Behavioral health providers' perspectives of delivering behavioral health services in primary care: a qualitative analysis

Abstract

BackgroundCo-located, collaborative care (CCC) is one component of VA’s model of Integrated Primary Care that embeds behavioral health providers (BHPs) into primary care clinics to treat commonly occurring mental health concerns among Veterans. Key features of the CCC model include time-limited, brief treatments (up to 6 encounters of 30 minutes each) and emphasis on multi-dimensional functional assessment. Although CCC is a mandated model of care, the barriers and facilitators to implementing this approach as identified from the perspective of BHPs have not been previously identified.MethodsThis secondary data analysis used interview data captured as part of a quality improvement project in 2008. Fourteen BHPs (48% of providers in a regional VA network) agreed to participate in a 30-minute, semi-structured phone interview. The interview included questions about their perceived role as a CCC provider, depiction of usual practice styles and behaviors, and perceptions of typical barriers and facilitators to providing behavioral healthcare to Veterans in CCC. Interviews were transcribed verbatim into a text database and analyzed using grounded theory.ResultsSix main categories emerged from the analysis: (a) Working in the VA Context, (b) Managing Access to Care on the Front Line, (c) Assessing a Care Trajectory, (d) Developing a Local Integrated Model, (e) Working in Collaborative Teams, and (f) Being a Behavioral Health Generalist. These categories pointed to system, clinic, and provider level factors that impacted BHP’s role and ability to implement CCC. Across categories, participants identified ways in which they provided Veteran-centered care within variable environments.ConclusionsThis study provided a contextualized account of the experiences of BHP’s in CCC. Results suggest that these providers play a multifaceted role in delivering clinical services to Veterans while also acting as an interdependent component of the larger VA behavioral health and primary care systems. Based on the inherent challenges of enacting this role, BHPs in CCC may benefit from additional implementation support in their effort to promote health care integration and to increase access to patient-centered care in their local clinics.

Clinician Staffing, Scheduling, and Engagement Strategies Among Primary Care Practices Delivering Integrated Care

“…As in prior research, practices in our study worked to balance their ideal approach to integrated care delivery with the resources and infrastructure at hand. 10,19,21 ACT and IWS practices that aspired to staff and schedule BHCs to enable real-time delivery of integrated care via warm handoffs secured resources to expand BHC staffing, dealt with billing structures that reinforced scheduling patterns for delivering traditional mental health care during 50-minute appointments, and put in the effort required to change care delivery in their organization. In addition, local availability and capabilities of the BHC workforce, who may be trained in a referral model with 50-minute prescheduled therapy appointments, may constrain what is feasible to implement, at least initially.…”

“…20 Research on practices that aspired to have BHCs provide brief treatment for both mental health and behavioral health concerns at the point of care found that implementation depends on an interaction between described ideals, locally available resources, and decisions regarding resource deployment. 10,21 Despite these apparent challenges with accessing BHC services, little is known about the relationship between staffing, scheduling, and a primary care practice's approach to integrated care.…”

Using the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to identify practice patterns

“…In our prior qualitative work, we found that PC-MHI providers tended to develop local models of CCC that were dependent upon both their level of knowledge regarding population-based models of mental health care and local resource limitations, such as provider staffing levels and physical layout of the clinic [26]. Thus, both provider and contextual factors came together to determine the degree of provider fidelity.…”

“…The professional training obtained by social workers may serve as a good foundation to becoming highly adherent PC-MHI providers. Social workers may also have an advantage over other providers because of their emphasis on providing holistic care to patients and knowledge of how to navigate large health care systems to connect patients to a wide range of services [26]. The most adherent cluster was also associated with a higher level of clinic integration as measured by the Level of Integration Measure.…”

The Role of Psychotherapy in Integrated Care

“…Nevertheless, one detailed study based on a survey of mental healthcare professionals in the VA system working in primary care facilities gives an enlightening account. 4 The fourteen "behavioral health providers" (BHPs) who responded represented 48% of the BHPs in that particular regional VA network; they were asked about their perceived role as co-located, collaborative care providers. Significantly, none of the respondents was a psychiatrist.…”