Primary Care Behavioral health

Primary Care Behavioral Health Consultation model (PCBH) is a psychological approach to population-based clinical health care that is simultaneously co-located, collaborative, and integrated within the primary care clinic. The goal of PCBH is to improve and promote overall health within the general population. This approach is important because approximately half of all patients in primary care present with psychiatric comorbidities, and 60% of psychiatric illness is treated in primary care. Primary Care practice has traditionally adopted a generalist approach whereby physicians are trained in the medical model and solutions to problems typically involve medications, procedures, and advice. Appointment times are short, with the goal of seeing a large number of patients in a day. Many patients present with mental health care needs whose symptomology may overlap with medical disorders and which may exacerbate, complicate, or masquerade as physical symptoms. In addition, many medical problems present with associated psychological sequelae (e.g. stress, emotional reactions, dysfunctional lifestyle behaviors), that are amenable to change, through behavioral intervention, that can improve outcomes for these health problems. Over 50% of medical visits to primary care clinics today are related to chronic medical conditions (e.g. chronic pain, diabetes, COPD, hypertension, obesity). As we learn more and more about the contributing factors to the development and maintenance of these medical problems, there is growing evidence that the PCBH model affords us the opportunity for early identification and behavioral/medical intervention that can prevent some acute problems from becoming chronic health care problems. Behavioral Health Consultants (BHCs) work side-by-side with all members of the clinical care team (including primary care providers (PCPs) and nursing staff) to enhance preventive and clinical care for mental health problems that have traditionally been treated solely by physicians. The role of the BHC is to facilitate systemic change within primary care that facilitates a multidisciplinary approach both from a treatment and reimbursement standpoint. BHCs typically collaborate with physicians to develop treatment plans, monitor patient progress, and flexibly provide care to meet patients’ changing needs In this review the terms Primary Care Behavioral Health Consultation and Behavioral Health Consultation will be used interchangeably. Primary Care Behavioral Health Consultation model (PCBH) is a psychological approach to population-based clinical health care that is simultaneously co-located, collaborative, and integrated within the primary care clinic. The goal of PCBH is to improve and promote overall health within the general population. This approach is important because approximately half of all patients in primary care present with psychiatric comorbidities, and 60% of psychiatric illness is treated in primary care. Primary Care practice has traditionally adopted a generalist approach whereby physicians are trained in the medical model and solutions to problems typically involve medications, procedures, and advice. Appointment times are short, with the goal of seeing a large number of patients in a day. Many patients present with mental health care needs whose symptomology may overlap with medical disorders and which may exacerbate, complicate, or masquerade as physical symptoms. In addition, many medical problems present with associated psychological sequelae (e.g. stress, emotional reactions, dysfunctional lifestyle behaviors), that are amenable to change, through behavioral intervention, that can improve outcomes for these health problems. Over 50% of medical visits to primary care clinics today are related to chronic medical conditions (e.g. chronic pain, diabetes, COPD, hypertension, obesity). As we learn more and more about the contributing factors to the development and maintenance of these medical problems, there is growing evidence that the PCBH model affords us the opportunity for early identification and behavioral/medical intervention that can prevent some acute problems from becoming chronic health care problems. Behavioral Health Consultants (BHCs) work side-by-side with all members of the clinical care team (including primary care providers (PCPs) and nursing staff) to enhance preventive and clinical care for mental health problems that have traditionally been treated solely by physicians. The role of the BHC is to facilitate systemic change within primary care that facilitates a multidisciplinary approach both from a treatment and reimbursement standpoint. BHCs typically collaborate with physicians to develop treatment plans, monitor patient progress, and flexibly provide care to meet patients’ changing needs In this review the terms Primary Care Behavioral Health Consultation and Behavioral Health Consultation will be used interchangeably. Primary Care Psychology: Provision of clinical mental health services through a population-based focus on the common problems confronting a majority of individuals. Such issues treated in primary care may include response to physical illness, stress, affective concerns, substance use and abuse, and developmental and situational issues among others. Primary care psychologists are co-located with primary care providers and usually share the same physical space in practice. Primary care psychologists may retain the traditional session length of specialty care or may adhere to a brief, consultative approach that is solution-focused. Primary Care Psychologists may often be trained in health psychology programs, but not exclusively so. Behavioral Health Consultant: Behavioral Health Consultants and Primary Care Physicians collaborate within the same system. The behavioral health provider works as part of the medical team to meet the wide range of needs with which patients present. Collaborative Care: This model uses databases or what are known as registries to track and monitor patients with certain conditions. Typical examples in primary care include diabetes and depression. Often the person managing the registry is a nurse or mental health professional who performs follow-up phone calls and assists the primary care team in following evidence-based protocols. There is often also a consulting psychiatrist who oversees the provision of care in primary care. Primary care has often been termed the 'De Facto' mental health system in the United States. Research shows that approximately half of all mental health care services are provided solely by primary care providers. Furthermore, primary care practitioners prescribe about 70% of all psychotropic medications and 80% of antidepressants. Thus, while it seems there are various 'specialty' mental health clinics and psychiatrists alike, the primary care environment continues to lend itself to an array of psychiatric issues. One reason is that physical health problems can contribute to psychological dysfunction and vice versa. Examples of the frequent comorbity between medical and psychological problems include: chronic pain can cause depression; panic symptoms can lead to complaints of heart palpitations; and stress can contribute to irritable bowl syndrome. While these mind-body relationships may seem obvious, often the presenting problem is far less clear, with the physical health problem being masked by psychosocial concerns. In fact, of the 10 most common complaints in primary care, less than 16% had a diagnosable physical etiology. The psychosocial impact on primary care is tremendous (approximately 70% of all visits); however, it is curious that few mental health providers have traditionally placed themselves where the demand for their services is arguably the greatest. Despite the availability of outpatient mental health resources, research indicates that patients are still driven to the primary care setting. In fact, studies show that as little as 10% of patients actually follow through when being referred by a physician to receive outpatient mental health treatment. Many experts believe this low completion rate is tied to the stigma that often surrounds mental health care, causing patients to deny or refuse to seek help for psychiatric needs. As a general rule, patients who do choose to address their mental health concerns express a preference for services in primary care likely due to its familiarity and less stigmatizing environment. However, as many medical providers will admit, their training has left them ill-prepared to appropriately treat the psychiatric sequalae that presents in their clinic. The PCBH model has sought to address this dilemma by providing access to mental health services on site to more effectively target the biological, psychological, and social aspects of patient care. Resulting from close collaboration between physicians and mental health providers, the patients’ needs are more adequately met by care that is more comprehensive and collaborative between physicians and mental health providers. Furthermore, the patients are more likely to follow through with primary care services, with referral rates around 80-90%. Behavioral Health Consultants are culturally competent generalists who provide treatment for a wide variety of mental health, psychosocial, motivational, and medical concerns, including management of anxiety, depression, substance abuse, smoking cessation, sleep hygiene, and diabetes among others. BHCs also provide support and management for patients with severe and persistent mental illness and tend to be familiar with psychopharmacological interventions. Paralleling general medicine, patients who require more extensive mental health treatment are typically referred to specialty care. BHC appointments are typically 15–30 minutes long with the goal of utilizing brief interventions to reduce functional impairment for the population as a whole. BHCs tend to provide focused feedback to PCPs with succinct, action oriented recommendations to help effectively manage patients’ needs. BHC interventions tend to be more cost effective and offer increased access to care, with improved patient and provider satisfaction. A comparison of an enhanced-referral system to a BHC model found that more than 80% of medical providers rated communication between themselves and the BHC as occurring 'frequently,' relative to less than 50% in an enhanced-referral model of care. Providers strongly preferred an integrated care model to the enhanced-referral model. Another single-site study at an urban community health center found that embedding BHCs resulted in reduced referrals to specialty mental health (8% of depressed patients were referred) along with improved adherence to evidence-based guidelines for the care of depression and reduced prescriptions for antidepressants. Moreover, a recent literature review revealed that improved outcomes in mental health care were associated with several fundamental characteristics, including collaboration and co-location with PCP and mental health providers, as well as systematic follow-up, medication compliance, patient psycho-education, and patient input into treatment modality. In general the number of empirical investigations that have examined the clinical impact and cost-offset of the BHC model is still limited, although a growing body of evidence supports the utility of other integrated behavior health programs (with varying degrees of integration) in academic settings, Veterans Affairs Medical Centers, and community health care settings. Specifically targeting depression, Schulberg, Raue, & Rollman (2002) reviewed 12 randomized controlled trials (RCT's) that examined evidence-based treatments for major depression (interpersonal psychotherapy & cognitive-behavior therapy) and problem-solving therapy, compared to usual care by PCP's (i.e. antidepressant medication, drug placebo, or unspecified control). The authors concluded that evidence-based psychotherapies adapted for the primary care setting are comparable to pharmacotherapy alone and superior to PCP's usual care. The use of brief evidence-based psychotherapies, such as those reviewed by Schulberg et al., 2002, are fundamental within the PCBH model. The PCBH model emphasizes a problem-focused and functional-contextual approach to assessment and treatment of behavioral health and mental disorders. Wolf and Hopko's (2008) recent review of treatments for depression in primary care concluded that adaptations of CBT for depression in primary care are 'probably efficacious.' Research also shows that providing basic training in CBT to PCPs is not enough to produce robust clinical outcomes (King et al., 2002); highlighting the importance of the BHC's integrated role in primary care. With respect to the impact of behavioral health consultation on pharmacological treatment of major and minor depression, compared to usual care Katon et al. (1995) found improved medication adherence, increased patient satisfaction with treatment, and overall greater improvements in mood over time for major depression. Inclusion of a behavioral health professional in the treatment of depression in primary care improves outcomes, patient and physician satisfaction, and costs less than usual care. The PCBH model prioritizes the usage of treatment algorithms based on scientific guidelines that include pharmacological and psychotherapeutic interventions. This approach seeks to ensure that patients receive the safest and most effective treatments available.