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Number of Visits in Primary Care Behavioral Health

Posted By Alexander Blount, Thursday, June 19, 2014
(This blog post is a reprint of a piece by Dr. Blount from May 2014. Click here for the original post.)

On the topic of number of visits: The short number of visits with a behavioral health clinician in primary care is because of the population encountered and the work done. It is not because there is a rule about the number. In fact, number of visits can be one way of assessing whether a practice is using its behavioral health clinicians as part of the primary care team (in which case the modal number of visits will be 1 and the average will be 2-3) or it is using them for specialty mental health services, in which case the average will creep up toward 6 or more depending on the population. 

Primary care behavioral health will be more focused on assessment, patient teaching, goal setting, healthcare behavior and family/social context. Most of us in primary care BH do not think of what we do as “psychotherapy.” That doesn’t mean we don’t see some folks several times or episodically for several years. For a lot of these folks it is as if from time to time they get a visit or two as a booster.

There are many more who will need several visits in the first episode of care and will be referred to specialty mental health either immediately or after some initial assessment visits. I often say to patients whom I am referring “You are working on very difficult issues, and you deserve someone who can see you every week to work with you. Let me find someone who will be a good fit to help you with your work.” Remember we don’t open or close behavioral health involvement in cases in primary care.

Some under value the difference between primary care behavioral health and specialty mental health  Specialty care is psychotherapy and medication management with the purpose of working together for longer periods of time. It can be done by a clinician in the same floor or building as primary care, or in a different organization. Most places have not had good luck having one clinician who does specialty MH for some days and primary care on others. The mind sets are too different. Programs with good primary care behavioral health make specialty mental health services working with them better targeted and more efficient. Programs who try to stick specialty mental health into primary care without a strong primary care behavioral health program tend to fail. The specialty folks get overwhelmed and don’t function as part of the team, thus failing to add the benefits of behavioral health expertise to the rest of the primary care services. 

Typically administrators and clinicians who have worked in mental health their whole careers at first do not notice or under value the difference between primary care behavioral health and specialty mental health. We created our Certificate Program in Primary Care Behavioral Health specifically to help them make the transition from mental health specialist to primary care generalist.

And having said this, I hear from programs in rural areas or who are just starting up who are right in the middle between PCBH and specialty care, and are doing good work and very appreciated by the physicians they are helping. And that gets us back to the first point, when you try to make a rule, rather than an observation about numbers, you are likely to impede rather than facilitate things.

Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA. At UMass he has developed training programs in Primary Care Behavioral Health and Integrated Care Management that have already trained 2000 people for the workforce needs of the transformation of healthcare. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’. He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.

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