Integrated Care:
The Behavioral Health Primary Care Model
Objectives
Brief Review of the History of Mental Health Care
The State of Mental Healthcare
The Role of Primary Care Medicine in Mental Health Care
Brief History if Integration Attempts
A New Model: Behavioral Health Consultant Model/ Integrated Care
Barriers for Psychologists
The State of Mental
Healthcare
50% of people with a mental disorder get no mental heath care at all! ( Bijl et. al., 2003) ,but 80% will see PCP in a year.
80% of this “no treatment” group will go to primary care for other health reasons
Primary care is the “de facto mental health system in the U.S.” Norquist, G.S. Regier, D.A. (1996 Most get care from PCP, ¼ get adequate care (Kessler, 2011).
No care worsen outcomes (e.g. 20% completed suicide rate untreated bipolar disorder ( McLaren, P. 2006) Primary care prescribes 75% of all psychotropic medications, with little specialty training in mental health.
Results in poorer outcomes vs specialty care Lopsided growth in mental healthcare professionals
Psychiatrists are not replacing themselves & estimated 45,000 needed now Use of prescription medication is increasing, use of psychotherapy is decreasing.
Limitations of Special Care
Models
Guarantees continued separation of healthcare and MH care (even in same facility)
Many PC pts reluctant to seek specialty MH care
Time-intensive: requires large expenditure of resources
Primary Care
Psychology-A Rapid Growth Psychology-Area
Behavioral Consultation and Primary Care: A Guide to Integrating Services
Robinson & Reiter
Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for
Assessment and Intervention Hunter, Goodie, Oordt & Dobmeyer
What Behavioral Functions Are
Relevant In Primary Care?
Screening for MH problems
Psychosocial Assess
Psychiatric Assess
Improving Adherence to Medical Procedures
Pain Management
Prep for med/surg procedures
Behavioral weight loss
Smoking cessation
Chronic illness
Response to trauma
Pharm. Management &
followup
Behavior Health Consultation
An integrative model of mental and physical healthcare
Transtheoretical model of change (Prochaska and DiClemente’s Stages of Change Model) and
Motivational Interviewing . Gentlemen, we can rebuild him. We have the technology. We have the
capability to build the world's first bionic psychologist. Better than he was before. Better, stronger, faster."
What is a BHC?
A behavioral health provider, usually at the LCSW or
PhD/PsyD level, who assists the PCP & the patient make
behavior changes in important health and psychosocial areas.
The BHC is not a therapist, though benefits usually associated with therapy are expected.
What is a BHC?
The BHC model is based on the following premises:
• a. small behavior changes can have significant impact
• b. population-based care is the best use of the skills of the BHC
• c. focused, time-limited intervention fits the primary care medicine model and the needs of stressed, disadvantaged persons.
The BHC model relies on evidence-based treatment tailored to the typical medical visit.
Specialty MH Care vs. BHC Model
Primary BHC
Specialty MH
Visits timed around provider
visits
Visit structure not related
to medical visits
Long term follow up rare, hi
risk only
Long term follow up
encouraged
Informal by provider
assessment/goals
Formal: intake & tx
planning
Low intensity, between
session interval longer
Higher intensity, more
concentrated care
Relationship not primary
focus
Relationship built to last
over time
Specialty MH Care vs. BHC
Model
Primary BHC
Specialty MH
Limited face to face contact
Face to face primary
vehicle
Uses pt education as
primary model
Education model ancillary
Consultant as technical
resource to pt
Therapist directs change
efforts for pt
Home-based practice to
promote change
Home practice linked
back to tx
May involve PCP in visits
PCP rarely involved in
visits
Challenges with the BHC
Model
General:
Not working in a psychological model/context
No office, less control over schedule
Faster pace, see 10-15 pts a day
Much hire rates of abuse reports, disability claims, legal problems, involuntary hospitalizations
Broad knowlege/skill base required (e.g. medications, neuropsych).
LCHC
Ethical dilemmas related to multiple roles
Specialty MH Care vs. BHC
Model
Dimension
Primary BHC
Specialty MH
# Sessions
1-3 (typical)
Variable, by
condition
Session Length
15-30 mins.
50 min. hr.
Qualities of An Ideal BH
Provider
Likes Fast Pace (Adrenaline Junkie)
Think Skin (working tights spaces, interdisciplinary jabbing, grumpy providers)
A Heart for Serving the massive underserved community Competencies and Capacities
Brief Assessment and Treatment Psychopharmacology
Group Treatment Medical Conditions
Opportunities In Primary Care
Where?
Federally Qualified Health Centers
Veterans Administration Medical Centers Rural Health Centers
The Military and Public Health System Centers
How?
Networking
CCHF.org (Christian Community Health Fellowship) CFHN.net (Collaborative Family Healthcare Network) SBM.org (Society of Behavioral Medicine)
State Primary Care Associations
nhsc.hrsa.gov (National Health Service Corp) Me
Barriers To Integrated Care
• LCSW/LPC dominated field so far primarily due to salary costs
References
Bijl et. al. (2003) The Prevalence Of Treated And Untreated Mental Disorders In Five Countries Health Affairs, 22, no. 3 122-133
Norquist, G.S. Regier, D.A. (1996). The Epidemiology Of Psychiatric Disorders And The De Facto Mental Health Care System. Annual Review of Medicine, 47, 473-479 Kessler, R. (2011). Psychiatric Epidemiology. The Carlat Psychiatry Report, 9, 3, 4-5 McLaren, P. (2006) Bipolar Disorder. Pulse, Vol. 66 Issue 17, p48-49, 2p.
