I sat in an integrated primary care elective course during the third year of my doctoral program in counseling psychology, mesmerized by the opportunity of working in primary care as a behavioral health consultant. After my completing this primary care elective and conducting brief psychotherapy for five years, I was convinced I would be prepared to jump into primary care. It is fair to say I severely underestimated the difficulty of this transition and found myself face to face with the steep learning curve promised by my supervisor. I felt underprepared and shell shocked by the multiple roles I played within the medical team. After a year-long practicum rotation in primary care, I began to understand the intricate details of impacting patient care through a population health approach. This transition took more than just skill acquisition—it required a complete cognitive shift of professional identity. I am a behavioral health consultant, not a therapist, and I am here to assist the primary care team with improving patients’ overall health. Below, I have provided a few, evidence-informed ideas to help the Early Career Professional begin to make the shift into primary care.

Introduction

Primary care providers (PCPs) have adapted their practices to integrate behavioral health consultants into their work flows in response to recognizing the limited access patients have to mental health services provided by specialty mental health. This comprehensive primary care approach has grown exponentially across the United States (Kelly & Coons, 2012). Integrated primary care consists of integrating behavioral health consultants (BHC) into primary care settings, working collaboratively with PCPs (Hunter et al., 2017). This need was rooted in the realization that PCPs provide most of this nation’s mental healthcare (Terry, 2016). Incorporating behavioral health into primary care addresses the question, “How do we make mental health services more accessible to the community?” In responding to this need, we have to ponder new questions: Who do we hire to provide these services, and how do we support the successful transition of specialty mental health providers into the culture of primary care?

Working in Integrated Primary Care

Programs that provide direct systemic training in integrated primary care are scarce, and spaces in pre-doctoral and post-doctoral psychology training programs in integrated primary care settings are limited. Due to the imbalance of available training opportunities and growing need for BHCs in primary care, a large majority of behavioral health provider positions are filled by licensed professionals who received their training in traditional psychotherapy models (Dobmeyer et al., 2016). However, competencies required to be efficient in integrated primary care are different from traditional psychotherapy approaches (O’Donohue, Cummings, & Ferguson, 2003). Mental health professionals (clinical social workers, psychologists, family therapists, and professional counselors) are asked to adapt their training and skills to provide same-day services in integrated primary care without the guidance of an accrediting body or specific training experiences outlining competency (Peek, 2009; Tew, Klaus, & Oslin, 2010; Serrano, Cordes, Cubic, & Daub, 2018).

Those providing traditional psychotherapy and behavioral consultation differ in their in roles, responsibilities, and systemic foundations. The role of the BHC is not only to provide intervention for the patient, as seen in traditional psychotherapy models, but also to serve as a consultant to the PCP, which can improve the health of the primary care clinic population. This requires the BHC to conduct brief, focused assessments and interventions (15 to 30 minutes) and communicate intervention plans clearly and concisely to PCPs (Pomerantz, Corson, & Detzer, 2009; Robinson & Strosahl, 2009). Medical knowledge is essential for BHCs in order to consult with PCPs and medical staff on how to effectively counsel their patients on disease self-management, health behavior change, and medication adherence (Blaney et. al., 2018). Therefore, mental health professionals trained in traditional psychotherapy approaches encounter the need to acquire new skills to function in an integrated primary care setting, which requires them to adopt a new professional identity. This identity is located within the medical team, and the transition requires acculturating to the medical team’s language, pace, and culture (Blount, 2003; Christian & Curtis, 2012; Hooper, 2014; Hunter et al., 2017 Patterson et al., 2002; Tew, Klaus, & Oslin, 2010). Finally, mental health professionals must expand their scope of practice beyond traditional mental health concerns (e.g., depression, anxiety, substance use) to include the behavioral management of chronic health issues (e.g., diabetes, chronic pain, hypertension) and health behavior change interventions (e.g., tobacco cessation, medication adherence; Glueck, 2015).

Robinson and Reiter (2016) provided a clear and concise description of roles and responsibilities a BHC has in an integrated primary care team. The GATHER acronym outlines the key essentials of primary care behavioral health. G is for Generalist. To be useful to the PCP it is important that the BHC is a generalist in training due the nature of Primary Care. The PCP serves people from birth to death and with a wide variety of medical and behavioral health needs. This does not mean you will know everything about everything but that you will know a little about a lot and know where to find and applying knowledge to aid in the treatment any condition. BHC can also participate in curb-side consults to PCP to assist in dx clarification, skill building, medication recommendation, and providing resources. The BHC may also serve as a mediator for communication difficulties between the PCP and the patient during patient visits.

A is for Accessible. The BHC must be available for same day consults (also known as “warm hand offs”). This allows the PCP to have feedback in real time to inform their decision about treatment. Additionally, this ensures that the BHC embraces population-based health in serving the many as opposed to serving the few. T is for Team-Based. The BHC is available in a variety of ways as a regular member of the team. BHC can assist with the flow of the PCP visit by participating in pre-PCP visits (“PCP prep”) to gather information and provide an intervention in order to shorten the PCP visit. The BHC can engage in consultation after the PCP visit or address another condition the PCP did not have time to discuss. Moreover, the BHC can come in after the PCP to make a concrete plan on recommendations and discuss possible barriers to plan implementation. BHC can provided group medical visits, classes, and assist with resource connection. The BHC can assist in brainstorming ways to reduce high utilization of emergency rooms and frequent re-hospitalizations. BHC can conduct co-visits with the PCP to help facilitate behavior change and improve communication between the PCP and patient. H is for High Productivity. The BHC sees 8-14 patients daily. BHC is readily available to assist with patients on PCP’s panel.  If the PCP is expected to see 25 patients in one day, the BHC should also be highly productive while providing high quality patient care. The BHC should work at a comparable pace as the PCP. E is for Educator. The BHC teaches other members of the team behavioral interventions, behavioral manifestations of physical health conditions, and other aspects of patient behavior that impact primary care. The PCP will always see more patients when compared to the BHC. By teaching the PCP behavioral interventions, the BHC’s impact on patient care grows. Additionally, the BHC can introduce different skills such as redirection and Motivational Interviewing to aid in the effectiveness and efficiency of PCP visits. Other members outside of the team can be trained in behavioral interventions such as medical assistants, case managers, community health workers and nurses to help assist in the patient flow if the BHC is not available. R is for Routine Pathways. The BHC can design clinical pathways or protocols that are routine for certain populations. This allows the PCP to have a clearly defined decision tree in the ways that the team can be helpful for the patient. Additionally, the BHC can train PCPs to introduce BHC services as a part of routine primary care to help de-stigmatize behavioral, habit, and emotional interventions and focus on improving health outcomes. This results in an increase in patient willingness to accept BHC services. Mental health professionals interested in primary care should review these roles and expectations to gather a sense if they are well-suited and attracted to a position as a BHC. Additionally, the GATHER acronym serves as an easy way BHC and their supervisors can examine current fidelity to the primary care behavioral health model (Robinson & Reiter, 2007).

Considering the challenge of identity transformation necessary for a BHC in integrated primary care, it is important to note the discovery that mental health provider attitudes may influence their adoption of a new way of practicing and training (Aarons, 2004). A change in mindset and differences in pacing for integrated primary care settings has been outlined as a necessity in anecdotal reports from mental health professionals in integrated primary care pilot projects (Pomerantz et al., 2009; Robinson & Strosahl, 2009). James and O’Donohue (2009) outlined key attitudes and behaviors conducive to working in primary care, regardless of one’s training background. These include: 1) readiness to learn and accept change, 2) high energy, 3) finding enjoyment in fast-paced practice, 4) competency in medial and behavioral health interventions, 5) case management skills, 6) clear and concisely communication in verbal and written form, 7) good emotional regulation, 8) knowledge of the population served by the clinic, 9) awareness of community resources, 10) ability to rise to a challenge, and 11) not steadfast to the specialty care assessment and treatment models. Blaney and colleagues (2018) highlighted that a clinician’s readiness to transition into a BHC role in primary care is a vital. Nash, McKay, Vogel, and Masters (2012) also stressed the importance of the clinician’s readiness because BHCs perform multiple roles within the medical system, including: direct patient care, champions or advocates in the process of successful integration, and training future trainees. The aforementioned characteristics are important for both employers and mental health professionals to consider when a traditionally trained provider is thinking of pursuing a career in primary care.

Post-Graduate Training in Integrated Primary Care

The availability of trainings focused on integrated primary care for BHCs is a significant barrier to effective integration (Blount & Miller, 2009; Bluestein & Cubic, 2009; Nash et al., 2012, Robinson & Strosahl, 2009). Since most BHCs lack prior training or experience in primary care, formalized training is necessary to function effectively in their new roles (Dobmeyer et al., 2016). There are a variety of options for those seeking training. For independent study, O’Donohue (2009) designated the following resources as key readings for clinicians interested in working in integrated primary care (see the Resources List at the end of this article).

Dobmeyer and colleagues (2016) added on to the concept of self-study by providing an outline for initial self-guided activities. Their discussion about BHCs’ training included a subsection called “pre-training requirement” to prepare potential BHCs for formal education on practicing in primary care. The BHCs were required to review readings, primary care service specific policies and clinical practice manuals, materials on clinical assessment formats, an initial appointment outline, and the Tri-Service BHC Core Competency Tool (CCT). The CCT evaluates the six different domains essential for practice as a BHC: clinical practice skills, practice management skills, consultation skills, documentation skills, team performance skills, and administrative skills (Air Force Medical Operations Agency, 2011; Robinson & Reiter, 2016) and expands upon detailed behavioral descriptions of desired behaviors and attributes. The CCT can inform employers and BHCs if they have met their training goals and are prepared to practice in primary care. Additionally, trainees were asked to memorize an informed consent introductory script specific for integrated primary care and designed to orient patients to the services in the initial patient encounters. Finally, trainees attended staff meetings and team huddles; shadowed PCPs in clinic; and learned about local mental resources for the community. Although these requirements were specific to Dobmeyer and colleagues’ training program, a similar structure can be adopted by other organizations or individuals interested in working in primary care setting.

Specialty mental health professionals interested in formal education on integrated primary care could investigate certificate programs. Interested individual can go to https://sites.google.com/view/integratedprimarycare2/training for further information on these programs. An example of a certificate program is through the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. The program’s cost is approximately $1,600 per student and the program requires both onsite and distance learning activities. The certificate takes six months to complete and covers topic such as: culture and language of primary medical care, behavioral health needs in primary care, consulting with PCPs, substance abuse in primary care, and evidence-based therapies. Interested individuals can seek this opportunity independently or request their current employer to consider integrated primary care certificates as part of employee training. Day-long continuing education workshops or integrated primary care certificates have been deemed as useful for training behavioral health providers. However, these trainings do not provide the in-depth, on-site, and recurring training needed to be successful in integrated primary care (Belar, 2011; Kelly & Coons, 2012; Linton & Coons, 2011).

At the systemic level, organizations should consider hiring a technical assistance consultant to train their BHCs as well as the primary care team. This strategy is most cost effective when seeking to train multiple clinicians and beginning to create a culture of change towards comprehensive primary care. Examples of consulting programs offering this assistance are Primary Care Behavioral Health Strategies, LLC (https://stacyogbeide.com/pcbh-consultation) and Mountainview Consulting (http://www.mtnviewconsulting.com).

Conclusion

Specific training for BHCs is necessary to effectively work in an integrated primary care setting. Despite the growing need for this training, limited options are available for the post-graduate mental health provider population looking to transition into a primary care setting. Options such as reading material, self-study activities, organizational consultation, higher education, and workshops or certificates are available. Regardless of type of training a new BHC acquires, Dobmeyer and colleagues (2016) stress the importance of an organization never underestimating the difficulty BHCs encounter when transitioning from specialty mental health. When personally facing this challenge, I found working in an environment that encouraged the team members to learn from one another, consistent review and conceptualization on BHC practice using the GATHER acronym for a BHCs roles (Robinson & Reiter, 2016), regular supervision and feedback from the medical team, and faith in the research supporting the effectiveness of integrated primary care as most helpful. Hall et al. (2015) found a pattern of underestimation of resources and time needed to prepare a new BHC for newly integrated primary care practice. The reality may be that some new BHCs will be unable to develop and demonstrate skills necessary for success, despite participation in a structured training program. Finally, a crucial component of continued success is the ongoing training and evaluation to enhance, expanded, and protect against the “regression to the mean” phenomenon (falling back in to old patterns of providing traditional mental health) of the BHCs’ competency and skills.

Resources List (adapted from O’Donohue, 2009)

Cummings, N. A., Cummings, J. L., & Johnson, J. N. (Eds.). (1997). Behavioral health in primary care: A guide for clinical integration. Madison, CT: Psychosocial Press.

Cummings, N. A., O’Donohue, W. T., Hayes, S. C., & Follette, V. (Eds.). (2001). Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. San Diego, CA: Academic Press.

Cummings, N. A., O’Donohue, W. T., & Ferguson, K. E. (Eds.). (2002). The impact of medical cost offset on practice and research: Making it work for you. Reno, NV: Context Press.

Cummings, N. A., O’Donohue, W. T., & Ferguson, K. E. (Eds.). (2003). Behavioral health as primary care: Beyond efficacy to effectiveness. Reno, NV: Context Press.

Cummings, N. A., Duckworth, M., O’Donohue, W. T., & Ferguson, K. E. (Eds.). (2004). Substance abuse in primary care. Reno, NV: Context Press.

Cummings, N. A., O’Donohue, W. T. & Naylor, E. (2005). Psychological approaches to chronic disease management. Reno, NV: Context Press.

Fisher, J. E., & O’Donohue, W. T. (Eds.). (2006). Practitioners’ guide to evidence-based psychotherapy. New York, NY: Springer Science and Business Media. http://dx.doi.org/10.1007/978-0-387-28370-8

Haas, L. J. (Ed.). (2004). Handbook of primary care psychology. New York, NY: Oxford University Press.

James, L. C., & Folen, R. A. (Eds.). (2005). Health psychology series. The primary care consultant: The next frontier for psychologists in hospitals and clinics. Washington, DC: American Psychological Association. http://dx.doi.org/10.1037/10962-000

O’Donohue, W., Fisher, J. E., & Hayes, S.C. (Eds.) (2003). Cognitive Behavior Therapy: A step-by-step guide for clinicians. New York, NY: Wiley.

O’Donohue, W. T., Byrd, M. R, & Cummings, N. A., & Henderson, D. A. (Eds.). (2005).Behavioral integrative care: Treatments that work in primary care setting. New York, NY: Routledge.

O’Donohue, W. T., Cummings, N. A., Cucciarre, M. A., Cummings, J. L., & Runyan, C. N. (2006). Integrated behavioral healthcare: A guide to effective action. Amherst, NY: Humanity Books.

O’Donohue, W. T., & Levensky, E. R. (Eds.). (2006). Promoting treatment adherence: A practical handbook for health care providers. Thousand Oaks, CA: Sage.

O’Donohue, W. T., Moore, B, A., & Scott, B. J. (Eds.). (2007). Handbook of pediatric and adolescent obesity treatment. New York, NY: Routledge.

Robinson, P. J., & Reiter, J. T. (2006). Behavioral consultation and primary care: A guide to integrating services. New York: Springer.

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Brittany Houston, M.S.

Brittany Houston is currently a Psychology Resident at UT Health San Antonio. For the past year and a half she has trained in the Primary Care Behavioral Health (PCBH) Consultation Model under the supervision of Dr. Stacy Ogbeide in the Family Medicine Residency. She is currently working toward her PsyD. in Counseling Psychology at Our Lady of the Lake University with a focus in Health Psychology and Child, Adolescent, and Family Therapy. Though not initially trained in Health Psychology, she has sought out course work and training opportunities to work with multidisciplinary teams in medical settings throughout my graduate career. At UT Health San Antonio she has taken an active role in educating medical residents, psychology trainees, and staff on the PCBH model and effective interventions. she extended her training and education opportunities by assisting Dr. Stacy Ogbeide on consulting with clinics in the Rio Grande Valley on the PCBH Model. Through these experiences, she noticed the need of continued education on the PCBH model to health services trainee’s as well as licensed professionals in the community. As a trainee originally trained in traditionally psychotherapy models she can speak to the difficult and rewarding transition to PCBH.