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“the vast majority of behavioral health providers and care facilitators that will be hired will not have the requisite skills to work efficiently and effectively in the PCMH” (Hunter and Goodie, 2012)
The MHS was an early adopter of the PCMH model with the Air Force Behavioral Health Optimization Project (BHOP) in 2000. The BHOP provided integrated behavioral care by placing psychologists in primary care clinics. The initial results were very positive with high patient and provider satisfaction with the model (Runyan et al, 2001) The Navy Behavioral Health Integration Program (BHIP) was a two-year demonstration project completed in 2005. Lessons learned from the Navy BHIP were that full integration requires sufficient time and resources, that patients who might not otherwise receive care were successfully engaged in treatment and that both BHC’s and PCP’s viewed the program favorably (Harris and LeFavour, 2005). The Army launched the Re-Engineering Systems of Primary Care for PTSD and Depression in the Military (RESPECT-Mil) in 2004. RESPECT-Mil was based on a three component model of treating Depression and PTSD that included; universal screening for depression and PTSD, validated assessments to assist in diagnosis of positive screens, and a nurse to assist the PCP with care management follow-up for patients. Results indicated that the program identified and treated patients who might not otherwise receive services, and that the majority of patients treated demonstrated clinically significant improvement (Engel et al, 2008).
As a result of these demonstration projects a DoD Task force on Mental Health recommended the integration of mental health professionals into primary care in order to improve quality, outcomes and cost of care (DoD Task Force on Mental Health, 2007). In response to this report a Mental Health Integrated Working Group (MHIWG) was formed in 2008. The group was led by Christopher Hunter, Ph.D., co-author of the highly regarded textbook on integrated behavioral health Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention (Hunter and Goodie, 2009). The MHIWG made key recommendations for integrating behavioral health providers into primary care: guidelines for ratio of BHC’s to patients, the role of the BHC within the primary care clinic, BHC’s and care facilitators to provide population health screening and follow-up, standards for integrated care collaboration, service-level oversight for programs (for details see Hunter and Goodie, 2012). On the basis of this report and continued advocacy by Dr. Hunter and others funding was approved for ongoing support of nearly 500 BHC’s in the PCMH model in 2012 (Hunter and Goodie, 2012). In addition, the MHS is reviewing outcome and process measures aligned with the Quadruple Aim that include readiness, population health, patient experience and quality of care, cost of care and provider learning (see Hunter and Goodie, 2012, for detailed list).
The Veterans Health Administration (VA) is rapidly adopting the PCMH model of care, known in the VA as the Patient Aligned Care Team (PACT) (Kearney et al, 2014). In the PACT model an inter-professional team of providers focus on integrated care for medical and behavioral conditions. The PACT model includes population health, stepped-care approaches to treatment for behavioral conditions that may be managed within the primary care clinic, while referring more complex cases to traditional specialty behavioral health providers. In addition to treating common behavioral conditions such as depression, anxiety and substance use disorders, the PACT also provides health behavior change for lifestyle problems such as obesity, nutrition and physical activity that underlie poor outcomes for chronic disease management.
The VA hires a health behavior coordinator (HBC) at each VA health care system under the Health Promotion and Disease Prevention Program. The HBC consults with PACT providers to develop and implement integrated behavioral health interventions for the prevention and management of chronic conditions. Examples include shared group medical visits, motivational interviewing, and education and behavior change for conditions such as hypertension, diabetes and nicotine dependence (Kearney et al, 2014).
Department of Defense Instruction: Integration of Behavioral Health Personnel (BHP) Services Into Patient-Centered Medical Home (PCMH) Primary Care and Other Primary Care Service Settings
Department of Defense Deployment Health Clinical Center 2102 and 2013 Report
Air Force Primary Care Behavioral Health Care Services Practice Manual 2011
Department of Veterans Affairs PACT Handbook
Department of Defense Task Force on Mental Health. An achievable vision: Report of the Department of Defense Task Force on Mental Health. Falls Church: Defense Health Board; 2007.
Engel CC et al. RESPECT-Mil: Feasibility of a Systems-Level Collaborative Care Approach to Depression and Post-Traumatic Stress Disorder in Military Primary Care. Military Medicine. 2008;173:935-940.
Harris DM, LeFavour J. Final evaluation of Navy’s medicine’s behavioral health integration project (BHIP) two-year demonstration program. The CNA Corporation; 2005.
Kearney LK et al. The role of mental and behavioral health in the application of the patient-centered medical home in the Department of Veterans Affairs. TBM. 2011;1:624-628.
Hunter CL, Goodie JL et al. Integrated behavioral health in primary care: step-by-step guidance for assessment and intervention. Washington: American Psychological Association; 2009.
Hunter CL, Goodie JL. Behavioral health in the Department of Defense patient-centered medical home: history, finance, policy, work force development, and evaluation. TBM 2012;2:355-363.
Runyon CN et al. A Novel Approach for Mental Health Disease Management: The Air Force Medical Service’s Interdisciplinary Model. Disease Management. 2003;6:179-188.