Behavioral Health Diagnostic Assessment in Primary Care Behavioral Health
My colleagues and I have been discussing the topic of PCBH providers conducting assessments and diagnostic clarification around behavioral health disorders (e.g. Mental Health and SUD Dx) and we would love input from this community.
We are finding quite a divide between those that believe it is absolutely in scope for a BHC to provide BH diagnostic assessment (usually conducted over 1-3 brief visits, e.g no more than 30 to 40 min. etc.) and those that believe it is not in scope for BHCs to provide BH assessment but more that they could offer BH diagnostic clarification and referral to co-location BH or specialty BH for the BH assessment.
If you happen to be of the believe that it is in the scope for BHC to offer BH assessment within a PCBH model can you please offer any guidance on how you avoid getting clogged down with lengthy BH assessments that leave you unavailable for your team and patients, etc.
Thank you so much for any thoughts on this matter!
I reject the premise that the “model” should dictate the organization of the service.
What do the PCPs want from the BH services? What services will lead to improvements in patient outcomes? What is the availability of specialty services in the community? How does this vary based on payer?
However, your question also raises a broader question about the role of assessment in primary care. I would propose that primary care clinicians (including BHPs) ought to have a fundamentally different relationship with diagnosis and assessment than specialists.
The scope of diagnosis and assessment should be limited to questions that will influence the delivery of an intervention that can be expected to improve outcomes. Stated more bluntly - there is limited value in clarifying a diagnosis if that clarification does not impact treatment. In most cases this is the standard the best primary care physicians use when making decisions about screening and assessment, and it is the standard that BH providers in primary care should be holding themselves to.
Consider three common scenarios:
1) A patient experiencing a depressive episode seeks treatment for that condition, but is absolutely unwilling to consider medication. The team wonders if this patient has a unipolar or bipolar mood disorder. The patient feels strongly that he has bipolar disorder. I am proposing that in this circumstance it probably isn’t that important to clarify the diagnosis, at least not in the near term. The sorts of behavioral interventions we can offer this patient won’t differ in most clinical settings depending on whether this patient has MDD or bipolar disorder 2. At this time its clear he is experiencing a depressive episode. The immediate focus should be on engagement of the patient and behavioral interventions that address the patient’s goals - in this case improving functioning. Time spent referring the patient for a thorough assessment and diagnostic clarity is unlikely to add value. In fact time spent clarifying diagnosis in this scenario would be in service of the teams “needs.” Not the patient’s needs and preferences. This approach is potentially harmful. It is acceptable for us to be uncertain about his “true” diagnosis. Especially in the near term. I would also argue that patience and time will clarify his diagnosis more accurately than testing and interviews.
2) An adult patient presents to primary care with a history of trauma. She currently complains of excessive worry, nightmares, and panic attacks. She seems to think and worry about the past, present, and future. In this scenario I am not convinced that substantial effort should be spent parsing her diagnosis. Given what we know about the low rates of success in referring patient to specialty mental health services, how much energy should be spent sending her for diagnostic clarification?
If the full assessment determines she meets DSM5 criteria for Panic Disorder and GAD but does not meet criteria for PTSD, how will that change what we offer her? Will it be substantively different than if she had met criteria for PTSD and panic, but not GAD? Perhaps in some communities it will. In many/most communities I don’t think it will make a difference.
In this scenario, the diagnostic clarification would not even offer much guidance in terms of medications. The efficacy of SSRIs for treatment of GAD and PTSD is generally overestimated. The risks of benzos have bene thoroughly discussed, though clearly they make an important positive difference for some patients. We have medications that can target nightmares with some effect, but do we need a thorough diagnostic assessment before we would try a pharmacological intervention for nightmares? I think the answer is no. We can provide effective treatments even while we tolerate diagnostic uncertainty.
3) A patient exhibits problematic behaviors in relation to providers and staff. Members of the team ask “Does this patient have borderline personality disorder?” As a BHP you think, perhaps the patient does have BPD. Perhaps not. But clearly her behavior is problematic. How would referring her for diagnostic clarification be helpful? If you are fortunate enough to live in a community that has access to a DBT program perhaps you would need the “official” diagnosis before the program would accept her. But this is only relevant in circumstances where the patient is willing to engage with DBT services. In this case the patient’s willingness to engage is more relevant than her “true” diagnosis. And as the BHP, if I thought she might have BPD and a DBT program was available, and the patient was wiling to go, I wouldn’t spend any of my time worrying about her “true" diagnosis. With her permission I’d put the diagnosis in her chart and connect her to the DBT program.
Now imagine you don’t live in a community with a DBT program that has availability. Or imagine the patient is unwilling to go anywhere other than primary care for treatment. What would be gained by clarifying her diagnosis? Why should we spend time on assessing a problem when the range of treatment options we have available is so greatly restricted? Either way our job is to help the team respond to her behavior in a therapeutic way. Maybe this would aided by giving her the diagnosis. Maybe not.
I could provide other examples related to cognitive decline and dementia. Or related to young children. Or related to specific substance use disorders, such as stimulants.
As a psychologist I spent nearly half of my time in graduate school learning to measure and describe and accurately label symptoms. However, nobody ever stopped and asked - What is the value of accurately labeling or measuring or describing a problem in the absence of available, effective treatment? Years of practice in primary care have taught me that it is critical to ask this question.
Specialists are generally willing and eager to measure and describe problems they can’t fix. Primary care behavioral health providers should work hard not fall into this trap. Before dedicating time and energy to assessment, we must ask, what is the probability that a more thorough assessment will lead to a meaningful improvement in this patients outcome?
That probably wasn’t really your question. No matter what your team does, in-house assessment or referral for assessment, I hope that they think about the functional value of the assessment in relation to expected patient outcomes.
This is a really great question Laura!
Dan’s response below is very rich and so reflective of our work in primary care.
I wanted to add a few thoughts.
PCBH is a true evolution of BH care (developmental concerns, mental health concerns, substance use concerns, and concerns related to health behavior).
Diagnostics are a common service in primary care.
Diagnostics are often not time intensive.
Diagnostics are an unfolding process.
Diagnostics happen after an investigation into life context (contextual interview).
Primary care clinicians (PCCs) and the people we provide care to both benefit from us clarifying diagnosis within our scope of practice.
The health record and PCCs are treasure troves of longitudinal information that we can use for diagnostics.
Patient Reported Outcome Monitoring Information System (PROMIS) implementation across clinic systems could provide primary care teams (including BHCs) even more biopsychosocial information visit-by-visit for a variety of clinical purposes including diagnostics.
I just wanted to “thumbs up” Daniel’s & Julie’s thoughts – at the risk of going off-topic and maybe ruffling some feathers, I would take this a step further and suggest that the many issues Daniel describes illustrate some fundamental problems with our current approach to psychological diagnosis in general…
This thread has been both useful and validating regarding the process that our team has been over the past year. Thanks to all those who shared, what a wise group of folks (and not just because I agree with you)!
Laura—to the nuts and bolts aspect of your question about not getting bogged down by lengthy assessment ( I assume you are, in part, referring to documentation):
Over the past year I have been developing a documentation template for our behavioral health team that provides a DSM 5 diagnosis where applicable. As many called out in this thread-we have actually found that the contextual interview lends itself quite readily to documenting what I would call a provisional diagnosis (I am in the camp of questioning the overall value of being too married to the DSM as the be-all of defining functional impairment but that is another conversation).
In the likely event that your current documentation template already reflects patient priority for intervention, onset and history of that problem and symptoms/functional impairment I think you will find it is not a stretch to put on your diagnostician hat and provide that provisional diagnosis. It is definitely an additional layer to documentation but I would argue that most of us are already quite aware when we are speaking with a patient who likely is experiencing a challenge that would meet criteria for something like GAD, MDD, PDD or PTSD for example.
I just completed training for my team (LCSWs, LPCs and PsyDs) on adding a diagnosis to our documentation where applicable and have developed a template for it. It is not perfect but it is functional and I would say once acclimated to thinking and documenting in this way it adds very little time to assessment if you are already in the habit of using screening tools such as the PHQ-9, EPDS, GAD-7. I find that these tools really help increase efficiency.
Happy to talk with you more if I can be of help!
This is great Katie!
I agree the standard use of psychosocial measures in addition to the standard biomedical ones (BP, weight, temp, etc) in primary care practice really helps BHC efficiency.
I threw in my last comment about PROMIS because I see a future where primary care uses a measure like this visit-by-visit. In that day, our work as BHCs in primary care teams would be more supported at the operation level and the whole operation of primary care would move closer to a biopsychosocial service for all.
PROMIS implementation or something similar to it would be a lift for primary care clinics...but I hope we all move in that type of direction in primary care practice.
As IBH in PC people we are the kind of people who together move big vision into large-scale reality...:)
I agree with Julie’s last comment. Further, it seems to me that this thread is predicated on patients who self-identify or exhibit obvious symptoms per Daniel’s three examples:
1. A patient experiencing a depressive episode seeks treatment for that condition.
2. An adult patient presents to primary care with a history of trauma. She currently complains of excessive worry, nightmares, and panic attacks.
3. A patient exhibits problematic behaviors in relation to providers and staff.
There is a case to be made for the silent majority that suffer without connecting the dots as either a topic for discussion with their PCC or a request for referral to BH. Studies have shown a majority of BH and MH cases are untreated no matter how severe. Every day patients’ physical symptoms are addressed without adequate consideration of a potential psychosocial source, such as somatization, for their lack of wellbeing.
Consider Julie’s suggestion for the delivery of a periodic, universal, and broad-based BH screening assessment to primary care patients. The patients who are pre-screened as likely for BH or MH conditions can be treated for their symptoms, when verified. The BH team can use the constellation of symptoms identified by screening to provide more timely and efficacious treatment and avoid the problems Daniel has identified. Diagnostic indications for coding are documented, step-by-step.
PROMIS is a system of outcome measures that are well suited for determining the improvement of patients during treatment, but it might not be the best instrument for broad-based BH screening assessment.
Thank you Dave for adding this comment to this excellent conversation. In my experience, we need both BHC input on assisting PCPs with diagnoses in patients that have reported emotional issues. And we need to continue to increase screening of all patients for potential behavioral and mental issues.
Thanks everyone for providing meaningful information,