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Integrated Behavioral Health in Primary Care Copyright American Psychological Association. share the same practice space and some shared years to help the PCP manage the patient s health. systems such as medical records The team works care plan through continuity consultation The BHC. together to address specific types of patient pre also makes recommendations as to how the PCP and. sentations An example of this is the collaborative team members can support this plan and what the. care model also referred to as the IMPACT model PCP and team might do to assist the patient in the. care management model or care facilitation future It is fundamental to this model that the BHC. model This model usually focuses on depres is always working as a consultant to the PCP helping. sion alone using a specific process of assessing the PCP manage patients needs. planning facilitating and advocating for options, to meet the patient s needs This model has been Why PCBH Focus. shown to improve the treatment of depression The strategies we cover are likely to be useful in. over standard primary care depression treatment any integrated care model but they are particu. Katon 2012 At the other end of the continuum larly germane to the PCBH model of integrated. is integrated care care This integrated model Robinson Reiter. 2016 has been used by several large health,The care that results from a practice team. care systems including Kaiser Permanente the,of primary care and behavioral health. Veterans Administration the Health Resources,clinicians working together with patients. Service Administration and Bureau of Primary,and families using a systematic and cost. Care through Federally Qualified Health Centers,effective approach to provide patient. and the Department of Defense C L Hunter,centered care for a defined population. Goodie Dobmeyer Dorrance 2014 Strosahl,This care may address mental health. Robinson 2008,and substance abuse conditions health. In short the PCBH model is designed to facilitate,behaviors including their contribution to. the delivery of a variety of evidence based inter,chronic medical illnesses life stressors. ventions which we present in this volume for a,and crises stress related physical symp. range of problems across the life span that include. toms and ineffective patterns of health,prevention as well as treatment of acute and. care utilization Peek the National,chronic conditions that focus on symptom reduc. Integration Academy Council 2013 p 2,tion functional improvement and better quality. An example of an integrated care model is the of life There is no limit to the number of appoint. primary care behavioral health PCBH model In ments a patient can have with a BHC Rather the. this model the behavioral health provider works as number of contacts depends on the patient s prog. a member of the primary care team and is referred to ress Services can occur before within or after an. as a behavioral health consultant BHC The BHC appointment with a PCP or be provided through. usually sees patients for an initial 15 to 30 minute psychoeducational groups shared medical appoint. appointment to conduct a focused assessment and ments clinical pathways or some combination of. to develop a treatment plan based on the health care these based on the patient population and avail. goals of the patient and PCP The BHC then provides able clinic and community resources We discuss. feedback to the PCP about the patient s symptoms the important components of clinical pathways and. and functional impairments and details a behavioral shared medical appointments and how the BHC. health change plan On the basis of the PCP s prefer might promote these approaches to improve popula. ence and patient needs the BHC may implement tion health impact in more detail in Chapters 1 and. monitor or change the intervention typically using 17 We believe the PCBH model can be used effec. focused 15 to 30 minute appointments until the tively in most primary care settings and aligns with. patient starts to show significant functional or symp the goals of population health care the Triple Aim. tom improvement When focusing on chronic condi and Patient Centered Medical Home goals discussed. tions e g diabetes obesity chronic pain BHCs in Chapter 1 For a more comprehensive review of. may periodically meet with patients over months or the PCBH model see Robinson and Reiter 2016. Copyright American Psychological Association Introduction. It has been argued that optimized integrated BECOMING AN INTEGRATED. care models would involve attention to mission CARE PROVIDER. clinical physical location operations information,We have been teaching behavioral health provid. and financial and resource integration Peek 2008,ers to adapt their training and professional prac. Strosahl Robinson 2008 Integrated behavioral, tices to the primary care environment for the past. health care is a way to bring the skills and expertise. 15 years Common questions we have received, for addressing behavioral health needs to a setting. include Where do I start What do I do,in which the patients who can benefit from those. Answers to these questions typically elicit the, services are already receiving care It normalizes the response I can t do that in 30 minutes We then. need for behavioral health support and reduces the explain why in the primary care setting the typi. stigma associated with it cal conventional model of psychological assess. Most behavioral health providers have been ment and intervention will not work The typical. trained in the traditional specialty mental health 50 minute interview cannot simply be condensed. care model In this model patients either seek help to fit in a 15 to 30 minute appointment Time. themselves or are referred to a behavioral health demands and practice expectations are structured. provider for problems identified as psychological differently in the primary care setting behavioral. e g anxiety depression interpersonal problems health services must be adapted to this fast pace. In specialty mental health care the practitioner The practicalities of adapting one s assessments. may see the patient in his or her office for brief and interventions to patient problems in the pri. psycho therapy e g 8 10 sessions or for long mary care setting are the main focus of this book. term therapy of indefinite duration In either case We use the abbreviation BHC throughout this. sessions last for 45 to 50 minutes on a regularly volume when referring to a behavioral health. scheduled basis e g weekly This type of behav provider working in primary care However. ioral health assessment and intervention can sup the strategies we describe are applicable to all. port the lower end of the continuum of integrated providers i e behavioral health providers and. care i e collaborative care and colocated care PCPs working in this setting. however it will not work in an integrated care,model To be an effective primary care team mem. ETHICAL CONSIDERATIONS, ber the behavioral health provider must be readily. available Because the integrated approach expects Behavioral health providers engaged in integrated. a much wider range of patients to be referred primary care behavioral health services quickly. for behavioral health assistance to address not learn that they face unique circumstances which. only mental health disorders but also subclinical are not always addressed by their discipline s. problems prevention adverse health behaviors ethical guidelines Ethical guidelines that do. and chronic medical conditions the demand for address the content areas of concern are typi. appointments will quickly exceed the behavioral cally not written to apply to the context of inte. health provider s ability to meet that need using grated team based primary care behavioral health. a specialty mental health model of care Patients service delivery which includes team profes. will have extended waiting times for services and sionals with different ethical guidelines expecta. in all likelihood the behavioral health provider tions and culture of care standards Common. will quickly become an irrelevant team member areas of concern for behavioral health providers. as a result of not being able to assist the PCP in a who are new to primary care include informed. timely manner As such behavioral health provid consent confidentiality complex relationships. ers working within an integrated care model have including whole family care multiple relation. to redefine how they think and what they do to ships scope of practice and competence Ethical. provide behavioral health services that will work in guidance for primary care behavioral health has. the primary care environment received increased attention over the past 5 years. Integrated Behavioral Health in Primary Care Copyright American Psychological Association. Although it is beyond the area of focus for this 2 Some evidence suggests that matching patients. volume we strongly encourage you to inform this with a provider who speaks their preferred. part of your work Additional information can be non English language might improve treat. found in a special issue devoted to ethics in col ment outcomes. laborative care in the journal Families Systems 3 Patient variables such as age and acculturation. and Health Runyan Robinson Gould 2013 may be particularly important to assess before. and in Robinson and Reiter 2016 making cultural adaptations because those. adaptations may be most effective for older less,acculturated patients. CULTURAL COMPETENCE AND,4 Some evidence suggests that provider patient. EVIDENCE BASED ADAPTATION,agreement on treatment goals and using meta. phors or symbols that match the patient s cultural. Although there is general agreement that cultural worldview may improve treatment outcomes. competence involves the awareness of cultural 5 Myth adaptation that includes the patient s. influences on patients behaviors and health beliefs about symptoms etiology course conse. beliefs and application of this knowledge to effec quences and appropriate treatment may improve. tively serve culturally diverse patients one size treatment outcome. does not fit all there is still no uniform defini 6 Addressing cultural factors implicitly rather than. tion of cultural competence and key terms are explicitly may be a way to get the benefits of cultural. used interchangeably Huey Tilley Jones adaptation without the risk of iatrogenic effects. Smith 2014 Cultural adaption tailoring has,Huey et al 2014 went on to say. been defined as the systematic modification of, an evidence based treatment EBT or interven These results provide some preliminary. tion protocol to consider language culture and guidance to researchers and therapists. context in such a way that it is compatible with when deciding what types of cultural. the client s cultural patterns meaning and values tailoring are likely to be most beneficial. Bernal Jim nez Chafey Domenech Rodr guez however additional research is neces. 2009 p 362 Cultural competence and evidence sary to replicate these findings in well. based cultural adaptation tailoring of primary care controlled trials before causality can be. behavioral health services goes beyond the area of inferred p 321. focus for this volume Nearly all the research in,We have included a cultural and diversity con. this area has been done in specialty settings not, siderations section in Chapters 4 through 16 which. primary care In fact entire books e g Bernal,describe information you might want to consider. Domenech Rodriguez 2012 T B Smith,when addressing these clinical content areas. Trimble 2016 have been written on cultural com,petence and the adaptation tailoring of EBT for. diverse groups We encourage readers to pursue THE 5A S. these resources as a way to improve their aware,Our format for assessment and intervention is. ness of what they might adapt based on the unique,based on the 5A s model Whitlock Orleans. patient populations they serve A recent compre,Pender Allan 2002 assess advise agree. hensive review and summary Huey et al 2014,assist and arrange The 5A s format has been. of multiple qualitative and meta analytic reviews,strongly recommended for assessment and inter. on cultural competence and treatment adaptation,vention across a range of problems in primary. tailoring came to the following conclusions,care Goldstein Whitlock DePue the Planning. 1 Adaptation targeting a specific ethnocultural Committee of the Addressing Multiple Behavioral. group is more effective than tailoring targeting a Risk Factors in Primary Care Project 2004 The. mixed group specific tasks within each of the 5A s vary depend. Copyright American Psychological Association Introduction. ing on the nature of the problem as well as its During the agree phase patients decide on their. severity and complexity Whitlock et al 2002 course of action on the basis of the options dis. Nevertheless the 5A s model can be applied to any cussed They might also decide that they do not like. patient in any clinic with any problem We have any of the options and suggest some of their own. found this flexible patient centered model invalu or they might take more time to think about their. able in providing behavioral health services in the options and discuss them with a significant other. primary care setting Figure 1 provides an over In the assist phase the BHC s job is to help. view of how the 5A s connect and how they lead to patients learn new information develop new skills. a personal action plan solve problems and overcome environmental or per. The assess phase involves gathering informa sonal barriers to implementing the behavior changes. tion on physical symptoms emotions thoughts This is where the formal intervention takes place. behaviors and important environmental variables In the arrange phase we specify when or if. such as family friends or work interactions From patients will follow up with the BHC PCP or a. a bio psychosocial perspective the goal is to deter specialty mental health provider If the patient will. mine what variables are associated with patients be following up with the BHC we also discuss what. symptoms and functioning and then on the basis will be evaluated or what information or skill will be. of patients values and what they have control over the focus of the next appointment. to determine what they could change or alter that Using the 5A s helps produce a meaningful and. would decrease symptoms and improve functioning personalized health care action plan The plan is. The advise phase involves describing to patients specific and focused on health behavior change and. their options for intervention on the basis of the is an integrated piece of the patient s overall health. data gathered in the assessment phase The goal is to care plan Ideally the plan is then monitored and. describe the intervention and the expected outcomes managed by the entire health care team. Risk Factors Behaviors Symptoms Attitudes,Preferences. Arrange Advise, Specify plans for follow up Specific personalized options. visits phone calls mail for treatment how symptoms. reminders Personal Action Plan can be decreased functioning. 1 List goals in behavioral terms quality of life health improved. 2 List strategies to change health behaviors,3 Specify follow up plan. 4 Share plan with practice team,Assist Agree, Provide information teach Collaboratively select goals based. skills problem solve barriers to on patient interest and. reach goals motivation to change, FIGURE 1 The 5A s model of behavior change in primary care From Self Management Aspects of the. Improving Chronic Illness Care Breakthrough Series Implementation With Diabetes and Heart Failure. Teams by R E Glasgow M M Funell A E Bonomi C Davis V Beckham and E H Wagner 2002. Annals of Behavioral Medicine 24 p 83 Copyright 2002 by Springer Adapted with permission. Integrated Behavioral Health in Primary Care Copyright American Psychological Association. PURPOSE AND ORGANIZATION we apply the foundations presented in Chapters 1. OF THIS VOLUME through 3 to the most common patient problems the. BHC will encounter in the primary care setting Each. With the increased need for efficient evidence, of the 12 chapters in Part II is structured as follows. based care this volume provides BHCs working, in primary care e g psychologists social work description of the problem area with emphasis. ers psychiatrists counselors PCPs and other on relevant biopsychosocial factors. medical care providers e g physician assistants cultural and diversity considerations. nurses health care educators with practical review of evidence based interventions in the. strategies they can use immediately Our sugges problem area. tions are drawn from evidence based data as well adaptation of interventions for the primary care. as our experience in translating evidence based setting. care to our clinical settings Overall our book is use of the 5A s format for assessment and. designed to give practical step by step guidance intervention. for targeting biopsychosocial factors in primary websites apps and books for patients and. care Students may also find this text useful assessment and intervention tools such as BHC. Undergraduate and graduate courses focused on scripts handouts worksheets checklists and. preparing individuals to work in primary care monitoring forms these tools can also be down. can use this book as part of a seminar on assess loaded from the APA Books website http pubs. ment and intervention in primary care or as part apa org books supp hunter2 and tailored to. of a larger class focusing on brief treatments for one s particular needs and setting. common behavioral health problems In Part III we address managing suicide risk in. The book is divided into three parts Part I con Chapter 16 and clinical pathways and shared medical. sists of three chapters that lay the foundation for appointments in Chapter 17. an integrated behavioral health care practice In For clarity throughout the volume the term spe. Chapter 1 we describe foundational concepts of cialty mental health refers to traditional or standard. population health service delivery and the patient assessment and treatment in an outpatient mental. centered medical home In Chapter 2 using the health clinic The term behavioral health refers to. 5A s we outline the steps for an initial consultation activities that are performed within the primary care. appointment This chapter provides a template for clinic Our goal is to provide straightforward easy. addressing patient problems in the primary care to use information to assist in addressing particular. setting and provides the foundation for conducting problems in the primary care setting We believe read. the initial consultation In Chapter 3 we describe ers will find as we have that this way of working with. the basic tools of interventions for behavioral patients will result in functional improvement and. health problems that can be implemented in one symptom change over a surprisingly short period. to four 15 to 30 minute consultation appoint We have had the opportunity to spend thousands. ments These include the following 10 interven of hours in primary care settings including family. tions relaxation training mindfulness exercises medicine internal medicine and obstetrics and. goal setting cognitive disputation motivational gynecology as part of successful integrated behav. interviewing problem solving self monitoring ioral health services We have also taught hundreds. antecedent behavior consequences analysis stimu of behavioral health providers to deliver effective. lus control and assertive communication We have behavioral health care in integrated settings We. found these 10 interventions to be effective for a hope that by using these evidence based assess. variety of symptoms and functional impairments ments and interventions coupled with our shared. For each intervention we apply the 5A s format and experiences you can become more effective in your. show how to present the intervention to the patient primary care work and can continue to improve the. in plain easily understandable language In Part II health of the population.
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