Integrated Care: The Behavioral Health Primary Care Model. M. Hunter Hansen, PsyD, MP

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Integrated Care:

The Behavioral Health Primary Care Model



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


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


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 &



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


Visit structure not related

to medical visits

Long term follow up rare, hi

risk only

Long term follow up


Informal by provider


Formal: intake & tx


Low intensity, between

session interval longer

Higher intensity, more

concentrated care

Relationship not primary


Relationship built to last

over time


Specialty MH Care vs. BHC


Primary BHC

Specialty MH

Limited face to face contact

Face to face primary


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



Challenges with the BHC



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).


Ethical dilemmas related to multiple roles


Specialty MH Care vs. BHC



Primary BHC

Specialty MH

# Sessions

1-3 (typical)

Variable, by


Session Length

15-30 mins.

50 min. hr.


Qualities of An Ideal BH


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


Federally Qualified Health Centers

Veterans Administration Medical Centers Rural Health Centers

The Military and Public Health System Centers


Networking (Christian Community Health Fellowship) (Collaborative Family Healthcare Network) (Society of Behavioral Medicine)

State Primary Care Associations (National Health Service Corp) Me


Barriers To Integrated Care

• LCSW/LPC dominated field so far primarily due to salary costs



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.