
Miller, 2015; Robinson & Reiter, 2016). This chapter summarizes literature
on BHC core competencies, as well as discusses key factors for success from
a broader, systems-level perspective. Emphasis is given to two systems-
level issues that can greatly influence the success of integration efforts. The
first, promoting an appropriate workflow for the BHC, involves schedul-
ing and patient flow processes to support a patient-centered yet efficient
integrated workflow. The second, implementing PCBH clinical pathways,
can effectively expand the reach of behavioral health services into the
population.

INTEGRATED PRIMARY CARE CORE COMPETENCIES

Providing integrated primary care services requires a significant practice
shift from traditional mental health services. Several individuals and orga-
nizations have described core competencies for integrated primary care to
guide training, program development, and evaluation. Core competen-
cies specifically for the PCBH model of integrated primary care, initially
developed by Strosahl (2005), included competencies in the domains

30
 FUNDAMENTALS OF PRIMARY CARE BEHAVIORAL HEALTH INTEGRATION

of clinical practice, practice management, consultation, documentation,

team performance, and administrative skills. His work formed the basis of
competencies used in the Department of Defense (Dobmeyer et al., 2016)
and has been further elaborated by Robinson and Reiter (2016).
Others have described competencies for integrated primary care,
regardless of the specific service delivery model. For example, the Ameri-
can Psychological Association (2015) developed a set of aspirational goals
for primary care psychologists and outlined core competencies in the
areas of science, systems, professionalism, relationships, application, and
education. A recent Substance Abuse and Mental Health Services Admin-
istration report outlined integrated care competencies for both providers
and systems in the categories of interpersonal communication, collabo-
ration and teamwork, screening and assessment, care planning and care
coordination, intervention, cultural competence and adaptation, systems-
oriented practice, practice-based learning and quality improvement, and
informatics (Hoge, Morris, Laraia, Pomerantz, & Farley, 2014). Finally, the
Agency for Healthcare Research and Quality (AHRQ) recently published a
summary of the current literature on integrated primary care competen-
cies (Kinman et al., 2015), integrating information from 24 competency
articles and highlighting not just competencies for individual behavioral
health providers but also those relevant for systems and primary care
practices seeking effective integration.
Information on competencies is briefly summarized here, with
emphasis on essential (vs. aspirational) competencies. A complete elabo-
ration of the integrated primary care competency literature is beyond the
scope of this volume; interested readers should become familiar with the
competency literature cited above.

Competencies for Behavioral Health Providers

The literature outlining competencies for individual behavioral health
providers highlights the need for skills across many professional domains.
Not only must they be skilled in the basics of providing focused assess-
ment and intervention in brief interactions, but they also must function

31
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

well as a member of an interdisciplinary medical team, provide on-target

consultative recommendations, effectively train and teach medical staff,
document in a style consistent with a primary care setting, and ethi-
cally navigate different challenges presented by team-based care, among
others. Table 2.1 summarizes these and other provider competency areas,
as described in the AHRQ literature review (Kinman et al., 2015).

Table 2.1
Select Provider-Level Competencies for
Integrated Primary Care

Competency Examples

Identification and assessment of Rapidly identify patients with behavioral health

behavioral health needs needs, including those with mental disorders,
adverse health behaviors, and medical conditions
being affected by psychosocial factors.
Select evidence-based brief screening measures.
Rapidly assess behavioral health problems and
needs.
Assess functional impairment.
Identify severity level to determine need for referral.
Treatment of behavioral health Select and implement brief, evidence-based treat-
needs ments (e.g., relaxation training, motivational
interviewing, health behavior interventions, cogni-
tive behavioral therapy, solution-focused therapy,
behavioral activation).
Monitor treatment progress and coordinate care.
Implement interventions to improve functioning.
Primary care culture: agenda setting, Effectively manage brief (15- to 30-minute)
prioritization, and workflow appointments.
Rapidly describe role and obtain informed consent.
Understand medical culture; work quickly and
flexibly; be open to interruptions.
Patient engagement Address adherence and treatment barriers.
Increase patient motivation and readiness to change.
Include patients in decision making; engage family to
support.

32
 FUNDAMENTALS OF PRIMARY CARE BEHAVIORAL HEALTH INTEGRATION

Table 2.1
Select Provider-Level Competencies for
Integrated Primary Care (Continued)

Competency Examples

Whole-person care and cultural Use biopsychosocial model to understand patient

competency problems.
Understand roles of cultural/family factors on patient
health.
Use interventions incorporating patient beliefs,
family, parents.
Coordinate effectively with family, agencies, schools.
Team-based care and collaboration Collaborate with team to provide interdisciplinary
care with shared decision making, treatment
planning, and responsibility.
Provide effective consultation to medical providers.
Teach staff about management of behavioral health
conditions.
Implement process improvements to enhance
teamwork.
Communication Use communication appropriate for primary care
(e.g., concise).
Regularly communicate with providers in a variety of
formats.
Communicate using shared medical record.
Communicate with patients using clear, understand-
able, culturally appropriate language.
Professional values and attitudes Value the culture/mission of primary care and
integrated care.
Demonstrate ability to rapidly adapt work to meet
patient needs.
Understand ethical and legal issues related to inte-
grated care.

Note. From Provider- and Practice-Level Competencies for Integrated Behavioral Health in Primary
Care: A Literature Review (pp. 5–12), by C. R. Kinman, E. C. Gilchrist, J. C. Payne-Murphy, and
B. F. Miller, 2015, Rockville, MD: Agency for Healthcare Research and Quality. Copyright 2015
by the Agency for Healthcare Research and Quality. Adapted with permission.

33
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

Competencies for Systems/Clinics

Successful integration requires not just skilled behavioral health pro-
viders with strong competencies in integrated care but also a practice
environment that supports integrated care. Kinman et al.’s (2015) review
identified a number of common themes in the competency literature and
grouped these into the following domains: workflow and operations,
administration and leadership, practice culture, team structures and roles,
and organizational support. These competency domains and specific
examples are summarized in Table 2.2.
Solid interprofessional communication and collaboration skills
among all primary care staff are also essential to the success of integrated
care. Examples of important elements include all staff using common
terminology related to integrated care and team members’ roles, all staff
providing patients a brief description of their role on the team when
introducing themselves, practices incorporating communication tech-
nologies (e.g., EHR) in effective ways to promote collaborative practice,
and avoiding the use of discipline-specific language when possible (Corso
et al., 2016).
Finally, Robinson and Reiter’s (2016) recent work contains an excellent
description of 35 core competencies for primary care providers (PCPs)
and nurses and is specific to the PCBH model of service delivery. Examples
include referring a broad range of patients to the BHC, supporting the
interventions recommended by the BHC, using BHCs to save a medical
visit, seeking curbside consultations with BHCs, and knowing multiple
ways to access BHC services, among others.

ENSURING OPTIMAL WORKFLOW

As highlighted in the competencies described earlier, one systems-level
challenge inherent in integration is ensuring that the BHC services are
seamlessly integrated into the workflow of the clinic, with administrative
and structural elements in place to decrease barriers to care. These include
elements such as a smooth appointing process, appropriate templates, and
open access for same-day availability, among others.

34
 FUNDAMENTALS OF PRIMARY CARE BEHAVIORAL HEALTH INTEGRATION

Table 2.2
Select Practice-Level Competencies for Integrated Primary Care

Competency Examples

Workflow and operations Workflow of clinic supports integration of behavioral

health (e.g., regular behavioral health screening, quick
consultation, warm handoffs, shared medical records,
patient registry to track progress, protocols for coding
and billing).
Behavioral health providers included in shared space of
clinic.
Administration and leadership Alignment between clinical, operational, and financial
processes.
Appropriate resource allocation.
Communication between leadership, staff, and providers
about integrated care expectations.
Regular staff training regarding integrated care issues.
Practice culture Practice culture supports team-based and population-based
whole-person care.
All providers and staff have understanding of others’ roles
within the team and feel valued as members of team.
Team structures and roles Care team ideally includes primary care provider,
behavioral health provider, care manager, and
psychiatrist.
Team values collaboration and uses biopsychosocial model.
Organizational support Clinical, operational, and financial systems are aligned to
support integrated care.
Practice works to create payment policies that provide
unified coverage, and seeks funding support.
Technical and decision supports for care are implemented.
Self-management supports for patients are available.
Processes support efforts for continuous quality improve-
ment (e.g., allow for measurement-based care and
tracking of outcomes).

Note. From Provider- and Practice-Level Competencies for Integrated Behavioral Health in Primary
Care: A Literature Review (pp. 12–15), by C. R. Kinman, E. C. Gilchrist, J. C. Payne-Murphy, and
B. F. Miller, 2015, Rockville, MD: Agency for Healthcare Research and Quality. Copyright 2015
by the Agency for Healthcare Research and Quality. Adapted with permission.

35
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

An AHRQ guidebook summarizing observations from exemplary

integrated practices notes that effective integrated practices consistently
use “multiple pathways or workflows to facilitate patient access to BHCs,
including warm handoffs, and consultations with or without the patient
present” (Cohen, Davis, Hall, Gilchrist, & Miller, 2015, p. 77). Thus, to
promote patient-centered, population health integrated care, BHC tem-
plates and appointing processes include multiple ways for patients to
access care with the BHC. Rather than a traditional specialty mental health
template in which hour-long appointments are the norm, wait times may
be several weeks, and same-day access is limited to acute emergencies,
BHC templates include a mix of open access and scheduled appointments.
Typically, 30-minute appointments for advance booking are available
at intervals throughout the day. Some practices also include 15-minute
appointments for some follow-up appointments. Scheduled appoint-
ments are intermixed with periods reserved for same-day appointments
(e.g., patients who request an appointment that day) and warm handoffs
from providers. These warm handoffs, in which the PCP or nurse directly
links the patient with the BHC following a PCP appointment, form the
primary way for new patients to access the BHC. Thus, open access book-
ing is not reserved primarily for patients in an acute crisis. Benefits of
warm handoffs include convenience for the patient who does not have to
return at a separate date, decrease in no-shows for initial appointments,
and capitalizing on what may be a period of heightened willingness to
address concerns immediately following discussion with their PCP. A
warm handoff truly communicates that behavioral health consultation is
a routine part of primary care.
An examination of scheduling and staffing approaches across 17 inte-
grated practices found that practices emphasizing warm handoffs for
patient engagement (rather than referrals with booked appointments
at a later date) had staffing ratios of one BHC for each two to six PCPs
(Davis et al., 2015). BHC schedules were more open and flexible and
built around brief (15- to 30-minute) encounters. A 2:1 ratio of open
access to advance booking appointments can be a good starting point for
many clinics; others may initially alternative unscheduled and scheduled

36
 FUNDAMENTALS OF PRIMARY CARE BEHAVIORAL HEALTH INTEGRATION

30-minute appointments. Clinics should regularly evaluate supply and

demand for different appointment types and adjust templates as needed
to maximize efficiency. Robinson and Reiter (2016) provided more detail
regarding BHC appointing options, including back-to-back PCP/BHC
appointments and use of “standing orders” with patients booked directly
into a BHC slot for certain conditions without first seeing the PCP.
Patients may also be seen jointly by the PCP and the BHC. When this
occurs, it is often the BHC who joins the patient’s appointment with the
PCP (although the reverse may also occur). Finally, BHCs may provide
consultation to PCPs regarding patients that the BHC has not seen (e.g.,
if the patient refuses an appointment).
The patient’s experience when attending the appointment will largely
mirror that of PCP appointments. Patients check in for their BHC appoint-
ments in the same way and wait in a common waiting room. They are seen
in an exam room similar (if not identical) to those of the PCPs. As with
other providers, BHCs may be interrupted briefly during appointments,
and they document in the EHR during the encounter. BHCs may step out
of appointments to consult with the PCP on an issue important for the
patient’s care that day. Patients leave with a written “behavioral prescrip-
tion” of actions they have agreed to take to improve their condition.

REACHING PATIENTS THROUGH

CLINICAL PATHWAYS
A second significant systems-level challenge in integrated care is ensuring
that the wide range of patients who could benefit from integrated behav-
ioral health services are appropriately identified and successfully linked to
the BHC. One approach to addressing this challenge involves the imple-
mentation of PCBH clinical pathways, an important avenue for increasing
penetration of integrated behavioral health services. Greater numbers of
at-risk patients can be identified and effectively linked to the BHC, have
their outcome data tracked, and care continuity provided. This can be
particularly useful when PCPs do not refer a wide range of patients to the
BHC, resulting in underutilization of the BHC.

37
 PSYCHOLOGICAL TREATMENT IN INTEGRATED PRIMARY CARE

Throughout this volume, PCBH clinical pathways are described as a

set of consistent steps, beginning with identifying patients for inclusion
in the pathway and ending with evaluating pathway outcomes. Various
primary care staff members may have responsibility for different aspects
of the pathway. More information on use of PCBH clinical pathways can
be found in Hunter et al. (2017) and Robinson and Reiter (2016).

Identify Patients
This first task in a clinical pathway is to identify patients who meet inclu-
sion criteria for a specific pathway. Inclusion criteria should be objective,
such as a specific score on a screening measure, the presence of a diagnosis,
or a cut-point on a lab result. Methods for identification could include one
or more of the following, depending on the problem area:

77 screening at PCP appointments;

77 identification of problem by the nurse or PCP during an appointment;
and
77 regularly scheduled data pull from EHR using diagnosis, labs, or other
clinical criteria.

To aid PCPs in remembering to consider referring patients to the BHC, it

can be useful to incorporate clinical prompts within the EHR. These point-
of-service reminders alert PCPs to patients who meet pathway inclusion
criteria and provide information on recommended actions, including
encouraging the patient to see the BHC.

Link to the Behavioral Health Consultant

Once a patient has been identified as meeting inclusion criteria for a clini-
cal pathway, specific methods to link the patient to the BHC should be
used. Such methods could include

77 facilitating a same-day warm handoff to the BHC after a PCP

appointment,
77 scheduling the patient for a BHC appointment before leaving clinic, or

38
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