Behavioral Health Integration: Obstacles & Successes

April 29, 2016   |  Tags: Blog   |  Tags: Behavioral Health Integration , OHA PCPCH , FQHC
Dr. Brian Sandoval

Behavioral health integration is a necessary and very beneficial part of patient-centered primary care. Yet, it can be difficult to start an integrated behavioral health program, as there are many moving parts to contend with and different models to choose from. The Patient-Centered Primary Care Institute (PCPCI) and the Oregon Health Authority’s Transformation Center are gathering resources for a Behavioral Health Integration Resource Library to add to the Institute website. This will be an assortment of valuable resources to aid with aspects of behavioral health integration. We have interviewed several clinics that have successfully integrated behavioral health across Oregon to begin to understand the work being done, the challenges, and successes. This blog is the first in this series, and will be linked to the Behavioral Health Integration Resource Library when that is launched. If you would like to be notified when the Behavioral Health Integration Resource Library is online, please email us.

We first spoke with Dr. Brian Sandoval, the Primary Care Behavioral Health Manager at Yakima Valley Farm Workers Clinic (YVFWC). YVFWC has locations throughout Washington and Oregon, and is a National Committee for Quality Assurance endorsed Patient-Centered Medical Home and is recognized in Oregon as a Patient-Centered Primary Care Home (PCPCH).




Hi Dr. Sandoval, thank you for taking the time to speak with us. To start with, can you tell us a bit about your role at YVFWC?

I am the Primary Care Behavioral Health manager at YVFWC. I am a psychologist by training, and I was hired approximately four years ago when they were beginning the process of becoming a Patient-Centered Primary Care Home. This was a concerted effort by YVFWC to really building whole person care as the standard of care, and this was the birth of the behavioral health integration program. We had some notable Behavioral Health Consultants (BHCs) in the past, including Patti Robinson, but my hire was an intentional effort to make primary care behavioral health a true “program” at YVFWC. This was in 2012, and there was only myself and one other person (Juliette Cutts) to begin and grow the program. Now there are 12 behavioral health consultants across nine clinics with the goal of all 16 clinics having BHC access in the coming years. My primary role is to oversee the program, provide clinical training and onboarding, and see patients at Salud Medical Center and Rosewood Family Health Center.

Is PCPCH and the medical home model still a big focus for your work?

A lot of times there is an arbitrary separation between the primary care home and integrated behavioral health care. In reality, we want to think of behavioral health as a necessary and regular component of primary care service delivery. The PCPCH has become a natural way to organize our efforts around multidisciplinary care so that it becomes an expected part of care delivery by our patients. Ultimately, BHCs have become an integral part of how we measure success in primary care, not only in terms of clinical and quality metrics but also in terms of utilization patterns and impact on patients of varying complexity.

Are there initiative focus areas – such as SBIRT – or implementing specific screenings, workflows, or metrics that have been a part of your behavioral health program?

We recently hired a psychiatric nurse practitioner onsite at Rosewood Clinic, and we are starting to explore a telemedicine option for psychiatric prescribing at other satellite clinics in Oregon. SBIRT has been implemented at all of our Oregon sites across the Portland/Salem area and at our Hermiston site. Perhaps the newest initiative is at our Rosewood Clinic, which focuses on social determinants of health and providing care in innovative ways to match the needs of our unique patient population. Overall, the goal is achieving better health outcomes instead of continuing to reinforce care delivery methods that are wedded to standard fee for service work (such as face-to-face visits). As part of this “Radical Rosewood” initiative, we have begun to focus on universal screenings rooted in the social determinants of health such as food insecurity, screening for trauma, housing, education, language and related factors. A key aspect of Radical Rosewood is the desire to dive in deep and explore the broad context of how we better help our patients move closer to health goals. Our providers and clinical team take two hours twice a week to step away from direct patient care and think about their population and discuss the next steps to engage the patients – phone calls, social work connections, telephonic intervention, or maybe even home visits.

Reflecting on implementation - what are some of the biggest obstacles you faced? What did you do to deal with those?

We have a standard process now for onboarding clinics, but one of the greatest obstacles we faced was getting clinics to change their practice habits. In particular, orienting primary care providers to accommodate BHC work can be challenging because they’re used to doing it all. One of the ways we addressed this barrier was by meeting with the providers and getting them engaged as early as possible. It helps to speak frankly with providers  about challenging days and complex situations, and doing a little shadowing if needed, to help them understand the broader scope of issues we can address.

Also, it is paramount to hire the right people in order to build trust for the service as a whole. So that if the primary care provider is not the one doing this work anymore, they can still trust that the work is getting done and that there is value in having the BHC participating in patient care.

What have been some of the major successes?

In the clinics where we have BHCs, our program is viewed by providers as truly a routine component of care. No longer is it a “luxury” for a clinic to have a BHC, but our service is now an essential part of patients’ care plans and clinic-level workflows. As far as clinical success, of all the patients screened that come up positive for depression, 65% of those patients experience positive pre-post outcomes in just one to two BHC visits. So essentially, our visits are as good as, if not better than, antidepressants therapies (considering monotherapy SSRI remission rates hover somewhere between 35-45%). I’m also proud of the fact that we’ve built a strong, engaged BHC team that has a passion for the work we do. Over my four year tenure, 92% of the people I’ve hired are still here at YVFWC (and plan to stay). Working in primary care is challenging and there is a great deal of burnout, especially for behavioral health providers.  You cannot just hire behavioral health providers and plop them into clinics without adequate support or direction. It can’t be stated enough how important it is for organizations to invest in building an actual program. People always talk about meeting the patients where they’re at – primary care is that location, because people show up there most frequently with health concerns. When we can meet patients there, physically and emotionally, and promote engagement in all aspects of their health, that is a beautiful thing.

Dr. Brian Sandoval is a clinical psychologist with 8 years of primary care experience in several capacities including clinical work, program development, and research. He is currently the program manager for Primary Care Behavioral Health at the Yakima Valley Farm Workers Clinic, an FQHC network with 16 clinics throughout Oregon and Washington. During his professional career, Brian has been involved in several projects integrating mental and physical health and his current interests include the development of state-level standards for population health service delivery. Brian has a passion for working with the underserved and continues to see patients on a part-time basis at Salud Medical Center (in Woodburn) and Rosewood Family Health Center (in Portland). He has also been a leader in his organization’s efforts for Level 3 recognition as a Patient-Centered Medical Home.