INTEGRATED BEHAVIORAL CARE PROGRAM ELEMENTS
Operational elements and principles of integrated behavioral care programs flow from the objectives of the program and can thus vary. One conceptual framework, put forth in “Providing Behavioral Health Services in a Community Health Center Setting”, Washington Association of Migrant and Community Health Centers, April 2002, is given here with slight abbreviations and modifications:
The philosophy of primary mental health care involves the use of behavioral interventions for a wide range of health and mental health complaints. The focus is on resolving problems within the primary care service structure, as well as on engaging in health promotion for “at risk” patients. The goal of integration is to position behavioral health consultants in the “second tier” of the primary care delivery system – to support the primary care provider and bring more specialized knowledge to problems that the provider thinks require additional help.
KEY PRINCIPLES IN PRIMARY BEHAVIORAL HEALTH CARE
Principle #1: The Behavioral Health Consultant’s role is to identify, target treatment, triage and manage primary care clients with medical and/or behavioral health problems using a behavioral approach.
Based on the concept that direct behavior change is the most powerful form of human learning, consultative interventions focus upon:
- helping patients to replace maladaptive behaviors with adaptive ones;
- providing skill training through psycho-education and client education strategies; and
- developing specific behavior change plans that fit the fast work pace of the primary care setting.
Many studies have demonstrated that the behavioral health model can significantly increase the quality of mental health care provided in the primary care setting, not only through improved behavioral health outcomes, but health outcomes as well. Behaviorally based interventions have demonstrated clinical effectiveness with a wide range of mental disorders and psychosocial problems, including depression, panic disorder, generalized anxiety disorders and chronic pain. Research has shown that these approaches can be tailored to fit the primary care setting without loss of clinical effectiveness.
The behavioral health approach is equally facile at addressing behaviors that promote health (i.e., exercising, having annual mammograms) and those that promote illness (i.e., smoking).
Behavioral health interventions are easily transferable to the client, using client education and self care models. Such models are already widely employed in the primary care management of chronic diseases such as diabetes. These models focus on teaching clients self-management and behavior change skills and then place more responsibility on the client for executing these behaviors.
Principle #2: The primary behavioral health program is grounded in a population-based care philosophy that is consistent with the mission and goals of the primary care model of care.
The service “mission” is not just to address the needs of the “sick” patient, but to think about similar patients in the population who may be at risk, or who are in need of care but do not seek it. Pivotal service delivery questions, which should directly influence behavioral health program planning at the local level, include: What types of behavioral medicine service needs exist in the population of clients served by the particular primary care team? What type of service delivery structure will allow maximum penetration into the whole population? What types of interventions will work with the “common causes” of psychological distress? What secondary, and more elaborate, interventions are appropriate for a primary care setting? At what level of complexity is a client better treated in specialty mental health care?
Two complementary frameworks exist for addressing the needs of the primary care population through integrated care. These are: Primary Care General Consultation
This is the framework upon which the Primary Behavioral Health Program is based, because most members of the primary care patient population can benefit from behavioral health services delivered in a general service delivery model. A distinguishing feature of Primary Care General Consultation is that it “casts a wide net” in terms of whom is eligible. From a population based care perspective, the goal is to provide brief, general psychosocial services to as many patients as possible. Traditional primary care medicine is largely based upon this type of approach. The goal is to “tend the flock” by providing a large volume of general health care services, none of which are highly specialized. Patients who truly require specialized expertise are usually referred into medical specialties. Similarly, patients with behavioral health needs can be exposed to non-specialized services; those that truly require specialty care are referred into the specialty behavioral health system.
Population Based Integrated Care
This framework involves providing targeted, more specialized behavioral health services to a well defined, circumscribed group of primary care patients, such as patients with major depression. This is a major contemporary development in primary care medicine, i.e., the use of a “critical pathway”, “clinical roadmap” or “best practices” approach. Targets for this type of approach are usually patient populations with high frequency and/or high cost conditions such as depression, panic disorder and chemical dependency and certain groups of high medical utilizers. With respect to frequency, a complaint that is represented frequently in the population (like depression) is a good candidate for a special process of care. With respect to cost, some rare conditions are so costly that they require a special system of care, for example, patients with chronic behavioral health problems. A good example of this type of problem involves patients with Acquired Immune Deficiency Syndrome (AIDS). In the behavioral medicine arena, high utilizers of medical care, by definition, compose a small but costly group that often is the targets of integrated care programs. There also exist a variety of patient populations within a typical medical setting that can be effectively served through classroom and group programs on an integrated care model. Such programs might include hypertension education, bereavement groups, diabetes education and so forth.
Two complementary frameworks exist for addressing the needs of the primary care population through integrated care. These are:
Primary Care General Consultation
Principle #3: Primary behavioral health services are based in and consistent with a primary behavioral health model.
The primary behavioral health model is capable of addressing the increased service demands likely to be encountered in a fully integrated primary care team practice setting. This approach involves providing services to primary care patients in a collaborative framework with primary care team providers. It may also involve engaging in the temporary co-management (with the primary care provider) of patients who require services that are more concentrated, but nevertheless can be managed in primary care. Both types of services are delivered as intervention for primary care clients who have behavioral health needs. If a client fails to respond to this level of intervention, or obviously needs specialized treatment, the patient is referred for more extended specialty care. Consistent with the service philosophy of primary care, the goal of primary behavioral medicine is to detect and address the broad spectrum of behavioral health needs in the primary care patient population, with the aims of early identification, quick resolution, long-term prevention and “wellness.”
The Behavioral Health Consultant’s role is to support the ongoing behavioral health interventions of the primary care provider. The focus is on resolving problems within the primary care service context. In this sense, the behavioral health provider is a key member of the primary care team, functioning much like the consultative internal medicine specialist. Behavioral health visits are brief (usually 15-30 minutes), limited in number (usually 1-6 visits), and are provided in the primary care practice area, so that the client views meeting with the behavioral health consultant as a routine primary care service. The referring primary care provider is the chief “customer” of the service and, at all times, remains the overall care manager.
Principle #4: The Behavioral Health Consultant promotes a smooth interface between medicine, psychiatry, specialty mental health and other behavioral services.
The underpinning philosophy is that an effective, full continuum of behavioral services is necessary to match the client’s potential level of need with level of care. A major system goal is to use a set of triage practices to effectively determine which clients can best be managed within primary care, and which require coordinated referral to other behavioral services. This is a two-way conduit; the behavioral health consultant facilitates referral into appropriate specialty behavioral services, while providing liaison assistance as cases are transferred back from County Mental Health to primary care providers for ongoing management.