At the broadest level, using a population-based approach means thinking beyond the patient in the exam room; it is about finding ways to improve the health of members of the population that the BHC might never even see. For example, when a BHC teaches a PCP a brief behavioral intervention, the PCP may use that intervention to help patients the BHC never encounters. Influencing the care provided by PCPs is one of the best ways to affect population health, since PCPs will always see many more patients than a BHC. Another example is when the BHC participates in the design of treatment guidelines for a given condition within his organization. The guidelines will influence how care is provided to many patients, including many patients seen only by the PCP. Yet another example is when a BHC accepts a warm handoff to complete a visit that the PCP started. Oftentimes, these warm handoffs save the PCP time that he can then spend with the subsequent patient(s), time that otherwise might have been deducted from subsequent visit(s) because of the PCP falling behind schedule. Like a shepherd, a BHC must tend to the entire “flock” while also keeping a close eye on the sheep that are sick.

Intensive specialty interventions offer significant help to certain identified individuals, but the downside is that the majority of individuals needing help go unidentified and/or underserved. In contrast, population-based approaches assume the occurrence of a health condition reflects the behavior and circumstances of society as a whole. They attempt to reach more members of the population, if in a more limited manner, in hopes that small improvements in many will lift the overall health of the population. As an example, a community-based approach to salt reduction is a best practice in the prevention of noncommunicable disease and may save a great deal of suffering among people who do develop chronic diseases (Asaria, Chisholm, Ezzati, Brown & Jones, 2007).

The PCBH model follows this approach by encouraging brief BHC involvement with the largest number of patients possible. The goal is to disseminate basic behavioral knowledge throughout the population in order to help lift overall population health. Such a perspective should shift a BHC’s priorities and goals from a focus on individual patients to the clinic population as a whole.

An analogy is the work of a battlefield medic. In battle, a medic would opt to help a soldier with a compound fracture before helping a soldier who is near death from a more severe injury. The rationale is that stabilizing the soldier with the fracture will require relatively little of the medic’s time, perhaps just a quick splint and tight wrap around the wound; and then that soldier could be put to use helping others who are injured, including the soldier with the life-threatening injury. In the trenches of PC, and viewing the work through a population health lens, a BHC’s time might be better spent in a one-time smoking cessation visit than in the twelfth visit for a patient with chronic anxiety. This is not to imply that a BHC should refuse to see certain patients or cap how often a patient can be seen. The point is merely that the PCBH model is about resource utilization, that is, finding ways for limited healthcare resources to reach as much of the population as possible.

Clinical pathway development and implementation is the fourth representation of the population health influence in the PCBH model. Pathways are care protocols that describe specific services the BHC will provide to improve outcomes within a targeted patient group. The group may have physical and/or psychological problems. Pathways also describe how services are to be evaluated. To create pathways, BHCs work with other PCBH team members to identify priority populations. Next, from possible empirically supported treatments (ESTs), BHCs work with pathway team members to select from possible ESTs the one that will have the greatest impact given the resources available to the clinic at that point in time. Additionally, the BHC works with the team to define outcome measurement strategies. Chapter 12 provides additional information on pathways.

New patients may be unfamiliar with the role of the BHC and what to expect during visits. To help ensure informed consent and encourage patient expectations of helpfulness, we recommend opening the initial visit with a brief, carefully worded introduction. Key components include the BHC’s profession and title, a description of the BHC’s role in the clinic, the structure of the visit and potential for follow-up visits, and possible outcomes of the visit. If the BHC service is new to the clinic, it is also helpful to share this introduction with PCPs, as it may help them understand how best to describe the service to patients.

Keep in mind that a good introduction focuses on what is provided by a BHC rather than what is not. New BHCs sometimes sound apologetic in the introduction, when discussing how brief their visits will be compared to the regular therapy process. The vast majority of patients will be perfectly satisfied by the structure of BHC visits, so speak enthusiastically about how the BHC will be enhancing the patient’s PC experience. Suggestions for specific wording of the introduction, along with more detailed instructions, are in Chapter 9.

Patients are accustomed to a healthcare system that approaches the mind and body separately. An important part of the BHC’s role is to help patients begin to understand health issues holistically. Approach this by talking with patients about different types of health—mental, physical, and social—and how stress, positive and negative, impacts health status. The stress–diathesis model (discussed more in Chapter 7) is helpful for this and should be something the BHC understands well. Put simply, the stress–diathesis model considers stress a normal and even helpful part of life, as long as stress levels remain within one’s ability to cope. When stress levels exceed one’s abilities to cope, the person may experience physical and/or psychological problems and, as a result, a diminished quality of life. A good explanation of the interactive nature of medical and psychological health may help reduce the sense of stigma many patients experience when addressing mental and/or physical health problems. As a result, patients may be more receptive to learning new skills that empower new responses to stress and better health outcomes.

Traditional diagnostic and personality assessment tools are usually not a good fit in a PC setting and the PCBH model. There are two problems with such tools. First, many of these tools are too lengthy. In general, any measure requiring more than 5 minutes for administration and scoring is too long. The brevity of BHC visits (30 minutes at the most) makes longer tools impractical, and taking extra time for lengthy personality or neuropsychological evaluations will undermine the BHC’s success. New BHCs are often tempted to block off big chunks of time each week for such evaluations of a specific patient or two, but BHCs must remember that PC’s role is to meet the needs of many, not focus on a few.

Second, in most cases, a focus on diagnosing lends little to the contribution the BHC can make. Rarely does a diagnosis need to be established in order for a behavior plan to be created and implemented. In fact, valuable time can be wasted trying to secure a diagnosis when what is really needed is a behavior plan focused on the concerns the patient presented with. We often see new BHCs spend an initial visit attempting to determine a diagnosis, only to end up out of time and unable to provide a behavioral intervention. In addition, brief visits are often insufficient for making a clear diagnosis. The end result is frustration for both the patient and BHC.

To avoid getting bogged down, we recommend using brief tools that assess broad problems in functioning and/or quality of life. As a rule, assessment tools consistent with the PCBH model should take no more than 5 minutes to complete, including administration, scoring, and feedback. Acceptable assessment tools should also be written at no higher than an eighth-grade reading level and ideally located in the public domain (i.e., free) because of the large patient volume they will be used for. Tools that have been translated into various languages are also preferable. Note that limiting the number of tools a BHC uses will increase the likelihood that PCPs will learn to use the measure during patient visits.

Examples of brief tools include the Duke Health Profile (Parkerson, Broadhead & Tse, 1990) the SF-12 (available online from Quality Metrics), for adults and, for children, the Pediatric Symptom Checklist (PSC-17; Gardner, Lucas, Kolko & Campo, 2007). These tools provide meaningful information that helps not only with assessing outcomes of importance to most patients (e.g., quality of life, level of psychosocial distress) but also with the crafting of a behavioral intervention. For visits addressing questions about medications, the BHC may use condition-specific screeners (see Chapter 8 for examples).

To help ensure the visit meets the goals of both patient and PCP, the BHC must clarify the reason for referral at the outset of the visit. This means talking with both the patient and PCP about what to focus on. Ideally, the BHC and PCP will have a brief, face-to-face discussion just prior to the patient visit, either as part of the warm-handoff process or via a quick check-in for patients seen on an earlier day by the PCP. If the PCP is not available, reviewing the PCP’s last notes or talking with the PCP’s MA may help clarify the reason for referral.

Asking for the patient’s understanding of the referral reason is also helpful. Typically the patient will know the reason, but if not, this is an opportunity for the BHC to clarify the PCP’s concern(s) with the patient. Occasionally, the patient will want to discuss a problem different from the concern indicated by the PCP. In such cases, some negotiating may need to occur between the BHC and patient. The most productive approach to this situation often involves thoughtfully receiving the patient’s concern and finding a way to connect it to the PCP’s concern. Sometimes a new concern may emerge during the visit that requires attention. If urgent, such as a report of domestic violence, the focus of the visit may need to shift. Nonurgent problems may be noted in the plan section of the chart note (e.g., “I recommend that Dr. Jones talk with patient about the risks and benefits of continuing to smoke, as patient expressed interest in quitting.”).

Limiting the scope of exploration to a single problem can be one of the most difficult transitions for MH providers moving from specialty MH care to PC. Many, if not most, patients seen in PC have multiple problems, physical and/or mental. The BHC’s job is to limit her focus to the problem indicated as the reason for referral and to develop a strong behavioral intervention for it. As noted above, sometimes a complaint comes up that cannot be ignored, but most of the information that will tempt diversion should simply be noted and left for a future visit. This may seem foreign to the new BHC, but this same focused approach to patient visits is used by PCPs every day. Remember, other team members can be called upon to help address additional concerns that arise. For example, if during a BHC visit for depression a patient mentions an interest in learning more about diabetes management, the BHC might try to arrange a same-day visit with a clinic RN or diabetes educator.

Prior to designing and implementing a treatment plan, the specialty MH provider will likely use an initial intake appointment (or two) to establish the patient’s diagnosis. In line with the PCBH model, where the initial visit is brief and must produce clear interventions and recommendations, the BHC must take a different approach. Instead of a lengthy psychosocial interview and diagnostic assessment, the BHC must explore aspects of the patient’s life as a context for the problem targeted in the consult and offer an intervention that will reduce the problem’s impact on the patient’s quality of life. The ability to conduct a brief life context interview is essential to the role of the BHC. More detailed information about life context interviewing is available in Chapter 9.

Functional analysis of the target problem often includes questions about when the problem started, what triggers it, how it’s evolved over time, and what seems to reinforce it. Other questions might assess what the patient has already tried to do for the problem and what results those efforts produced, both in the short term and the long term. Chapter 9 describes functional analysis in greater detail.

The BHC integrates information from contextual and functional analyses to design interventions that make sense to the patient and will improve the target problem. Effective BHCs couple good listening skills with solid general intervention skills to create evidence-based interventions easily understood by the patient as relevant to his situation. A tendency among novice (or overwhelmed) BHCs is to have a pat set of symptom-reduction tools that are used repeatedly from one patient to the next. For example, knowing that a patient was referred for anxiety, a BHC might plan on teaching diaphragmatic breathing before even meeting with the patient, having already developed a plan without knowledge of the patient’s history. This “cookie-cutter” approach is not recommended. In many cases, any number of evidence-based interventions may be reasonable to suggest, but selecting the one that best fits the patient’s skill repertoire, level of motivation, and cultural context is much more likely to generate patient buy-in and ultimately promote change.

Most patients want to choose how to address target problems. Through functional analysis, a BHC with a broad knowledge of ESTs should easily be able to offer the patient choices. Consider this example:

With the increase in stress in your life, it looks like you have been feeling more nervous and this has had a negative impact on your concentration and mood at work. We could take a number of different directions to address this. One is to focus on reducing one or more specific stresses using problem-solving strategies. Another is to focus more on increasing your sense of calm by teaching you new relaxation skills. Which direction makes the most sense to you?

It is possible to teach the patient more than one intervention during the initial visit, but it’s usually best to focus on mastering one, saving the second for a follow-up visit.

In recent years, more and more information is available to guide best practice within the PCBH model, and keeping abreast of these developments is important. Appendix A includes suggested books on the adoption and implementation of behavioral interventions in PC consistent with the PCBH model. In addition, several journals often include content directly relevant to the PCBH model, including the Journal of Clinical Psychology in Medical Settings, and Families, Systems, and Health. Other potentially helpful journals include the Journal of Health Psychology, Annals of Behavioral Medicine, Journal of Consulting and Clinical Psychology, Cognitive and Behavioral Practice, Professional Psychology: Research and Practice, and the Behavior Therapist. Though content in these journals is not always directly relevant to BHC work, much of it can be applied.

Keeping an eye on journals commonly read by PCPs and also having some awareness of the best, most current practice guidelines followed by PCPs are also important. There is a surprising amount of behavioral health research and practice information that can be found in PC journals. Some of the best journals to monitor include Family Medicine, Journal of Family Practice, The New England Journal of Medicine, Journal of the American Medical Association, Annals of Internal Medicine, Pediatrics, and British Medical Journal. A frustrating reality is that PCPs and BHCs tend to read on similar topics but from different sources using different jargon. Staying current on research from both medical and behavioral health journals helps BHCs overcome problems with language and conceptual differences that often act as communication barriers between BHCs and PCPs. BHCs should be able to speak in terms familiar to PCPs, and through discussion, both BHCs and PCPs should gain an enhanced understanding of the other’s perspective.