September 9, 2014 | Tags: Blog | Tags: PCBH , Behavioral Health Integration , Interview , Willamette Valley
In the fall of 2012, through feedback collected in stakeholder interviews , the Patient-Centered Primary Care Institute identified a significant and growing community interest in training and technical assistance related to behavioral health integration (BHI) as part of the development of robust patient-centered primary care homes. In the fall of 2013, the Institute partnered with Patricia Robinson, PhD, of Mountainview Consulting Group to deliver trainings and offer on-site coaching to clinics working on BHI in Oregon and to build a library of resources, including a 200+ page Primary Care Behavioral Health Implementation Toolkit, accessible to clinics on the Institute website.
Behavioral health integration can take many forms, but the Primary Care Behavioral Health, or PCBH model, includes a Behavioral Health Consultant (BHC) as part of the primary care team with the primary function of delivering brief interventions and other behavioral health services in consultation with the clinician leading the care team. Read more about the PCBH model in this sample chapter from Behavioral Health Consultation in Primary Care: A Guide to Integrating Services, Robinson & Reiter, 2007.
PeaceHealth Medical Group in Eugene participated in the BHI training, received on-site practice coaching, and was selected as a BHI Best Practice Site for their efforts in adopting the Patient-Centered Behavioral Health (PCBH) model of care.
As a Best Practice Site, PeaceHealth Medical Group serves as a resource to other practices interested in adopting the PCBH model. We spoke with Jacque Travis, Behavioral Health Consultant at PeaceHealth, about their experience implementing the PCBH model.
Q: What makes the PCBH Model a good fit for PeaceHealth Medical Group?
There are at least two reasons. The first is that because we have a mission of providing care to people regardless of their capacity to pay, it is important that we make sure we maximize the benefit to our patients by giving them the appropriate level of care when they need it rather than withholding care and having people go to the emergency room. The PCBH model enables us to provide primary behavioral health care at the primary care level and reduce the costs associated with emergency room utilization and hospitalizations.
The second reason is that PeaceHealth in Eugene/Springfield has had a strong presence and foundation in mental health services. We have historically provided inpatient and outpatient services to our community, and it is natural and sensible that we increase our provision of those services for optimal community health and resilience through the PCBH model. The PCBH model provides a framework for enhancing patient understanding of and participation in their health- through education, skills and support, which have typically been modeled in behavioral health interventions.
Q: What were your most significant barriers to optimal initiation of the PCBH program?
Our behavioral health group had begun some co-location initiatives but we were in need of more systematic training to implement an effective integrated service delivery model. I had been doing half time consultative and care coordination activities as a behavioral health specialist for five years. The team was ready to make the next series of steps to achieve full integration of a BHC, but weren’t clear on what those steps should be. We needed to work on increasing administrative support to sustain the growth at several sites where social work care coordinators were already fully embedded as part of the primary care team.
Q: What were some of the most notable improvements to your practice that resulted from the coaching received from Dr. Robinson and what is your plan for continuing to make improvements?
Our leaders are now much more engaged, and are proactively searching out financial and operational support at the system level to further this goal. This site visit gave us a well laid out plan for moving forward. Having behavioral health and primary care at the table, hearing the message together, has brought cohesion and a shared understanding.
Dr. Robinson helped us organize the leadership and decision-making at PeaceHealth, which resulted in the forming of a common cause in order for us to fully support and implement the PCBH model of integrated care.
We now have a BHC in the primary care setting full-time, for easy access and better utilization of the BHC by primary care physicians. We maximize BHC availability, allowing for day-of-visit focus, stacking of patients, and interruptions for urgencies.
Furthermore, we have adopted mindfulness, relaxation and breathing techniques as well as other best practice education and behavior intervention protocols that were modeled by Dr. Robinson. We have refined our documentation process so that it is more concise and fully embedded in our electronic medical record.
The BHC has been welcomed into the family medicine space as a valued and integral part of their team, and the department manager has voiced a solid interest in training master’s level care managers as BHCs. As of this date, these plans are moving forward with the recent addition of Trillium grant monies (our local CCO) to spread and activate BHCs in additional PeaceHealth primary care clinic locations. We have also submitted a proposal to the larger PeaceHealth system to be included in a Patient-Centered Medical Home Pilot project. This will afford us more resources for process and workflow improvements, as well as workforce optimization.
Q: What advice would you share with other clinics looking to adopt the PCBH model?
It is important to understand the very specific and newly developing role of the BHC in primary care. Understanding and willingness to learn best practice interventions for a variety of routine mental health issues such as depression, anxiety, stress, and grief is essential to the BHC as well as using skills to assist patients in their desire to reduce use of harmful substances. Capacity to do screening for more serious mental illnesses- including psychosis- must be referred to resources beyond the primary care setting with ongoing support and coordination to the individual and their families. BHCs are responsible to recognize urgent mental health needs versus crisis symptoms and orchestrate interventions at the necessary level of care.
BHCs must build understanding and a willingness to learn about medical issues and symptoms, many of which are modifiable through behavior changes initiated by the patient with the help of the BHC. Practicing motivational interventions and understanding change processes are essential to the development of BHCs in order to enhance patient self-efficacy (increasing their capacity to become their own change agents). Understanding of local resource availability is necessary when referring out to additional or specialty providers. Care must be taken to assure the BHC can adapt their practice expectations to the needs of the health care team and the patients with whom they are working in nontraditional ways.
Also, clinics looking to adopt this model should be aware that patient-centered primary care based behavioral health care is specifically meant to be very short-term focused: to help patients with health issues they and their PCPs have identified during their current visit- which are limiting the patient in their ability to maximize their best health outcomes from treatment provided. BHCs assist patients by identifying a couple of small changes the patient is willing and able to make to enhance their participation more fully in their health and to assist them in building the confidence they need to move their health concerns in a positive direction.
In our expression of the PCBH model here at PeaceHealth, we incorporate support of our triage processes as an important function of BHC expertise as well as behavioral health consultation directly to the provider on questions of concern. This can include the necessity of intervening with phone or walk-in patients (in real time)who may be experiencing a suicidal, substance abuse or other mental health crisis. The BHC has much to offer the primary care team with support, education and modeling of skills and resources.
The PCBH model requires the active creation of a working team across disciplines- where work flow processes maximize efficiency, as well as accountability, to place the health care concerns of the patient at the center of all our work.
Jacque Travis, M.Ed. is a Behavioral Health Consultant at PeaceHealth Medical Group in Eugene. With more than 25 years of in-patient psychiatric care experience from a care coordination perspective, Jacque has focused on integration of behavioral health for five years.
PeaceHealth offers a wide spectrum of services to its patients in its dozens of clinics throughout the Pacific Northwest. Their group includes medical doctors, surgeons, nurse practitioners, audiologists, chiropractors, dietitians, hospitalists, optometrists, ophthalmologists, physician assistants, physical and speech therapists, psychiatrists, midwives, nurse anesthetists and licensed clinical social workers.
If you have questions for or would like to discuss PCBH implementation further with PeaceHealth Medical Group, contact Jacque at JTravis@peacehealth.org.
For more information about the BHI trainings held in the fall of 2013, visit our website>>>