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Primary Behavioral Care Model Institutes a New Career Track for Therapists
Few people need to be convinced of the need for behavioral care today. Demand exceeds available resources, even while practical barriers suppress access and needs go unrecognized for many. While the status quo is failing, new digital and virtual products are only partial solutions. Primary care seems destined to become a critical locus for behavioral services, but we are still searching for the right model.
We need a primary care model that extends well beyond consultation and embraces a clinical focus more comprehensive than medication. The dominant model today for integrating into primary care, the collaborative care model (CCM), is largely a medication consultation model that cannot resolve the wellspring of unmet behavioral needs encountered in primary care.
A recent Health Affairs study found primary care physicians (PCPs) are increasingly addressing “mental health concerns.” While nearly 11% of primary care visits addressed such a concern in 2006-07, this rose to almost 16% by 2018. This is still likely the tip of the behavioral iceberg. PCPs may want more support from behavioral clinicians, but it is up to experts in our field to define, staff, and operationalize a viable model.
The challenge requires our clinicians and executives to jointly institute a new model that serves as an alternative to CCM and traditional psychotherapy. We need protocols that are flexible and easily enhanced, allowing us to gradually build the workforce inside primary care with existing human and financial resources. “Primary behavioral care” (PBC) is a simple term for working on healthcare’s frontlines.
Primary Behavioral Care, Defined
PBC must first be defined in contrast to CCM. Therapists would work in primary care as team members caring for patients, not as consultants to PCPs, providing psychosocial services. Most problems do not require medication (e.g., difficult life adjustment, mild-moderate behavioral disorders, unhealthy behaviors) and complex medication management is adequately covered by CCM.
Psychotherapy may be the premier psychosocial service, but it cannot address the scale of behavioral needs. PBC therapists have visits like PCPs, lasting up to 20 minutes. Many people respond well to brief interventions, and many others can benefit from primary care’s recurring visits over many years. Some may need traditional therapy and will be offered an external referral.
PBC relies on the therapist’s judgment. This applies to both brief therapeutic interventions and decisions to refer for external services. Therapists make assessments, but they are more clinical judgments than formal diagnostics. Therapists may refer for external work, but every primary care encounter is primarily intended as a therapeutic experience for the patient.
Primary Behavioral Care, Staffed
Staffing starts by realizing few clinicians have any direct training for their role in this model. The prerequisite is being a good therapist with some personal resilience. The job is to think and act like a therapist during brief encounters. Behavioral healthcare executives must drive the process of creating, staffing, and funding this new career track. It will take time to find therapists well suited for this work.
Traditional therapy roles will continue to exist but will be supplemented by a primary care career track. Behavioral care is primary care, and yet it will always be an independent specialty as well. Therapists need not make a long-term commitment. Executives should collaborate with local primary care practices to offer therapist volunteers for 6-month commitments at one full day per week of clinical service.
Executives will create a rotation of therapists in and out of the setting to determine those fitting best. Executives will research the best funding source in each instance because some clinical time may be billed under fee-for-service codes, while other medical practices have global (e.g., value-based, ACO, capitated) funding arrangements that might cover services.
Primary Behavioral Care, Instituted
None of this will evolve naturally. PCPs have their own internal struggles and need our field to do the heavy lifting to facilitate integration. Sadly, most care access solutions have marginal support. For example, our workforce might be too small, but no infusion of funding is forthcoming to grow it. Technology thrives because investors reap profits, but tech products are largely ancillary or supplemental to professional solutions.
Healthcare payers can shape institutional practices. They do this by deciding what services to reimburse routinely and what initiatives to fund periodically for a return on investment. They seek best practices for solving quality and cost concerns. Our field must show that primary behavioral care is a viable idea before payers will commit substantial funding to its expansion.
Our field must own its dismally poor care access rates (regardless of its sources), and this means putting forward big solutions. Primary behavioral care not only has big potential, but it is realistic. It presents an alternative career path for clinicians today who might thrive on the rapid pace and diverse challenges of frontline care. Let us build a new institution that will support our field well into the future.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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