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Addressing Fidelity in Primary Care Behavioral Health with the PPAQ: Measurement Matters

Posted By Greg Beehler, Thursday, January 11, 2018

(Brief History)

My colleagues and I at the VA Center for Integrated Healthcare (CIH) first developed the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to address a fundamental question: What do PCBH providers do every day?  We all know that variation in clinical practice is common.  In short, clinicians don’t perfectly follow conceptual models or detailed protocols in their usual practices for any number of reasons. Thus, we developed the PPAQ with the goal of creating a self-report measure of PCBH provider fidelity. 

Fidelity typically refers to the degree to which a model of care (or a specific treatment) is implemented as intended. To craft our measure, we started with an expert consensus study to help identify the essential components of the PCBH model that could be measures by self-report. This expert consensus study (1) ensured that we included the right survey items in our measure. A subsequent study ensured that the measure had adequate technical quality in terms of reliability and validity (2). Additional research showed that the PPAQ was effective at classifying PCBH providers as engaging in high or low fidelity practices (3). 



The PPAQ is a 48−item self-report measures that uses a 5−point, Likert-type response scale ranging from “never” to “always.” It sounds long, but don’t worry! It only takes about five minutes to complete. The PPAQ includes essential items, which measure behaviors that are highly consistent with the PCBH model, and prohibited items, which measure behaviors that are inconsistent with the PCBH model. The items are organized into four content domains:

1.     Clinical Scope and Interventions

2.     Practice and Session Management

3.     Referral Management and Care Continuity

4.     Consultation, Collaboration, and Interprofessional Communication

The PPAQ can be used for research and evaluation, but to make it easy to use as a quality improvement tool, we also converted it into a toolkit that was found to be highly acceptable as a self-assessment to frontline PCBH providers (4). 

The best way to get to know the PPAQ is to visit our webpage to download the PPAQ Self-Report Form and various versions of the toolkit to take a look for yourself:



So why should you care about fidelity and the PPAQ?  I think the answer to this question is quite simple: fidelity is an indicator of care quality. Consider the following:

       Monitoring fidelity means you are keeping an eye on quality of services

      Areas of low fidelity can indicate targets for quality improvement initiatives which are key to improving service delivery

       We can advance the knowledge base in PCBH by addressing fidelity in our research and evaluation

      Formally linking provider behaviors to patient and system outcomes will help us determine what aspects of care provided by PCBH providers matter most

       Fidelity assessment can enhance training and implementation efforts

      PCBH is a challenging and complex model. Using a measure like the PPAQ can assist providers with understanding what behaviors constitute high quality practice

It also should be noted that high fidelity practice doesn’t mean providing the same service to all patients every single time in a mindless, if technically correct fashion. Purposeful modifications to high fidelity practice can ensure high quality, patient-centered care.


(Future steps)

Currently, the VA has undertaken a huge step in addressing competencies among integrated primary care providers.  In summer of 2017, experts at CIH have developed a comprehensive competency training program that will be completed nationally by all VA Primary Care Mental Health Integration providers. The PPAQ is being used as part of an evaluation plan to assess changes in provider behavior as a result of the training program (…and early results are encouraging.) Initial competency training will be conducted at all VA healthcare systems through December 2018 with ongoing training occurring for new providers thereafter.

Also in 2018, the PPAQ-2 will be made available. Since integrated primary care comes in many shapes and sizes, the PPAQ-2 has been expanded and re-validated to include new subscales to address essential components of collaborative care management.  The PPAQ-2 will now be useful for both PCBH providers and care managers.

I hope you will consider embracing fidelity measurement in PCBH. It’s a chance to make care quality better.


1. Beehler, G. P., Funderburk, J. S., Possemato, K., & Vair, C. (2013). Developing a measure of provider adherence to improve the implementation of behavioral health services in primary care: A Delphi study. Implementation Science, 8, 19. (Link to PubMed Abstract)

2. Beehler, G. P., Funderburk, J. S., Possemato, K., & Dollar, K. (2013). Psychometric assessment of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ). Translational Behavioral Medicine, 3, 379-391. (Link to PubMed Abstract)

3. Beehler, G. P., Funderburk, J. S., King, P., Wade, M., & Possemato, K. (2015). Using the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to identify practice patterns. Translational Behavioral Medicine, 5, 384-392. (Link to PubMed Abstract)

4. Beehler, G. P., & Lilienthal, K. R. (2017). Provider perceptions of an integrated primary care quality improvement strategy: The PPAQ Toolkit. Psychological Services, 14, 50-56. (Link to PubMed Abstract)


Gregory P. Beehler, PhD, MA is the Associate Director for Research and a Clinical Research Psychologist at the VA Center for Integrated Healthcare in Buffalo, NY. He is an adjunct assistant professor in the Department of Community Health and Health Behavior and the School of Nursing at the University at Buffalo. Dr. Beehler is a licensed psychologist and medical anthropologist currently conducting research in the following areas: improving the implementation of primary care-mental health integration, fidelity assessment, measurement-based care, developing and implementing brief interventions for chronic pain, and promoting wellness among cancer survivors.


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