Implementing Clinical Interventions in Integrated Behavioral Health Settings: Best Practices and Essential Elements

The patient, Ms. Willard, is a 43-year-old Caucasian female. She lives with her husband of 18 years and two children, aged 16 and 12. She is employed at an elementary school as a Teacher’s Aide. Ms. Willard has been a patient of the Fairview Health Center (FHC) for 8 years and her PCP is Dr. Bergman. She has been diagnosed with hypertension and elevated cholesterol. Ms. Willard’s weight gradually increased over the years, and her BMI is currently 34. She suffers from chronic pain in her left knee and left ankle from an injury sustained in a motor vehicle accident a decade before. Ms. Willard has a history of major depressive disorder, which has been treated intermittently with an antidepressant medication.

As a patient at FHC, she has attended appointments when she has had acute health concerns. For example, she has suffered from occasional sinus infections and has had flu three times in the past 10 years. She has attended annual physical exams some years, but not every year. Her appointment frequency recently increased to address concerns about her knee and ankle pain. Most of these appointments have been with Dr. Bergman, but on occasion she saw one of his practice partners.

Team Composition and Communication

Within the past 2 years the FHC hired a part-time Clinical Care Manager (CCM), Ms. Martin, who is a Registered Nurse, and a Behavioral Health Provider (BHP), Ms. Donner, who is a Licensed Clinical Social Worker. Ms. Martin received training in approaches to CCM through a statewide learning collaborative, which was developed to help practices with the transformation to the Patient-Centered Medical Home. Ms. Donner completed clinical training rotations in medical settings, but she has never worked in a primary care setting. She has training in Cognitive-Behavioral Therapy and an introduction to brief interventions, such as Solution-Focused Therapy.

The team members communicate about patients through electronic communications in the health center’s Electronic Health Record. They meet formally every 2 weeks for an hour over lunch. They also discuss shared patients informally in hallway consultations.

Shared Identified Patient

Ms. Willard was first identified by her nurse and PCP at an appointment for acute sinusitis after completing a Patient Health Questionnaire-9 (Kroenke, Spitzer, & Williams, 2001), with positive screening results for depressive symptoms. A medical assistant on the team administered the written questionnaire when she noticed that Ms. Willard had not been screened in the past 12 months. The positive screen activated a targeted consultation process within the FHC, through which the patient was referred to the CCM. The CCM was responsible for monitoring her progress. The PCP assessed Ms. Willard’s depressive symptoms and invited the CCM to meet with the patient.

Prior to entering the exam room, the PCP told the CCM about Ms. Willard’s intermittent episodes of depression and her reluctance to engage in psychotherapy. The CCM then met with Ms. Willard and answered her questions, confirming that she understood the importance of taking her antidepressant medication regularly. During this discussion, the CCM presented the possibility of meeting again to discuss different skills that might help her feel better. Using Motivational Interviewing skills, she asked Ms. Willard about her readiness to make some behavioral changes to help improve her mood. Ms. Willard indicated a low readiness to change when asked about her depressed mood, but a high readiness to change regarding her difficulties with sleeping. She expressed an interest in figuring out ways to help improve her sleep without using sleep medications, as she believed that those medications would leave her feeling groggy all day. The CCM asked Ms. Willard if she would be willing to meet with the BHP to discuss some potential ways she might be able to improve her sleep. The CCM also described her role and prepared her for a phone call in 2 weeks to check up on her symptoms and provide support.

Clinical Intervention: Sleep Stimulus Control and Motivational Interviewing

Ms. Willard and the BHP, Ms. Donner, met in another exam room. Ms. Donner assessed Ms. Willard’s current sleep schedule, her current difficulties with sleep using the Insomnia Severity Index (Morin, Belleville, Bélanger, & Ivers, 2011), and identified several areas for improvement. The BHP explained the importance of a regular sleep schedule and associating Ms. Willard’s bed with sleep. Using MI skills, the BHP asks Ms. Willard to identify on a 1–10 scale her confidence in being able to make the changes they have discussed and the importance of these changes to her. Using that information, they continued to discuss potential barriers and the BHP provided additional relevant information.

Quality Improvement: Patient Level

Each time Ms. Willard met with the CCM or BHP, they assessed her depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9) and her level of sleep disturbance using the Insomnia Severity Index. After meeting with the BHP two times, Ms. Willard’s score on the ISI significantly decreased and she reported greater satisfaction with her sleep. The CCM noted that Ms. Willard’s PHQ-9 score also decreased as she has maintained medication compliance. Ms. Willard continued to be reluctant to engage in cognitive-behavioral treatment for depression, but she stated that she will consider it if she does not feel better soon.

Table 13.2

Clinical case example understood through parameters

Integrated behavioral health parameters		Clinical case example
Team	1. Team composition and roles	PCP: initial assessment, medication and evaluation and referrals
		CCM: follow-up with patient, track progress
		BHP: provide CBT and MI, document patient-centered goals and progress
	2. Level of collaboration or integration	Integrated—shared space, EHR systems, shared care plans, shared culture
		Biweekly team meetings to review patient care
Identification of population	3. Nontarget or targeted population screening	Identification of an adult patient during an acute care visit using the PHQ-9
		PCP identifies patient behavioral/emotional factors interfering with chronic illness care, chronic pain, sleep, and fatigue
Clinical system	4. Population identification and screening	Clinical protocol initiated for individual with positive PHQ-9 scores
		Referral to CCM at time of visit (warm hand-off)
		Follow-up session(s) scheduled with BHP after patient meets with CCM
	5. Clinical interventions	Standard Chronic Care model of clinical pathways: PCP identification, referral to CCM and BHP
		BHP incorporates evidence-based interventions: Sleep Stimulus Control treatment and MI
		CCM monitors patient care, routine f/u phone calls
	6. Level of patient engagement	Explicit shared decision-making between BHP and patient
		Chronic Care Model is clinic team driven
Office practice and financial system	7. Level of practice reliability/standardization	Standard practice of MA and PCP screening adult patients for depression at all visits
		Consistent referral process to CCM and BHP
		Shared—transparent documentation of treatment plans between providers
	8. Business model/billing system	Billing for screening process
		CCM is supported through grant funds
		BHP services are billed with Health and Behavioral codes
QI and effectiveness measurement	9. Practice-based data collection, analysis, and actual use	PHQ-9 and Insomnia Screening tool are used to monitor individual progress
		PHQ-9 data for adult patients is compiled
		No routine team review of population-based data

Team Composition: Roles, Responsibilities, Training, and Supervision

Identifying the configuration of an integrated clinical team is a challenging process for health care providers and administrators. In health care centers, providers and staff are often organized within discipline groups rather than in multiprofessional clinical care teams—for example, nurses meet with nurses, physicians with physicians, and support staff with support staff. In contrast, integrated behavioral health begins with multiprofessional teamwork. Multiprofessional teams in primary care vary widely in their composition. Team configurations may range from a structured, well-defined group, such as a primary care provider (PCP), psychiatrist, clinical care manager, and BHP with clear roles, such as the IMPACT model (Unützer et al., 2002) in contrast to the unique, unprescribed, clinical-provider behavioral health patient care approach seen in the Cherokee Health initiatives (Freeman, 2007). Integrated behavioral health and primary care team members may include primary care physicians, psychiatrists, nurses, medical assistants, BHPs (e.g., mental health clinicians), or clinical care managers (CCM). These behavioral health team members may have a variety of roles and responsibilities ranging from coordinating patient care and follow-up, educating patients regarding their health, improving patient engagement in their health care, prescribing medications, or providing behavioral health coaching via phone or face-to-face. There is no research that specifically evaluates or compares the benefits or limitations between different composition of integrated clinical care teams and standard primary care so there are no set guidelines for key elements in a collaborative team other than the inclusion of a team member who is skilled at implementing behavioral health interventions. However, there are some general principles that can guide administrators and providers in building teams that support integrated behavioral health and primary care practices. These principles are: (1) defining roles and expectations of each team member, (2) educational/training experiences necessary, including specialized training in integrated behavioral health and/or knowledge, clinical skills, and professional attitude, and (3) team communication—all of which will help build a successful integrated behavioral health practice.

Defining Expectations and Responsibilities

Successful integrated teams need to delineate clear expectations and responsibilities between the team members. For example, team members need to define who is responsible for clinical tasks from screening to referrals to follow-up visits, and follow-up monitoring and reassessing. For example, the nurse may be designated to administer a screening tool, the PCP’s role is to review the screening tool and make a referral to behavioral health, the BHP has a follow-up assessment and treatment and flag PCP with progress and recommendations, and the CCM has the task of scheduling monthly follow-up phones for monitoring. Organizing and clarifying these communication practices are critical. These practices typically include routines for follow-up care and ensure that the practice’s patients are not lost to follow-up.

Educational/Training Experiences

The educational foundation for BHPs in primary care is an emerging area for workforce development in health care. Individuals with diverse educational backgrounds, such as social work, nursing, psychology, counseling, marriage and family counseling, and psychiatry, may function as BHPs in primary care settings. Their educational background typically includes Master and Doctoral degrees, or medical degrees. Even some primary care physicians have fellowship training in psychiatry and are doubled boarded or are licensed marriage and family therapists. However, it is not common for these different disciplines to have specific training in the foundations of primary care behavioral health. Currently, there is no states licensure specifically for behavioral health providers. Typically, individuals may focus on areas (e.g., clinical health psychology, medical social work, etc.) that mesh with the knowledge and skills for primary care clinical practice (Alexopoulos, Reynolds, Bruce, et al., 2009; Hunter, Goodie, Oordt, & Dobmeyer, 2009; Robinson, 2005). The advantage of incorporating advanced degree BHPs (e.g., Ph.D., MD) is that they usually have training and knowledge of psychiatric assessment and empirically supported clinical interventions, such as Motivational Interviewing or Cognitive-Behavioral Therapies. They are also able to help patients with complex mental health issues, as well as help to train and supervise other team members on behavioral health issues/interventions.

CCMs are typically providers with medical assistant or nursing backgrounds. In PCMHs there is renewed interest in including CCMs with advanced behavioral health skills. There is a growing recognition that many primary care patients have chronic co-occurring medical and behavioral health needs that can be managed by CCMs with behavioral health expertise. This role has been supported by the research on depression in primary care (Unützer et al., 2002). CCMs may function as the coordinators of behavioral health after a referral from the PCP or screening assessment for behavioral health care has been initiated. CCMs may provide continuity of care in a variety of ways. They support patients’ medication regimens, monitor patients’ follow-up appointments with a PCP or psychiatrist, provide phone contact and assess patients for risk factors, and refer patients into more intensive clinical care options when necessary. The CCMs serve the crucial role of connecting patients with other members of the primary care team and with specialty services as needed. Typically, these team members have a Bachelor’s or Master’s degree that may include specific behavioral health training (Alexopoulos et al., 2009; Rubenstein et al., 2010). However, CCMs may have limited prior experience in caring for patients with complex comorbid medical and behavioral needs. Often times they will have expertise in one of these areas, but require support in developing confidence and expertise in the others.

Medical providers—physicians, psychiatrists, advanced nurse practitioners—provide another function within the integrated behavioral health and primary care approach. These team members have the expertise to assess and treat patients with medications and help monitor other health risks with medically complex patients (e.g., hypertension, drug interactions, diabetes). When caring for patients with complex comorbid medical and behavioral health needs, the perspective offered by this continuity is often critical for engaging patients and improving outcomes.

Specialized Training in Integrated Behavioral Health

Many different mental health disciplines offer foundational behavioral health skills, but few programs offer specific training for the knowledge, skills, and professionalism that is specifically applicative to integrated behavioral health. There are only a small percentage of graduate programs, clinical practicums, internships, or fellowships specifically designed to train providers in the unique knowledge and skill set for primary care. For psychologists, social workers, and marriage and family therapists, most of this training tends to occur within internship and postdoctoral programs (Garcia-Shelton & Vogel, 2002; McDaniel, et al., 2004). For instance, Malcolm Grow Medical Center’s Primary Care Training internship program at Andrews Air Force base offers doctoral psychology students a chance to gain experience in behavioral health consultation in primary care through a required 6-month rotation for 1 day per week (Dobmeyer, Rowan, Etherage, & Wilson, 2003). The Collaborative Family Healthcare Association maintains a helpful website that lists current internship programs (see http://cfha.net//pages/Clinical-Internships/).

There are few graduate programs that are being designed to address the need for specialized training in medical family therapy, behavioral health, or clinical health psychology. For instance, the Doctorate of Behavioral Health program at Arizona State University provides specialized coursework and practicum experiences focused on developing a new brand of providers capable of working effectively within integrated health care systems (see http://sls.asu.edu/dbh/about.html). This 18-month program, while not governed by an accrediting body, does require a prerequisite of a clinical master’s degree.

There are also certificate programs in Primary Care Behavioral Health. The University of Massachusetts Medical School’s Center for Integrated Primary Care hosts a certificate program that consists of 36 hours of didactic and interactive training, delivered in 6 full-day workshops. Behavioral health professionals enrolled in this program can choose from two tracks: one for those who work as generalist behavioral health professionals in primary care settings and one for those who work with patients with severe and persistent mental illnesses (see http://www.umassmed.edu/cipc). Fairleigh Dickinson University also hosts a certificate program in Integrated Primary Care, delivered through a distance format, utilizing the Internet and email to deliver 20 interactive modules (see http://integratedcare.fdu.edu). Both certificate programs cost around $1,500. While continuing education credits are provided through discipline-specific organizations, there is no accrediting body that oversees such certificate programs and it is not recognized formally within specific disciplines. Also, these are knowledge-base programs do not require direct clinical supervision experiences within primary care settings for the certificate. Psychologists can also obtain a board certification from the American Board of Professional Psychologists in clinical health psychology. Individuals with this certification have a significant level of training in clinical health psychology; however, they may not have had specific training in primary care (see http://www.abpp.org/i4a/pages/index.cfm?pageid=3353).

All team members, including CMC, PCP, and BHPs, will benefit from continuing professional development opportunities as this field takes shape. Workshops and conferences, such as those offered during the Collaborative Family Healthcare Association Annual Conference (see www.cfha.net) and the web-based training program offered by the University of Massachusetts Medical School (Blount & Miller, 2009) (see http://www.umassmed.edu/cipc) or by the National Council of Community Behavioral Health Care (see http://www.thenationalcouncil.org), offer opportunities to provide continuing education opportunities.

Knowledge, Clinical Skills, and Professional Attitudes

There are a range of clinical competencies that are important for providers to function effectively within an integrated behavioral health team (see Table 13.3 for a summary). The various team members may need to develop competencies in different areas for effective clinical care.

Table 13.3

• Summary of the clinical competencies to consider prior to hiring a BHP/CM

Knowledge base

• Strong background in behavioral medicine and healthy psychology needed to collaborate with primary care providers

° Solid foundation in common psychotropic medications

° Basic knowledge of medical terminology and disease

° Understanding of biopsychosocial relationships involved in symptom presentation

Patient communication

• Ability to translate medical terminology into everyday language

• Provision of a clear explanation of the biopsychosocial relationships related to patient’s symptom presentation

Mental health assessments

• Selection of reliable and valid assessment tools for specific presenting problems

• Administration of assessment tools

• Scoring and interpretation of measures

• Selection of evidence-based practices based on assessment results

• Use of results to monitor reduction/escalation of symptom presentation

Risk assessment

• Comfort with risk assessments with patients reporting suicidal ideation

• Knowledge of risk management protocols and available resources

Solid foundation in motivational interviewing

• Prior training (involving feedback and coaching) aids in the effective delivery of Motivational Interviewing techniques, used to motivate patients towards changing their behaviors ranging from alcohol use to medication adherence

• Members of the Motivational Interviewing Network of Trainers (MINT) can train others

First, BHPs need to have a foundational knowledge in behavioral medicine and health psychology. Specifically, it is important that they have a solid foundation in common medications, especially psychotropic medications, and basic knowledge of medical terminology and chronic diseases (Hunter et al., 2009; Robinson & Reiter, 2007). BHPs must have conceptual and scientific knowledge of the interrelationship between biomedical and psychosocial factors in health risks and health promotion. Other members of the team must have an awareness of when and how BHPs can add to effective patient care and health outcomes.

Second, BHPs and PCPs must develop strong relationship and communication skills, as well as assessment, consultation, and brief intervention skills. Assessment skills must be relevant to the primary care setting. For example, BHPs often administer and interpret behavioral health assessments such as the Patient Health Questionnaire-9 and share this information with their clinical team. BHPs should be comfortable administering the various types of mental health assessments, such as screening tools or brief cognitive assessment within an integrated behavioral health practice. Assessing a patient’s risk for suicide, violence, or significant mental disorder is another critical BHP skill. PCPs often care for patients reporting serious mental health symptoms and rely on the BHPs to provide an assessment, support, coaching, and crisis intervention or referrals for these patients.

Other essential clinical skills for all members of the integrated team, especially the BHP, include brief Cognitive-Behavioral Therapy and brief Problem Solving interventions in addition to a solid foundation in health behavior change approaches such as Motivational Interviewing (MI). MI is a method of communication that has been found to be effective in helping to motivate patients to change behaviors ranging from alcohol use to medication adherence (Burke, Arkowitz, & Menchola, 2003; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010; Rubak, Sandboek, Lauritzen, & Christensen, 2005; Vasilaki, Hosier, & Cox, 2006). Research has shown that attendance at a MI workshop alone (without feedback or additional coaching) does not yield individuals who will be able to maintain proficiency at implementing MI (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). Rather, it is important to find candidates who have had additional feedback and coaching in the implementation of MI.

Third, all of the team members must demonstrate the professional attitudes and awareness of each other’s professional cultural-climate to bridge the communication between biomedical and psychosocial worlds. Developing the professional sensitivity to communicate with a diverse professional team is crucial for integrated behavioral health. BHPs are often cultural brokers and translators between patient’s understanding and values and the medical provider’s perspective and goals (Hunter et al., 2009; Robinson & Reiter, 2007). A fundamental component of every integrated behavioral health model is the ability of all of the team members to demonstrate respect and acknowledge the value of behavioral health issues to whole-person care. Without being able to demonstrate these professional attitudes of respect and shared vision of patient care, the team members will function in silo, parallel practice modes.

BHPs are also behavioral health ambassadors at the frontline of primary care, helping to close the gap between biomedical and psychosocial worlds. BHPs may help defuse the stigma that PCPs or patients have towards behavioral health. In addition, BHPs help bridge the services and communication between the specialty mental health services and primary care centers. This coordination can happen when the BHP providers have confidence, assertiveness, and flexibility, and especially when they are a trusted member of the primary care team.

HOW: Team Communication

Defining who is part of the collaborative team and the knowledge and skills of team members is only one aspect of integrated behavioral health. Collaborative teams need to define the method of communication (e.g., Electronic Health Record (EHR), team meetings, huddles) and how often team members communicate about patient care. Daily team huddles before clinic or monthly team meetings are some common methods for team interactions, but teams may also communicate through EHR system sharing assessment and patient treatment plans. The shared EHR also makes it possible for team members to post follow-up messages to each other. No single approach to coordinating care or communicating between team members has been demonstrated to be superior to other approaches, but the advantage of integrated behavioral health is the accessibility between team members and the ease of “impromptu” hallway consultations.

Building a high functioning integrated behavioral health team requires intentional planning. Members must be recruited with the appropriate skills, and knowledge gaps must be addressed with additional training. Encouraging patterns of regular communication is also essential. This section highlights the different knowledge, skills, and professional team factors that are critical for effective team communication. Chapter 10 describes in more detail the variety of team roles and communication processes with integrated behavioral health systems.

Clinical Care for Targeted and Nontargeted Patient Populations

Integrated behavioral health and primary care programs will vary based on which populations they serve. As a result, successful integrated behavioral health and primary care teams are intentional in identifying protocols that focus team members to work with a defined patient population as well as provide specific clinical pathways for treatment. It is possible to develop these protocols and pathways by first distinguishing between targeted and nontargeted patients. Targeted patients are those who have been identified through screening or medical exam to have a specific symptom or condition that may benefit from behavioral health interventions. These conditions may be either psychiatric conditions (e.g., depression, anxiety, substance abuse) or medical conditions with behavioral components (e.g., tobacco use, diabetes, obesity). Nontargeted primary care patients are those patients who may benefit from a wide range of behavioral health clinical strategies to improve patient health outcomes, healthy choices, self-management, or goal setting.

Patients identified through targeted or nontargeted screening are connected with the appropriate members of the primary care team. Typically, these team members may be BHPs or CCMs. It is the responsibility of the BHP or the CCM to provide the patient with an evidence-based intervention suitable to the patient’s needs. The decisions about what intervention(s) should be provided are typically made through a collaborative process that includes the integrated behavioral health team, the patient, and the best evidence-based approaches.

Evidence-Based Clinical Approaches for Targeted Populations

For integrated behavioral health programs that have identified targeted consultation pathways to be used by CCMs or BHPs (e.g., all patients with Major Depressive Disorder), the delivery of evidence-based clinical interventions can be relatively straightforward. A variety of resources are available summarizing evidence-based interventions for a wide variety of populations. These assessments and interventions can be developed into well-defined paths for patients in the targeted population. Detailed descriptions of pathways for select populations are already available (Collaborative Care for Depression in the Primary Care Setting: A Primer on VA’s TIDES Project, 2008). Based on the USPTF findings, there are only a handful of targeted patient populations that have empirical support within the primary care setting (www.USPTF.org). This section provides an overview of those clinical interventions/pathways that have significant evidence supporting their usefulness in primary care or are evidence-based and would be feasible within the constraints of an integrated primary care setting.

Alcohol misuse. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a population-based approach that incorporates universal screening, interventions, and treatment strategies that target substance use disorders and at-risk substance use (Babor et al., 2007) within primary care at the point of care (Saitz, 2010). The United States Preventive Services Task Force (USPSTF) identifies alcohol screening and intervention as having sufficient evidence (e.g., level B) to recommend this as a standard of clinical care. The international wealth of literature supporting the efficacy of brief alcohol interventions in reducing alcohol use within the primary care setting for patients reporting at-risk drinking (e.g., often defined as drinking that involves repeated consequences or drinking greater than 14 (7 for women or men ≥ 65 years old) standard drinks per week or greater than 5 (4 for women or men ≥ 65) on any given occasion) (US Department of Health and Human Services. National Institute on Alcohol Abuse and Alcoholism, 2005) is quite extensive (Funderburk, Maisto, Sugarman, Smucny, & Epling, 2008). This literature has found that these interventions can help reduce alcohol use by an average of 38 g per week (Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005) and help reduce the number of at-risk drinkers by 12 % compared to no intervention (Beich, Thorsen, & Rollnick, 2003). Evidence supporting the efficacy of brief alcohol interventions for reducing alcohol consumption in those patients meeting criteria for alcohol dependence is not available to date (Saitz, 2010). It remains unclear whether brief alcohol interventions are useful within that population.

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