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An example Of IBHI Integration of behavioral health services in primary care

The abstract below describes the context and scope of the work that was proposed by IBHI and then provided under a HRSA grant to the Community Health Centers of Benton and Linn Counties (BCHC) 

BCHC provides primary care and behavioral health specialty services to members of their community who are indigent, enrolled in the regional Medicaid health plan (IHN CCO), or otherwise designated as safety net populations. The Benton FQHC commenced operations in 2004. It has primary care staff and behavioral health staff that closely coordinate their services, but full integration has not yet been achieved at any of their four primary care clinics.

National experience informs us that behavioral health integration efforts only succeed when (a) behavioral health clinicians are trained (or retrained) to work in primary care settings; (b) the primary care settings reorganize their operations and create a work culture that can make effective use of these specialized clinicians; and (c) primary care practitioners are trained to work with and make effective use of their behavioral health consultants (BHCs).  Accordingly, BCHC will leverage the funding provided through HRSA-14-110 to implement a team-based, integrated model of care across all primary care clinics and increase access to behavioral health services in these settings. We will accomplish this by:

  • Adding one onsite, full-time equivalent (FTE) licensed behavioral health providers to our current complement of primary-carebased behavioral health providers 
  • Establishing a common conceptual framework and skill set for all BHC's working in primary care settings. This will be accomplished by enrolling all four behavioral health clinicians in a nationally accredited Certificate Program in Integrated Primary Care program as well as providing expert case consultation for these clinicians after they have completed their certificate program.
  • Redesigning the operations of our primary care sites so that they effectively make use of the BHCs who have been trained through this program. 
  • Using a variety of evidence-based screening tools, including SBIRT and the new Depression Screening and Follow Up performance measure, to screen all clients served through our primary care sites for behavioral health problems as well as physical health problems (e.g. obesity, diabetes, COPD) which could benefit from team-based treatment which utilizes the services our BHCs. 

IBHI was involved at every phase and every level of the Behavioral Health Integration Project (BHIP). Our scope of work included:

Project Management

  • IBHI created an engagement structure that was designed to support the successful implementation of BHIP goals and objectives. IBHI served as the BHIP Project Coordinator. The agency's senior managers serve as Project Sponsors. The Mental Health Program Manager served as the BHIP Project Manager.Together, these individuals were assembled as the project team (called the Core Implementation Group [CIG])that was responsible for monitoring and oversight, decision making, stakeholder identification, and project validation. 
  • IBHI organized the efforts of the CIG to create a Project Workplan and develop reports and metrics to monitor the effectiveness of implementation efforts. At each meeting we discussed successes as well as barriers to progress, and collaborated to arrive at viable solutions. Monthly IBHI meetings with the BCHC Project Manager assisted in identifying issues to take to the CIG and issues to take to our consultants. Quarterly IBHI meetings with Project Sponsor kept senior management fully informed of engagement progress and challenges and provided an opportunity for their input into key strategic decisions and oversight of the work performed by IBHI.
  • Regular IBHI meetings with Project Sponsors insured that there was buy-in from senior management throughout the engagement
  • A  "Sustainability Plan," which IBHI is drafting, is designed to identify the tasks and challenges which lie ahead in the months and years after the HRSA grant has ended.
  • IBHI helped to coordinate efforts among subcontracted trainers such as Dr. Brian Sandoval, Denna Vandersloot, and others to ensure fluid communication between project management and practice-level training
  • IBHI helped facilitate validation of reports to achieve measurable outcomes for the grant and facilitate long-term sustainability

Training

An excellent behavioral health clinician who has worked in specialty care for many years is not qualified to work in primary care as a Behavioral Health Consultant - not without additional training. The BHC role and the specialist role are quite different. To gain an in depth understanding of the BHC role, all BHCs were enrolled in and completed course work in a graduate level certification program in Integrated Behavioral Care. These programs were selected and monitored by IBHI for quality and relevance. BHCs also attended a two day training program in Portland to learn how Acceptance and Commitment Therapy in primary care.

IBHI brought national experts to BCHC to provide trainings to all clinical staff (BHC's, physicians, nurses, medical assistants, pharmacists) in: 

  • SBIRT
  • Motivational Interviewing
  • Mental Health First Aid 

Non-clinical staff also received training in Working With Challenging Staff as well as Mental Health First Aid

Supervision

IBHI provided both onsite and remote clinical supervision of BCHC's four BHCs. This work was performed by Brian Sandoval, PsyD. (See brief bio below.) 

Over the first two months of the grant, Dr. Sandoval spent several days observing the day to day operations of each of BCHC's four clinics. He met with all clinic staff,  including front office staff) to assess the efficiency and effectiveness of each sites efforts to achieve the agency's goal of integration. From this work, a customized plan was developed to provide onsite consultation and training.

Dr. Sandoval returned to each clinic many times over the course of the grant to both shadow BHC's in their work and provide them feedback as well as to model the BHC skill in action. This allowed the BHCs to see how Dr. Sandoval interacted with patients, doctors, nurses, front office staff, etc.  He also participated in weekly group BHC supervision by phone 

Consultation

IBHI provided assistance in BHC in the selection and hiring of new BHCs. No task is more critical to the challenge of integration than hiring the right clinician to be in the BHC role. Training and clinical judgement are not enough. The right personality is critical. IBHI consultants have years of experience in this area, having learned as much from getting it wrong as getting it right.

Training clinicians to work in primary care settings is necessary, but not sufficient, for integration efforts to succeed. The day to day operations of the clinics themselves need to be redesigned to make effective use of retrained behavioral health clinicians. IBHI consultants Dr. Brian Sandoval and Denna Vandersloot took the lead in consulting with clinic staff to achieve this goal. Every step of the way, the work of IBHI consultants was coordinated with BCHC managers. It is critical that our work reflect the goals, perspectives, and realities our clients. 

The implementation of the HRSA grant has led to BCHC successfully developing integrated behavioral health services at the four clinics covered by the grant. In addition, a fifth clinic, which was outside the scope of the grant, is in the process of adding integrated services. This clinic is benefiting  greatly from the IBHI that assistance that was provided to the other four clinics.