Why should practices rethink the role of the behavioral health specialist in primary care?
There is increased recognition of the need to integrate care for mental, behavioral and psychosocial issues into primary care. The relationship between mental/psychosocial/behavioral health and physical health is strong, and it is often difficult to address physical issues without first addressing psychological issues and vice versa. To provide patients with holistic and effective care, it is essential that practices integrate behavioral health services into primary care teams. Integrating behavioral health into primary care is a complex and challenging innovation area. Many of the LEAP sites were still experimenting with models for behavioral health integration. This module is intended to be used in conjunction with the Behavioral Health Integration module. If you have decided to improve upon your clinic’s approach to behavioral health integration, this module will help you consider options for adding new staff and/or modifying the roles of existing staff to ensure that they are an integrated team member.
How should the role of the behavioral health specialist change?
Behavioral health integration is a key component of many patient-centered medical home initiatives. But many primary care clinics do not have a behavioral health specialist as a member of their primary care team. In those cases, the question isn’t “how should the role change,” but “what behavioral health expertise and services do we need, and how do we best integrate them into our team and our care?” Other clinics might have a behavioral health specialist on-site but the services they provide may not be fully integrated into the primary care team.
For practices to have comprehensive behavioral health integration, they need access to three types of specialists: 1) a behavioral health specialist able to assess patient behavioral health needs, provide non-pharmacologic interventions for episodic and/or acute behavioral health needs, and collaborate with team around patients with complex chronic care needs, 2) a psychiatric specialist able to consult with primary care providers on the management, especially medication management, of severe/chronic mental illness and/or actively manage these patients in collaboration with the primary care team; and 3) an addictions specialist.
LEAP practices generally see co-location as critical for a number of reasons, including availability for warm hand-offs, reduced patient stigma associated with mental health referral, and ability to provide whole-person care through regular communication with primary care providers and staff.
In LEAP practices, behavioral health specialists most often were:
- Co-located with or near the primary care team.
- Available for warm hand-offs.
- Focused on short-term therapy.
- Helpful in referring people with more severe, long-term mental health issues for more specialized care.
- Able to efficiently communicate with other members of the primary care team.
There are many training and licensure pathways for behavioral health specialists, making it challenging to decide which type of behavioral health specialist to hire. One key consideration is whether a behavioral health specialist has the credentials to bill for services, making the role easier to sustain.
What do we gain by making these changes?
Integrating a behavioral health specialist into primary care teams can improve health outcomes and address many barriers patients face accessing this type of care. Patients are often reluctant to seek help for behavioral health issues for a number of reasons, including:
- Stigma associated with seeing a behavioral health specialist.
- Lack of awareness or recognition of behavioral health issues.
- Lack of insurance coverage for behavioral health services.
- Limited knowledge about insurance coverage due to the complexity of how behavioral health benefits are administered in many organizations and states.
- Inability or unwillingness to find or go to a new health care provider.
Integrating behavioral health specialists into primary care allows patients to be seen at their primary care clinic. Because primary care clinics do not specialize in mental health treatment, patients often find it less stigmatizing and easier access to services. Integrated behavioral health services also benefit the provider and team by providing: 1) additional support for complex patients, 2) education and consultation on behavioral and psychiatric issues, and 3) behavioral health support for team members. The last of these benefits were demonstrated at a handful of LEAP sites, where behavioral health specialists actively used their professional skills to improve team dynamics and communication.
- If your practice has a behavioral health specialist, assess whether they are actively participating in team-based care.
It is not uncommon for primary care practices to have on-site behavioral health services. But many demonstrate very little integration and coordination between the primary care team and the behavioral health specialist. Integration goes beyond co-location to include: the ability to provide warm handoffs and “curbside” consultation; ongoing consultation on patients with major and/or chronic issues; inclusion of the behavioral health specialist in team huddles and regular meetings to discuss patients in need of more intensive support; and the sharing of clinical records.
- If your practice does not have a behavioral health specialist, determine your approach to acquiring the expertise and services you seek.
Practices that do not currently have a behavioral health specialist will need to assess their clinical priorities for behavioral health care. This should be based on the needs of their patient population. The practice then needs to consider whether to add a new person or persons to the practice team in order to acquire the support and services they need. If yes, does the person have to be an employee of the primary care organization, or could he/she be an employee of a mental health agency detailed to primary care.
Go to the Behavioral Health Integration module to assist you in developing a model for behavioral health integration.
- Define the behavioral health specialist role(s) clearly.
Regardless of the model chosen, it is important to clearly define the behavioral health specialist role and develop methods for increasing communication and shared responsibility for patient care with other members of the primary care team. At some LEAP sites the focus was primarily on providing direct patient care, however in a few LEAP sites the behavioral health specialist(s) also supported the primary care team by facilitating and counseling team to ensure healthy interpersonal relations and educating/consulting with staff around behavioral health issues.
For providing therapy or counseling, a behavioral health specialist may be a masters-level therapist, licensed clinical social worker, professional counselor, or psychologist. In addition to having a behavioral health specialist who can provide counseling, practices will also want to develop a collaborative relationship with psychiatric consultants (Psychiatrist or Psychiatric Nurse Practitioner) who can advise and support the primary care treatment team on evidence-based collaborative care for depression, anxiety, or bi-polar disorders. This may not involve direct contact with the primary care team or patient. These consultations can be done using phone or other communication technologies (Skype, videoconferencing, etc.)
- Hire the right person.
As with all team-based primary care roles, it is important that your behavioral health specialist(s) have the skills to work effectively in a team environment. These include excellent communication skills, a willingness to adapt to changing care processes, and comfort working outside of a traditional specialty behavioral health setting. They may also need to have expertise and comfort working outside of traditional face-to-face consultation formats and payment models.
- Provide training for the Behavioral Health Specialist.
Behavioral health specialists on primary care teams may need additional training in specific types of assessment and short-term approaches to therapy. Most will need an orientation to primary care processes such as use of an EMR, quality improvement approaches and team member roles and workflows.
- Provide training for other members of the primary care team.
High-quality integrated care requires effective teamwork with clear roles, protocol, communication approaches, and processes. It’s important to bring all members of the team together for training and discussion. The goals of the training include: agreement on treatment protocols, treatment targets, assessment methods, and follow-up; criteria for hand-offs; and guidelines and strategies for communication. The team might also benefit from activities that strengthen team functioning and promote on-going changes in work processes to maximize use of the behavioral health specialist(s).
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