The Primary Care Behavioral Health (PCBH) model is a prominent approach to the integration of behavioral health services into primary care settings. Implementation of the PCBH model has grown over the past two decades, yet research and training efforts have been slowed by inconsistent terminology and lack of a concise, operationalized definition of the model and its key components. This article provides the first concise operationalized definition of the PCBH model, developed from examination of multiple published resources and consultation with nationally recognized PCBH model experts. The definition frames the model as a team-based approach to managing biopsychosocial issues that present in primary care, with the over-arching goal of improving primary care in general. The article provides a description of the key components and strategies used in the model, the rationale for those strategies, a brief comparison of this model to other integration approaches, a focused summary of PCBH model outcomes, and an overview of common challenges to implementing the model.

The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition.

Many primary care clinics struggle with rapid implementation and systematic expansion of primary care behavioral health (PCBH) services. Often, an uneven course of program development is due to lack of attention to preparing clinic leadership, addressing operational factors, and training primary care providers (PCPs) and nurses. This article offers competency tools for clinic leaders, PCPs, and nurses to use in assessing their status and setting change targets. These tools were developed by researchers working to disseminate evidence-based interventions in primary care clinics that included fully integrated behavioral health consultants and were then used by early adaptors of the PCBH model. By deploying these strategies, both practicing and teaching clinics will take a big step forward in developing the primary care workforce needed for primary care teams, where the behavioral health needs of a patient of any age can be addressed at the time of need.

Creating a Primary Care Workforce: Strategies for Leaders, Clinicians, and Nurses.

In recent years in the United States (US), there has been a shift in primary care service delivery through patient-centered medical home (PCMH) implementation, a focus on the Triple Aim, and the passage of the Patient Protection and Affordable Care Act (Baird et al., 2014; National Committee for Quality Assurance [NCQA], 2014; Nielsen, Gibson, Buelt, Grundy, & Grumbach, 2015). These efforts have set the stage for payers, primary care service professionals, and patients to expect integrated behavioral health services as an essential component of primary care. Three prominent models of integrating behavioral health services in primary care include the Screening, Brief Intervention and Referral to Treatment (SBIRT) model, the Collaborative Care model (CoCM), and the Primary Care Behavioral Health (PCBH) model. The SBIRT model focuses on patients with risky, but not yet problematic substance use, and has received ample review on model components and effectiveness (e.g., Moyer, 2013). The CoCM largely focuses on patients with depression and anxiety and has been widely described and evaluated with a review of 79 randomized controlled trials summarizing model impact (Archer et al., 2012). The PCBH model has also been described in a number of publications (e.g., Gatchel & Oordt, 2003; Hunter, Goodie, Oordt, & Dobmeyer, 2017; Robinson & Reiter, 2016; Serrano, 2015; Strosahl, 1998, 2005). It has been implemented across the US in large healthcare systems (e.g., Hunter, Goodie, Dobmeyer, & Dorrance, 2014; Kearney, Post, Pomerantz, & Zeiss, 2014), community health organizations (e.g., Freeman, 2011; Kanapaux, 2004), family medicine residency programs (Hill, 2015), university health centers (e.g., Funderburk, Fielder, DeMartini, & Flynn, 2012; Sadock, Auerbach, Rybarczyk, & Aggarwal, 2014), and homeless clinics (Ogbeide, Buck & Reiter, 2014). There is also a growing number of PCBH model studies examining patient and implementation outcomes (Hunter et al., 2017). Despite these efforts, there remains confusion in the literature and professional community regarding the core goals, tenants, and strategies of the PCBH model. In an attempt to remedy this situation, this special issue is designed to serve as a one-stop information foundation for the PCBH model overview and definition; current state of the science; ethical considerations; diverse intervention strategies, training, and workforce development; and payment, legislative, and policy developments. We hope that this collection of articles will achieve a number of goals. One major aim is to provide the field with a concise definition of the PCBH model to aid in understanding key model features using consistent terminology. Such a definition could serve as a benchmark for clinicians, administrators, and researchers in determining what the PCBH model “is” and “is not” across diverse settings and organizations, and more clearly distinguish it from other models of integrated care and from co-located care. This is a prerequisite for the continued progression and dissemination of the model. A second major goal of the special issue is to provide comprehensive summaries of the major challenges currently facing proponents of the PCBH model. These include lack of clear ethical guidance specific to integrated service delivery models, difficulties with reimbursement and funding due to unsupportive policies and regulations, lack of a sufficiently trained behavioral health and primary care * Christopher L. Hunter christopher.l.hunter16.mil@mail.mil

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Integrating Behavioral Health Services into Primary Care: Spotlight on the Primary Care Behavioral Health (PCBH) Model of Service Delivery.

Anyone, Anything, Anytime: A History of Emergency Medicine

Eating disorders are a serious, life-threating condition impacting adolescents and young adults. Providers in primary care settings have an important role in identifying disordered eating (DE) symptoms. Unfortunately, symptoms go undetected in 50% of patients in medical settings. Using the behavioral health screen, this study identified DE risk profiles in a sample of 3620 female adolescents and young adults (ages 14–24), presenting in primary care. A latent class analysis with twenty psychosocial factors identified three DE risk groups. The group at highest risk for DE was characterized by endorsement of internalizing symptoms and a history of trauma. The next risk group consisted of those with externalizing symptoms, particularly substance use. The group at lowest risk for DE reported more time spent with friends compared to their peers. Primary care providers and psychiatric teams can benefit from knowing the psychosocial risk patterns affiliated with DE, and using brief, comprehensive screening tools to identify these symptoms.

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Identifying Risk Factors for Disordered Eating among Female Youth in Primary Care

The growth of the Primary Care Behavioral Health model (PCBH) nationally has highlighted and created a workforce development challenge given that most mental health professionals are not trained for primary care specialization. This work provides a review of the current efforts to retrain mental health professionals to fulfill roles as Behavioral Health Consultants (BHCs) including certificate programs, technical assistance programs, literature and on-the-job training, as well as detail the future needs of the workforce if the model is to sustainably proliferate. Eight recommendations are offered including: (1) the development of an interprofessional certification body for PCBH training criteria, (2) integration of PCBH model specific curricula in graduate studies, (3) integration of program development skill building in curricula, (4) efforts to develop faculty for PCBH model awareness, (5) intentional efforts to draw students to graduate programs for PCBH model training, (6) a national employment clearinghouse, (7) efforts to coalesce current knowledge around the provision of technical assistance to sites, and (8) workforce specific research efforts.

The State and Future of the Primary Care Behavioral Health Model of Service Delivery Workforce.

Introduction The Health Federation of Philadelphia, which hosts a network of Behavioral Health Consultants (BHC) operating within the Primary Care Behavioral Health model (PCBH), identified a need to systematically evaluate PCBH model fidelity and to rigorously evaluate the competency assessment process to further their workforce development. A simulated patient exercise was developed for evaluating BHC PCBH specific competencies. Method A simulated BHC encounter was held at a clinical learning center using standardized patients, repeated twice over 2 years. A competency based rating scale was developed by the network for the simulation (BHC-ORS), patient feedback was captured using the Working Alliance Inventory (WAI), and BHC feedback was collected using a questionnaire. Dedicated consultants were hired to develop the internal process, as well as conduct the evaluation in a way that might make a contribution to research. Results Targeted PCBH competencies generally improved after being identified as training needs in Year 1 of the simulation. Patient feedback showed average ratings for the majority of the BHCs. BHCs identified the experience as valid and useful. Important changes in methodology between Years 1 and 2 of the pilot limited a more complete analysis. Discussion The use of simulated patients to evaluate BHC adherence to the PCBH model was helpful for training and adds to the workforce development literature. The authors suggest that doing practice based research will always entail unanticipated needs that interfere with quantitative research but that there are ways in which researchers can attempt to anticipate these changes. Review of possible applications to community PCBH practice is included. (PsycINFO Database Record

Using standardized patients as a means of training and evaluating behavioral health consultants in primary care.

Discusses the problem of people with serious mental illness not feeling welcome in primary care. The issue may be that health care providers are simply uncomfortable with the symptoms of serious mental illness, and this results in avoidance, both individually and as a system. This health disparity can only be addressed if the affected population is part of the conversation. Community-based primary care has a responsibility to address the physical health needs of the seriously mentally ill. To do this, we need to start by acknowledging our discomfort, listening deeply to the voices of people with severe mental illness, and learning how to intervene effectively to improve their health.

Suzanne Daub

Papers

The State and Future of the Primary Care Behavioral Health Model of Service Delivery Workforce.

Using standardized patients as a means of training and evaluating behavioral health consultants in primary care.

Turning toward treating the seriously mentally ill in primary care.