In the DOD, the behavioral health provider working in the PCMH provides services using a Primary Care Behavioral Health model of service delivery. This is a population-­health-based model of care where the medical team and behavioral health provider share information regarding patients using a shared electronic health record (EHR), treatment plan, and standard of care (Hunter & Goodie, 2010). The behavioral health provider is embedded (works in the primary care clinic as a full-time team member) with the PCMH team and serves as a consultant to the PCP in the assessment, intervention, and health care management of the full spectrum of concerns patients bring to the clinic. In addition to common mental health concerns, the behavioral health provider engages with the patient and PCP on problems usually addressed by clinical health psychologists and behavioral medicine specialists (e.g., chronic pain, headache, health risk behavior, medical non-adherence, sleep disturbance, smoking cessation, weight management). Consistent with a consultation model, the behavioral health provider operates within a scope of practice and a standard of care that is consistent with PCMH primary care and differs from the scope of practice and standard of care for a specialty outpatient mental health clinic (e.g., no separate mental health record, no signed informed consent about the limits of confidentiality). The behavioral health provider typically sees patients in appointments that are 30 min or less, documents patient appointments in the shared medical record, and typically provides feedback the same day to the PCP regarding the assessment, intervention started, and recommendations regarding how the PCP might manage, support, or monitor a “behavioral health provider”-initiated plan. This feedback typically takes place through verbal discussion, secure email, alerting the PCP to review EHR note, or some combination based on PCP preference. Behavioral health providers deliver care in the primary care clinic where patients are seen by PCPs. The goal is to have a team-based approach to care where PCPs and patients are given direct access to behavioral health provider services/consultation when a need is identified.

Clinics that have multiple PCMH teams with 7,500 or more enrollees will have a minimum of one full-time behavioral health provider and one full-time care facilitator who assists with depression and anxiety treatment monitoring and functions as a clinical care manager. The behavioral health provider and care facilitator work in a Blended Model of care (Zeiss & Karlin, 2008) which combines the Primary Care Behavioral Health Model with a Care Management model of service delivery. A Care Management model is a population-based model of care focused on a specific clinical problem (e.g., major depressive disorder, post-traumatic stress disorder, diabetes). The Care Management model incorporates the use of specific clinical practices (e.g., set screening and assessment measures used as specific intervals of treatment) that systematically and comprehensively address how behavioral health problems are managed in the primary care setting. Typically the care facilitator and behavioral health provider have some form of systematic interface (e.g., weekly case review and treatment change recommendations) with a behavioral health specialist with prescriptive privileges (e.g., psychiatrist, psychiatric nurse practitioner, prescribing psychologist, or another provider credentialed for independent practice who can prescribe medication and has specialty training in the use of psychotropics). In a Blended Model, the PCP, behavioral health provider, and care facilitator share information regarding patients using a shared medical record, treatment plan, and standard of care. In over 90 Army clinics, a care management model for depression and PTSD has been implemented, and there are weekly meetings with a care facilitator and psychotropic prescriber to discuss new patients and patients not responding to treatment. The goal is for the behavioral health provider to join these weekly team meetings in the Blended Model of service delivery.

The minimum staffing requirements for the Blended Model of service delivery are based on DoD and civilian staffing experiences (Hunter & Goodie, 2010) that suggest this is the minimum number of behavioral health providers and care facilitators needed to meet the generic needs of a given number of enrollees. The age and health status of enrollees vary across MTFs. As such, some larger clinics may have greater chronic health condition and/or behavioral health problem prevalence and might benefit from additional behavioral health provider and care facilitator staffing. However, since this system rollout is new, the determination on the benefit of mandating additional behavioral health provider or care facilitator personnel for larger clinics could not be determined yet. Staffing requirements were set to minimize excessive personnel cost as a result of overstaffing. It should be noted that the minimum staffing requirements are not iterative. For example, in a clinic with 15,000 enrollees, the minimum staffing is still one behavioral health provider and one care facilitator, not two behavioral health providers and two care facilitators. A clinic can integrate staffing into larger clinics if the need exists.