In PCBH care, as in general medicine, BHCs may be compensated according to productivity, so a thoughtful approach to interpreting the data is important. Establishing productivity standards can be difficult, and the reasons for unexpectedly low productivity will be different from clinic to clinic. A BHC service in a larger clinic might expect to be busier than one in a smaller clinic, and this is often the case. However, much can also depend on the PCPs in the clinic. A small clinic with mostly biopsychosocially oriented PCPs might keep a BHC continuously busy, whereas a larger clinic with mostly biomedically oriented PCPs might be slower for a BHC. Similarly, one might expect that a busier clinic that sees a higher than average number of patients per day would also keep a BHC busier. Yet, because such clinics are so busy, PCPs may be reluctant to take the time for a BHC referral (especially in the early months of a BHC service, when its value might not yet be perceived). Clinics with a high turnover of PCPs or in a period of flux with their providers also typically produce fewer BHC referrals, because temporary providers have not developed practice habits that include utilization of a BHC. The schedule of the BHC provider can also influence referral rates. Full-time BHCs usually have much more of a presence in the clinic, with more opportunities to shape the practice habits of PCPs and to involve themselves in PCBH pathways and general clinical pathways, whereas part-time BHCs might have a harder time establishing themselves. The point here is that productivity data need to be interpreted in context. Many factors that influence productivity are under a BHC’s control, while others are not.

Solutions to increasing productivity need to address a broad range of factors. These include clinic and system factors (e.g., the design of the BHC template, the transparency of the BHC schedule to other team members, the ease with which team members can access the BHC for same-day visits, etc.). Of course, core competency training for BHCs (see Chapter 5) and PCPs/RNs (see Chapter 6) is also of fundamental importance to optimal use of BHC services.

The Barriers to Using the BHC (BUB) Questionnaire and the Barriers to Same-Day Services (BUS) Questionnaire are useful surveys for understanding BHC productivity. They are available in Figures 10.​10 and 10.​11, respectively. One or the other may be administered every 3–6 months during the first 12–18 months of a BHC service, ideally as part of a provider or nursing meeting. In some cases, administrators and medical leadership need to be involved in solving productivity barriers that are identified. Many other factors also influence productivity, such as access, the BHC’s no-show rate, the number of warm handoffs, and others. Tracking these can also highlight the degree to which the BHC is working in the manner intended. We discuss these and other program metrics in the next section. The more metrics one tracks, the more possible it becomes to determine the factors responsible for low productivity (and, hence, potential solutions).

A healthy BHC service should tend to a range of patient problems that go well beyond depression and anxiety. Included in a list of the most commonly referred problems should be some chronic medical conditions, lifestyle-influenced somatic complaints, subthreshold syndromes, and preventive visits, as well as the full gamut of psychological conditions in patients of all ages. The types of patients seen should also mirror the clinic’s population demographics. For example, if a clinic sees many pediatric patients, so too should the BHC. In such a case, problems common to that population (e.g., parenting problems, behavior problems, ADHD, etc.) should be among the most frequent referrals. If patient race, ethnicity, and/or primary language can be tracked, these should also be represented proportionally in the BHC’s visits. New EHRs often make collection of this data much easier.

Since the goal of PCBH care is to help PCPs be more efficient and effective with behavioral issues, evaluating success with this is important. A helpful practice is to survey PCPs annually as to their experience with the program and the impact of program services on their practice of medicine. Potential survey items are shown in Table 8.2. Responses are on a scale of 0–10, with 0 indicating “not true” and 10 indicating “completely true.” Be sure to instruct PCPs to not put their name on the survey (for anonymity), and administer it during a provider meeting to help ensure it gets done.

Additional questions that could be asked include the percentage of continuing education funds spent on presentations related to behavioral health issues and how frequently PCPs/RNs utilize specific techniques the BHC taught that year (e.g., mindfulness, relaxation training, stress management training, etc.). The Barriers Questionnaires (see Chapter 10) can also be administered, to gain feedback about barriers to BHC access, which will hopefully diminish as the BHC service matures.

In addition to surveys, billing data can sometimes provide helpful feedback about PCP impact. Specifically, does access to PCP appointments improve after starting a BHC service? Is the PCP productivity increasing? Is PCP retention improving? Many fluid factors influence these areas, so change can be difficult to see and/or to attribute to a BHC service, but it can be worth an annual look regardless. Keep in mind that implementation is an incremental and ongoing process, involving frequent reeducation of PCPs and staff. Regular surveying can help one understand what education may be needed.

A BHC might be seeing an impressive number of patients each day but, if they come from the same small pool of patients seen week after week, the overall penetration into the population will be poor. As such, measuring the ratio of new to follow-up patients is important. In our experience, a good goal to aim for is a 1:1 ratio; meaning on any given day the BHC is seeing roughly an equal number of new and established patients. A ratio favoring new over follow-up patients (e.g., 2:1) suggests that the practice is receiving a healthy influx of new patients but could be struggling to meet follow-up needs. When the ratio favors follow-up patients (e.g., 1:3), this may indicate that the BHC is sliding back into a therapy focus rather than a population health focus. The BHC that falls into a pattern of seeing patients for an excessive number of follow-ups quickly develops access problems, which often leads to frustrated PCPs slowing down or stopping new referrals.

The availability of BHC services during all clinic hours of operation is also helpful for accommodating work-ins. If the BHC service is part time, the PCP may hesitate in pursuing a warm handoff because it takes more time to find out if the BHC is around than it does to just have the patient scheduled. This problem may be worsened by variation in hours by part-time BHCs, as PCPs may eventually give up, thinking, “I never know when she is going to be here—so I just send a referral.” Understaffing BHC time also inhibits work-ins because if PCPs see the BHC struggling to meet demand, they may take pity on him. They may develop a habit of having their NA check the BHC’s schedule, and if it is full they may not pursue a warm handoff. Note that this may also affect overall productivity because while work-ins have by definition a 0% no-show rate, scheduled patients, of course, do not. Thus, missing a work-in opportunity because of a full schedule can be a double whammy if the scheduled patient fails to show. When BHCs are understaffed, a template that reserves half of the appointments for work-ins is recommended.

Another way to assess access is to look at the number of days until a scheduled appointment is available with the BHC. This is referred to as the third next-available appointment (third next) metric and is commonly used for PCPs (Institute for Healthcare Improvement, 2014). The actual calculation is the average number of days, over a month, that a patient would need to wait for the third next available appointment with the BHC. Usually a manager will calculate this weekly and then obtain an average for each month. (The third next appointment is used because the “next appointment” could be open by a fluke such as a cancellation). The goal for this metric is zero days for PCPs (Institute for Healthcare Improvement, 2014), and we recommend the same for BHCs.