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Necessary components of Integrated BH in Rural Primary Care

Posted By Joe Evans and Rachel Valleley, Thursday, January 17, 2013
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Joseph and Rachel's
blog is the third post
in a month-long series
on integrated care in
rural settings.

Read the entire
series here.

Recently, while preparing yet another grant application, I resurrected one of my favorite quotations related to integrated behavioral health care. Dr. David Lambert, of the Rural Health Research Center at the University of Southern Maine, stated, back in 1999, that, "Integrated behavioral health care is a concept that is frequently discussed, but seldom implemented.” Over the years, this quotation has resonated with me and colleagues as we attempt to prepare students to work in integrated pediatric primary care practices. Just what is it that makes an integrated behavioral health clinic in primary care successful? What are the essentials that we need to pass on to our trainees as they enter the field, particularly those who opt to work in rural primary care?

The concept of integrated behavioral health in primary care is certainly far from a "new” idea. Dr. Nick Cummings and his associates have been espousing this notion for over three decades. As noted by Alexander Blount, the integration of physical and mental health care seems to be such an "obvious” and necessary part of the overall health care system that few can argue with its theoretical underpinnings and utility. Why, then, has the implementation of such a beneficial approach to healthcare taken so long in being recognized and implemented. Why have attempts to integrate behavioral and physical health care failed in the past? What makes some practices extremely successful in this venture while others have experienced major difficulties? Are we looking at the essential and necessary components for positively integrating behavioral healthcare and can we learn from successful implementations by others in the field?

Using the approach of "translational research”, Carol Trivette of the Puckett Institute in Morgantown, North Carolina, has emphasized identifying the "kernels, nuggets, and gems” from research findings that are applicable to applied practice. Identification of those characteristics of programs and practices that "stand out” as most important in successful practices is an approach that we, as a field, have not yet applied to integrated behavioral health care, particularly in rural settings. While we all have ideas of what should be involved in an integrated behavioral health practice in primary care, we have not conducted investigations into what factors truly differentiate what makes a practice successful versus unsuccessful in integrated care.

During our Nebraska experiences in implementing integrated behavioral health into 17 rural primary care practices, we have had our share of successes and disappointments.

By way of example, Wolfe and colleagues at the Achievement Place Project in Kansas conducted an analysis of the necessary components of a treatment group home program for delinquent adolescents following an initial "failure” of the program to be replicated. While, initially, it was felt that their well – researched token economy would be the most essential component of the treatment program, further investigation revealed that it was actually the "relationship” and "teaching style” of the group home Teaching Parent staff that was most important in the implementation of the program. Based on this finding, the training component of the program shifted emphasis to development of "teaching skills” with the token economy being a secondary "tool” in the social skills educational process. This program has now been successfully replicated in literally hundreds of agencies in the USA and in foreign countries.

Similarly, in the area of integrating behavioral health into primary care practice, we need to examine some of the parameters that have separated successful versus unsuccessful implementations of the integrated care approach. We may also need to assess whether there are "differences” in the necessary components for Pediatric versus Family Medicine versus Geriatric primary care practice. Our experiences would lead us to propose that there may be significant differences in successful implementation of an integrated behavioral health approach in a Pediatric or Geriatric setting where much of the intervention implementation is mediated by caregivers (parents and nursing staff) versus direct intervention with the patient as is typical in adult Family Medicine integrated MH care.

Some attempts have been made at identifying commonalities of integrated behavioral health care services by examining existing programs. A study funded by the Robert Wood Johnson Foundation, (2007) reviewed 16 programs that, in various ways, identified themselves as providing integrated behavioral health services. Findings suggested that "Integration implementers and goals varied,” and "Integration approaches vary.” Differences in definitions of integrated behavioral health care, a variety of funding mechanisms, and differing target service populations made the task of identifying commonalities difficult to impossible. Additionally, almost all of the programs reviewed operated in major urban areas and focused on "publicly funded” mental health care for severe mental illness.

Examination of components of successful integrated care practice in rural areas may have some distinct advantages due to commonalities found in rural practices. First, the majority of health care in rural areas is provided by Family Medicine or Pediatric primary care physicians. Secondly, there is generally a lack of local "MH specialists” to whom primary care physicians can refer within the immediate area, particularly psychiatrists. Thirdly, most primary care practices in rural areas have a small number of physicians (with an increasing number of Nurse Practitioners and Physician’s Assistants). Fourth, these primary care physicians are expected to address the full range of health problems, with very few having any type of "specialty” clinical practice. Finally, rural primary care physicians generally have a ready "network” of specialists to whom to refer, frequently at University Medical Centers, for various severe conditions. (In the case of behavioral disorders, however, scheduling for appointments can take weeks or months.) Because of these commonalities, finding necessary components of rural integrated care implementations may be more feasible.

During our Nebraska experiences in implementing integrated behavioral health into 17 rural primary care practices, we have had our share of successes and disappointments. The remainder of this blog will discuss some components that we feel are necessary for successful integration of behavioral health into primary care and we will provide some examples of factors that seemed to undermine our attempts. First, a necessary component, in our experience, is the establishment of positive relationships by the behavioral health specialist with not only the primary care physicians but also office staff (nurses, billing clerks, receptionists, etc.). In one of our first replication attempts, some office staff initially viewed our presence as a "burden” and would frequently neglect to notify our behavioral health provider of patients in the waiting room. After "earning her spurs” by successfully treating one of the children of a support staff member, however, relationships improved markedly and staff became some of our greatest supporters. Lesson learned: be sure to develop relationships with staff by chatting, bringing "treats” on occasion, and providing reinforcing comments for cooperation and services provided, no matter how menial. With physicians, reinforcing the "appropriateness” of referrals and information about treatment successes greatly contributes to relationship building.

Secondly, communication with primary care physicians and staff is paramount for establishing a consistent flow of patient referrals when implementing integrated care. In many cases, physicians are unaware of the types of services and skills that are possessed by behavioral health providers. During their training, most primary care doctors receive one to two months of rotations in psychiatry during their residency years. Depending on their experiences during these rotations, primary care physicians frequently place behavioral health providers into a single category, dealing with only the most severe disorders. Communication about the "types” of services that can be offered should occur during the first 6-12 months of program implementation. Noon conferences, presentations to local hospital "rounds,” and "sitting in” on patient sessions can all be forums for providing information to physicians and staff. Recently, by way of example, a family presented in a new clinic with a behavioral concern about "head banging” by their four-year-old child. Following the physician’s citation of the percent of children who engage in this behavior and reassurance that the child would eventually outgrow this activity, our behavioral health professional was able to indicate having some skills in reducing potentially self – injurious behaviors and was able to "solve” this problem in only two sessions using parental differential attention and timeout. Following this episode, the number of "warm handoff referrals” (a la Kirk Strosahl) increased. Other methods for increasing communication include timely intake reports, discussions of combined medical and behavioral plans, notes about when an outside referral needs to be made, offering assistance in behavioral diagnostics, and monitoring of psychotropic medication effects.

It is important to note that communication can best be achieved through physical proximity and seeing patients in examining rooms in the primary care practice. In one instance, an office manager, in an attempt to provide better "clinic space,” assigned a room at the end of the hall to our behavioral health provider. While accommodations were better for seeing patients, contact with physicians, nurses, and office staff was reduced and referrals dropped markedly. Using examination rooms on physicians’ days off allows contact with other doctors as well as providing access to support staff.

A third critical component in implementing Integrated care, in our estimation, relates to the "economics” of primary care practice. Behavioral health providers need to have enough "business acumen” to understand the financial pressures and incentives in primary health care. A number of models of funding for behavioral health reimbursement exist (and may increase with the implementation of the Affordable Care Act). Capitated care, fee for service, Medicaid, co-pays, sliding scale payments, HMOs, and insurance panels are all examples of how behavioral health services can be reimbursed. Providers need to understand the number and "mix” of patients being seen in the primary care practice according to payment source and reimbursement allowed. Negotiating "overhead” costs for space and staff support should also be taken into consideration. These factors help determine estimates of potential income and number of patients that need to be scheduled. Consideration of the economics for primary care providers should also be a point of awareness for integrated behavioral health providers. Initially, we recommend keeping staff demands and supports at a minimum until the overall "value” of integrating behavioral healthcare into primary care physicians’ practices is established. This can be done by the behavioral health provider transcribing his/her own notes, handling return schedules, making reminder calls, and performing billing and collection functions. As the benefit of having behavioral health available in the practice, many of these functions can be absorbed into the day-to-day activities of support staff.

Data that we have collected over the years indicates that primary care pediatricians spend literally double the amount of time on behavioral referrals as compared to acute care episodes or well – child visits. When collectible fees for providing behavioral health services by physicians were analyzed in one of our studies, physicians unable to utilize mental health codes in their billing. This resulted in reimbursements that were only 45% of "typical” collections for acute and well – child care. Following this logic, physicians should be able to be 15-20% more productive with time freed up when a behavior specialist is available to deal with mental and behavioral health issues within the practice. In our experience, once the that physicians recognize the amount of time savings, economic benefit, and improved diagnostic and treatment capacities resulting from having a behavioral professional in the practice, referrals flow steadily and benefit all parties: primary care physicians, behavioral health professionals, and patients.

Finally, and possibly the most important component in preparing behavioral professionals for primary care practice, is knowledge and skills necessary to treat behavioral problems presenting in primary care physicians’ offices. Unfortunately, there is not a direct correspondence between graduate education in many behavioral health graduate training programs and medical practice in the community. Training in addressing the most common behavioral problems presenting in primary care is a necessity. Most psychology training programs are not located in, nor do they collaborate with, colleges of medicine. In integrated pediatric primary care, by way of example, behavioral providers need to be able to accurately assess and treat the most commonly presenting problems of childhood and adolescence.

Specific protocols for diagnosing and providing therapy for sleep disorders, feeding disorders, thumbsucking, nocturnal enuresis, learning disabilities, ADHD, habit disorders, childhood depression, aggression, anxiety, school motivation problems, medical compliance, and the psychological effects of chronic conditions such as diabetes, epilepsy, cystic fibrosis, and genetic conditions should be mastered in order to be successful in integrated pediatric primary care practice. We recently had a student in a pediatric practice in an underserved, high need poverty area. Her training did not include education in many of the behavioral conditions noted above and she spent a good deal of her time doing assessment and then referral out of the practice. This simply added another "layer” of delay between the physician and eventual treating agent. Similarly, we have had students who are well trained in standardized and "manualized” therapeutic programs requiring consistent attendance at 10-12 consecutive sessions. In primary care, this is a practice that is rarely successful and often leads to treatment failure. In our estimation, short – term, evidence – based, protocol driven and prescriptive therapies are the "norm” in pediatric integrated primary care practice.

In summary, as educators of future integrated behavioral health specialists, we are very interested in sharing and hearing the experiences of others, both positive and negative, who have been successful in implementing integrated care programs. We have attempted to share some of our successes and "tales of woe” that will hopefully be of benefit to you in your future endeavors.


Joseph Evans
Dr. Joseph Evans is a Professor at the Munroe-Meyer Institute (MMI) and in the University of Nebraska Medical Center's (UNMC) Department of Pediatrics. He is the Director of the Psychology Department at MMI and the Division Director of Pediatric Psychology in the UNMC College of Medicine. Dr. Evans administers a staff of eleven Psychologists, nine Doctoral Interns, five Post-doctoral Research Associates, four graduate students in Applied Behavior Analysis, and support staff. He is an active clinician and manages the ADHD Clinic conducted at MMI as well as serving as a staff psychologist for the DHHS Children with Special Health Care Needs program.

Rachel Valleley
Rachel J Valleley, Ph.D., is a licensed psychologist in the Department of Psychology at the Munroe-Meyer Institute for Genetics and Rehabilitation and Associate Professor in Pediatrics and the Munroe-Meyer Institute at the University of Nebraska Medical Center.  Her research and clinical interests revolve around behavioral health in primary care. Specifically, she is interested in the impact that behavioral health problems have on primary care, demonstrating the effectiveness of the integrated model on behavioral health, and the unique contributions that behavioral health specialists can have upon primary care. She is currently Coordinator of MMI’s Outreach Behavioral Health Clinics, overseeing 13 rural clinics, 7 Omaha area clinics, and 4 collaborating sites. She has published nearly 20 scientific papers and chapters related to children with behavioral health and academic concerns.

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