PCP and RN Competencies

and Jeffrey T. Reiter²

(1)

Mountainview Consulting Group, Inc., Zillah, WA, USA

(2)

HealthPoint, Seattle, WA, USA

Electronic supplementary material:

The online version of this chapter (doi:10.1007/978-3-319-13954-8_6) contains supplementary material, which is available to authorized users.

Keywords

Primary Care Provider/Nurse Core Competency Tool (PCP/RN CC Tool)Self-assessmentCareer development planSelf-studyShadowingCoachingModelingGuided rehearsalPractice support toolsScriptsCompetency scorePassingAdministrative supportPCP/RN orientation presentationMetricsDefines roles accuratelyBrief self-report measuresPediatric Symptom Checklist-17Functional impact of problemBehavioral health prescription padCo-trainingBook websiteLifestyle groupsRegistriesQuality of Life ClassPain and Quality of Life PathwayPain medication agreementTriageReferral reflexCurbside consults1-minutes feedbackCourt-ordered care

“No matter whether you are new or an old team member, you need time to adjust to one another.”

Yao Ming

Core competencies are not just for behavioral health consultants (BHCs). Successfully starting, expanding, and sustaining a BHC service also requires that primary care providers (PCPs) and nurses (RNs) develop a new skill and knowledge base. To help with this, we developed the Primary Care Provider/Nurse Core Competency Tool (PCP/RN CC Tool; Figure 6.1) for both new and experienced PCPs/RNs. Core competencies for PCPs and RNs include 35 specific skills, organized into six domains: (1) clinical practice, (2) practice management, (3) consultation, (4) documentation, (5) team performance, and (6) administrative practices. These are the skills that will enable PCPs and RNs to work with BHCs as a team to improve the health of the clinic population. In this chapter, we discuss ideas for training PCP and RN colleagues using the PCP/RN CC Tool as a guide. We are speaking primarily to PCPs and RNs who are reading the text but secondarily to BHCs who may assist them with learning various competencies.

Figure 6.1

Primary Care Provider/Nurse Core Competency Tool

PCP and RN Training Strategies

Training for medical colleagues can be done in many ways. It may begin prior to the arrival of a BHC (as self-study, initiated by the PCP/RN) or with the arrival of a BHC (using the BHC as a guide), and it is probably most effective as an ongoing process. Coaching and guidance may occur in a variety of formats, including staff meetings, brief individual meetings, and academic detail trainings arising spontaneously during the course of daily practice. Training methods include modeling, guided rehearsal, and/or provision of practice support tools (e.g., scripts suggesting phrases to use in certain clinical situations), in addition to didactics and discussion.

To start the training process, we recommend PCPs/RNs read this chapter and then complete the PCP/RN CC Tool as a self-assessment. The Tool helps identify training targets for further practice. For PCPs/RNs who work with a BHC, the BHC can assist with developing skills in weaker areas. Those PCPs/RNs who are self-training might review relevant videos on the book website (www.behavioralconsultationandprimarycare.com) and discuss and/or practice weaker areas with a peer whose self-rating is higher. Having a BHC or a PCP experienced in the PCBH model shadow a PCP/RN in practice for several hours may often generate good learning experiences. As a rule of thumb, we consider “passing” to be a competency score of three or higher in all domains of the PCP/RN CC Tool.

Getting Administrative Support

Training PCPs/RNs requires two key components: a competent BHC and time. Thus, new BHCs should first establish their own competence before training teammates (see Chapter 5 for BHC core competencies). Once this has been accomplished, the next step is to ask clinic administrators for time. In PC, meeting time is often at a premium, so being realistic and flexible is important. Blocking a PCP for just an hour can cost the clinic hundreds of dollars in lost visits. Nonetheless, if the BHC service has demonstrated its value, the clinic’s leadership will most likely welcome the BHC’s thoughtfulness and will find some way to support training activities.

The best practice is to have an ongoing training and support process that starts by providing basic core competency training to new PCPs/RNs. On the book website, we provide a document for new employee orientation called the PCP/RN orientation presentation. This brief presentation addresses the critical information new PCPs/RNs need immediately in order to optimally use PCBH services. From that point on, finding a way to meet regularly with PCPs/RNs is strongly recommended. A supportive administrator may be willing to provide lunch quarterly to encourage PCP/RN attendance at a lunchtime training, or allow time to be reserved during a recurring provider meeting, or allow interested PCPs/RNs to use their continuing education time to block their schedule in order to train individually with the BHC.

However it is accomplished, training is important. While establishing cause and effect is difficult, we often observe in our consulting work that the PCPs who understand and use the BHC service the least are those experiencing the most stress. Use of a BHC service can help PCPs immensely, so ensuring they know how to utilize the service may benefit not only patients and the BHC but also PCP/RN teammates. Giving administrative leaders the opportunity to ask questions and attend a training session can also be helpful. Their understanding and wisdom is critical to the success of the service. Subtle shifts in a variety of tasks (how they are performed and by whom) will make a big difference in how readily PCPs/RNs implement competencies suggested by the BHC.

Make It Count

After competency is established, tracking regular metrics regarding PCP/RN performance can be helpful. Commonly, these metrics include the average number of referrals per month to the BHC, the variety and types of problems referred, and the number of warm handoff (versus scheduled visit) referrals that are made. This is usually data that can be accessed fairly easily from the EHR (though a specific indicator for warm-handoff appointment types will be needed for that metric). Reviewing these metrics at a recurring provider meeting, or at least providing each PCP/RN with a monthly summary, can help generate discussion about the BHC service. It may also increase PCP/RN use of the service by showing them how their utilization compares to that of their peers. With some ideas in place regarding how to train and how to assess the impact of training, we can now get to a discussion of what to train, so let’s dive into explanations of the 35 competencies!

Domain 1: Clinical Practice Skills

This tool has 13 clinical practice skills, several of which are similar to the clinical practice domain on the BHC CC Tool. We describe all skills in the following section. However, before beginning, we recommend reviewing the Clinical Practice section of the BHC CC Tool in Chapter 5 (Domain 1). Knowing what exactly a BHC service has to offer will help the PCP/RN to better understand what is being asked of them clinically in this model.

1. Applies Principles of Population-Based Care to Preventive and Chronic Care Services

While this is a familiar skill for most PCPs/RNs, incorporating the BHC in preventing and managing chronic disease involves a new set of skills. A good example of using a BHC for disease prevention is to include her in well-child visits, for conducting anticipatory guidance. Because of the behavioral nature of much anticipatory guidance (especially in children of older age), the BHC can be a good fit for this task. This also can save the PCP considerable time. This is discussed in more detail in Chapter 11. Prevention targets may be more specific as well. For example, BHCs may be called in to help patients of any age quit smoking, or make healthy diet and exercise changes, or engage in safer sex.

In regard to patients with one or more chronic conditions, PCPs/RNs may routinely involve BHCs in a variety of ways, all with a common goal of providing more expertise concerning behavior change. First, referral to the BHC is very helpful to patients who are newly diagnosed with a chronic disease. For many patients, diagnosis with a chronic condition has a significant emotional impact. Many a newly diagnosed patient may walk away from the PC clinic secretly believing that the doctor made a mistake and, over the course of the next few hours or days, convince himself that he doesn’t feel that bad, that he doesn’t need to return to the clinic, and that the folks there seem “negative and always in a hurry.” Routinely referring patients newly diagnosed with a chronic disease offers them a chance to safely experience emotional reactions, which can promote better acceptance of the condition and a stronger motivation to make changes, one at a time.

PCPs/RNs may also want to consider a BHC referral when patients with chronic condition(s) experience a period of destabilization. Such may be discovered when the patient seeks care on an urgent basis, perhaps in an ER. More acute problems with chronic disease often occur in the context of heightened life stress and may or may not be compounded by lapses in self-management routines. The BHC can take the time to sort this out with a patient, assisting with the application of effective problem-solving skills to stressful life events and helping the patient avoid further complications and urgent care outside the PC clinic. For all patients with chronic condition(s), BHC services in the context of monthly group visits (led by the BHC solely or co-led with a PCP or RN) may help the PCMH team obtain better outcomes. The BHC has training in techniques that support group cohesion, mindful attention to daily behaviors, and value-based behavior change techniques.

2. Applies Principles of Population-Based Care to Mental Health Problems

While PCPs/RNs have a significant history with taking a population-based care perspective on chronic disease, many have less experience with applying this lens to MH problems, even though there are many prevention opportunities in PC. An example of a prevention opportunity is that of identifying children whose parents struggle with mental health (MH) problems and attempting to improve their chances to model their behavior after a wider range of adults by involving them early on with BHC services. Truly, one of the factors that define children who survive multiple adverse events in childhood is the connection with one or more healthy adult models outside of the home. As an auxiliary member of the PCMH team, the BHC can provide intermittent support and skill training over the course of childhood.

Given the huge proportion of the population who suffers from a MH problem, management of acute and chronic problems in PC requires a population-based care perspective. This is possible only when PCPs, RNs, and BHCs take a team approach to creating feasible services for this large group of people. Many patients with acute and chronic problems benefit from access to intermittent visits with the BHC during periods of greater stress and from access to support and skill training groups and classes on an ongoing basis. Many patients with more chronic MH problems have been treated only with medications; their response is limited by the care available to them. With the addition of the BHC to the team, patients can learn new skills and some may reduce use of medications or taper off of them completely. PCPs/RNs will need to take the initiative in supporting the creation of groups that support patient skill training and in encouraging patients to participate on an ongoing basis. Many times, protocols for use of the BHC can take the pressure off of PCPs/RNs to be the ones that remember to encourage patient participation in population-based care services designed to improve outcomes. We refer to such protocols as PCBH pathways; we discuss this approach and provide more examples in Chapter 12.

3. Defines Roles Accurately

Before having a BHC service, PCPs/RNs have likely managed patients alone or referred them to the community for behavioral health services. Their role was to be either a solo or a referring provider. With the arrival of a BHC service, however, this role will change. Having a BHC on the team means that MH problems can more likely be managed in the clinic, and that care will involve a team approach with close communication. Therefore, a PCP/RN may need to frame their role a bit differently for patients they refer to the BHC. For example, a PCP might say, “I’d like for you to see our BHC; he will give us some new ideas on this problem. Of course, I’ll remain in charge of your care.” A variation of this statement for RNs is: “I would like for you to see our BHC; he will give the team some new ideas on this problem. Of course, your doctor will remain in charge of your care.” In other words, the message is that care will be delivered in the clinic, with the BHC as an advisor and team member and the PCP in charge of the PCMH team.

4. Shows Understanding of Relationship Between Medical and Psychological Systems

Patients are accustomed to a healthcare system that separates the mind and body. Integrating behavioral health into PC is one step toward breaking down this division, and the PCP/RN can help facilitate this process by discussing the importance of a holistic approach with the patient. A good strategy is to talk with patients about different types of health—mental, physical, and social—and to describe how stress, positive and negative, affects overall health. The stress–diathesis model is a helpful way for thinking about this. Most simply, this model states that stress is a normal and even helpful part of life, as long as the level of stress is in line with a person’s skills for coping with it. When there is an imbalance, and stress exceeds one’s coping abilities, the person experiences physical and psychological problems and diminished quality of life. The PCP/RN may convey these important ideas in a simple compassionate statement, such as, “So, it seems like life has been a little too hard on you lately and you are feeling overwhelmed and your blood sugar has become a real concern.”

A good explanation of the interactive nature of medical and psychological health may help reduce the stigma some patients feel when told emotional stress is contributing to physical problems. Many times, the individual is not choosing the stresses that happen, much less any health effects. However, the PCMH team can help patients learn new skills that empower new responses to stress and better health outcomes.

5. Refers a Broad Range of Patients to BHC

In the early stages of a BHC service, PCPs/RNs typically refer mostly patients with MH problems. This is understandable, given that the BHC is an MH provider and there are many PC patients with MH problems. That being said, as a service progresses, the goal is for PCPs/RNs to broaden the range of referrals they make patients with mild life stresses, preventive care needs, lifestyle-influenced somatic conditions (e.g., headaches, irritable bowel syndrome, obesity, etc.), and chronic conditions (e.g., chronic pain, hypertension, diabetes, etc.) all make for excellent referrals.

6. Rapid Problem Identification for BHC Referral

When referring patients for MH services in the community, a PCP often talks in general terms. A common statement is, “I’m going to refer you to the community MH center for some counseling to help you with these problems.” Referrals to a BHC service benefit from a more refined approach in which a specific problem is identified for the BHC to help with. An example of a referral statement is, “I’d like for you to talk with our BHC about your headaches. I think she might be able to suggest some relaxation strategies to help you with this.” Another example might be, “Your blood pressure is high and you are reporting a lot of stress right now. I’d like to involve our BHC in treating this. Would you be willing to check in with her today about ways to lower stress?” More specific descriptions of the concern(s) help ensure both the patient and BHC understand the goals for the referral and also help the BHC be efficient.

7. Uses Appropriate Assessments

Brief self-report measures (e.g., Duke Health Profile, Pediatric Symptom Checklist-17) can be useful in PC, and PCPs/RNs will benefit from understanding the most commonly used ones. Typically the PCP does not administer these, but knowing how to score and interpret them is important. These measures may be used during a PCP/RN visit (administered by the NA) or during a BHC visit. In Chapter 8, we review assessment tools appropriate for PC, including quality of life and problem-specific measures.

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