Chris's blog is the first
post in a series on
integrated care for
military and veterans.
In a recent article, the president of the American Medical Association highlighted the importance of integrating mental and physical health care. He noted important policy, finance and paradigm service delivery changes that make today ripe for such change. He further argued the importance of providing integrated care for at risk individuals with a special emphasis on retooling health care service providers so they can deliver efficient and effective whole person care. He goes further to highlight the importance of ensuring these services are available for our military service members. I couldn’t agree more and am pleased to report that the integrated care for our active duty and retired military service members as well as their families has been available for the last 13 years, and has continued to grow and improve.
Integrating behavioral health services into primary care in the Military Health System (MHS) is not a new concept. In 2000, the Air Force launched its Behavioral Health Optimization Program (BHOP). This program embedded behavioral health providers (primarily psychologists) into primary care clinics to provide integrated behavioral health services using a Primary Care Behavioral Health (PCBH) model of service delivery. In 2003 the Navy launched a 2-year demonstration project building on the work of the Air Force BHOP. The Army launched the Re-Engineering Systems of Primary Care for PTSD and Depression in the Military (RESPECT-MIL) feasibility study in 2004. This was a systems-level, care management model approach to improve recognition, management, and follow-up of depression and post-traumatic stress disorder.
|Despite the early work done in the Air Force, Navy and Army, the Department of Defense (DoD) MHS had no shared vision or implementation strategy across Services for integrating behavioral health services into primary care. The need for an enterprise-level vision and strategy was amplified when the Report of the DoD Task Force on Mental Health in 2007 recommended the integration of mental health professionals into primary care settings to improve the access and outcomes of behavioral healthcare. |
"As AMA president, I will note the need to
better integrate mental health care into
other aspects of medical care – to provide
more resources to treat more people."
"Just like we'll need you to make a
concerted effort to help our returning
troops, veterans and their families."
Inaugural address of AMA President,
Jeremy A. Lazarus
It was clear that if the DoD was going to move forward with a shared vision and strategy there needed to be a DoD level lead. To that end a DoD Program Manager for Behavioral Health in Primary Care position was created. I was fortunate to be hired to fill this role.
Over the last 4.5 years a number of milestones have been reached.
1. Agreement on "minimum” staffing levels…a minimum of 1 behavioral health provider (BHP) in clinics with 1500-7499 enrollees using a PCBH model of service delivery and 1 BHP and 1 Care Manager using a blended model of care with enrollments of 7500 or greater.
2. Funding began in FY 2012 to hire and train 470 behavioral health personnel to meet those minimum staffing levels by the end of FY 2016.
3. Clinical, Administrative, and Operational Standards for delivery of behavioral health services in primary care to include a phased training process with over 21 hours of in person intensive didactic and role play training to meet minimum core competency standards prior to the BHP engaging in any service delivery in primary care. This is followed by in-clinic training and feedback to facilitate acquisition of additional core Clinical, Administrative, and Operational competencies.
4. Currently 61% (207 of 336) of MHS adult primary care clinics have full-time staffed integrated care programs:
Percent of Clinics with Specific Model:
Care Management Model Only: 32.8% (68 of 207)
PCBH Model Only: 46.3% (96 of 207)
Blended Model: 20.7% (43 of 207)
Electronic medical record (EMR) BHP screening, assessment and clinical documentation and service delivery templates for mental health, substance misuse and health behavior problems (e.g., tobacco, pain, obesity) are in the process of beta and pilot testing. Once pilot testing is complete, behavioral health personnel in 120 military treatment facilities (which can have more than one primary care clinic) will be trained to use the EMR templates and expected to use the templates on every patient encounter per Army, Navy and Air Force practice standards. These notes allow for centralized data pulls in common fields with the same medical terms and screening/assessment scores across the Army, Navy and Air Force.
Program evaluation plans are well under way and are expected to start within this fiscal year. Evaluation is centered around the Quadruple Aim….improved readiness to deploy, better outcomes, patient and provider satisfaction, and cost management. Both process and outcome metrics will be collected, through enterprise wide program assessment as well as discrete process improvement projects in selected clinics across the Army, Navy and Air Force.
Ensuring that our active duty and retired Service members and their families have outstanding healthcare is a top priority. Integrating full-time behavioral health services in our MTF Patient-Centered Medical Homes, is an important part of that outstanding care. A great deal of work has been and is still left to be done. However, I’m confident that the programmatic clinical, operational, administrative, financial and program evaluation components in place will facilitate meeting Quadruple Aim goals and provide easy access to evidence-based behavioral health services in primary care.
Additional information can be found in: Hunter C. L., & Goodie, J. L., (2012). Behavioral health in the department of defense patient-centered medical home: History, finance, policy, work force development and evaluation. Journal of Translational Behavioral Medicine, 2, 355-363.
Dr. Hunter graduated from the University of Memphis specializing in behavioral
medicine. He is board certified in clinical health psychology and works for
TRICARE Management Activity (TMA) as the DoD Program Manager for Behavioral
Health in Primary Care. He is a previous Chair for the Society of Behavioral
Medicine’s integrated primary care special interest group and has been
Collaborative Family Health Care Association board member. In
2002 he received the Arthur W. Melton Early Career Achievement Award
from AP Division 19 (Military Psychology). He has published several research articles and book chapters and in is
the lead author on the book Integrated
Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and