Primary Care Behavioral Health Provider Training: Systematic Development and Implementation in a Large Medical System.

The expansion of integrated, collaborative, behavioral health services in primary care requires a trained behavioral health workforce with specific competencies to deliver effective, evidence-informed, team-based care. Most behavioral health providers do not have training or experience working as primary care behavioral health consultants (BHCs), and require structured training to function effectively in this role. This article discusses one such training program developed to meet the needs of a large healthcare system initiating widespread implementation of the primary care behavioral health model of service delivery. It details the Department of Defense's experience in developing its extensive BHC training program, including challenges of addressing personnel selection and hiring issues, selecting a model for training, developing and implementing a phased training curriculum, and improving the training over time to address identified gaps. Future directions for training improvements and lessons learned in a large healthcare system are discussed.

Therapeutic alliance and change in suicidal ideation during treatment in integrated primary care settings.

A strong therapeutic alliance is considered to be an essential factor for the effective assessment and management of suicidal patients; however, to date this has received little empirical attention. The current study evaluated the association of future change in suicidal ideation with therapeutic alliance during first appointments with primary care behavioral health consultants. The Behavioral Health Measure (BHM; Kopta & Lowery, 2002 ) and Therapeutic Bond Scale (TBS; CelestHealth Solutions, 2006) were completed by 497 primary care patients who kept 2 to 8 appointments with the integrated behavioral health consultant. Results indicated that suicidal ideation generally improved over the course of several behavioral health appointments and that therapeutic alliance was rated very high by patients. Therapeutic alliance during the first appointment was not associated with eventual change in suicidal ideation.

Therapeutic alliance and treatment outcome in the primary care behavioral health model.

The current study investigated therapeutic alliance and clinical improvement within an integrated primary care behavioral health model. Participants included 542 primary care patients seen in two large family medicine clinics. Mental health symptoms and functioning were assessed using the 20-item Behavioral Health Measure (Kopta & Lowery, 2002) at the beginning of each patient appointment. Therapeutic alliance was measured with the Therapeutic Bond Scale (CelestHealth Solutions, 2008) following an initial appointment with one of 22 behavioral health consultants (BHCs). Primary care patients rated their therapeutic alliance following a first appointment with a BHC as statistically stronger than alliance ratings from a previously reported sample of outpatient psychotherapy patients after the second, third, and fourth psychotherapy sessions (Kopta, Saunders, Lutz, Kadison, & Hirsch, 2009). Results of a bootstrapped linear regression analysis indicated that therapeutic alliance assessed after the first primary care behavioral health appointment was not associated with eventual clinical change in mental health symptoms and functioning. A strong therapeutic alliance was able to be formed in a primary care behavioral health modality. This exceeded the magnitude found in outpatient psychotherapy alliance ratings. Early therapeutic alliance was unrelated to overall clinical improvement in primary care.

Severity of mental health impairment and trajectories of improvement in an integrated primary care clinic.

OBJECTIVE: To model typical trajectories for improvement among patients treated in an integrated primary care behavioral health service, multilevel models were used to explore the relationship between baseline mental health impairment level and eventual mental health functioning across follow-up appointments. METHOD: Data from 495 primary care patients (61.1% female, 60.7% Caucasian, 37.141 ± 12.21 years of age) who completed the Behavioral Health Measure (Kopta & Lowry, 2002) at each primary care appointment were used for the analysis. Three separate models were constructed to identify clinical improvement in terms of number of appointments attended, baseline impairment severity level, and the interaction of these 2 variables. RESULTS: The data showed that 71.5% of patients improved across appointments, 56.8% of which (40.5% of the entire sample) was clinically meaningful and reliable. Number of appointments and baseline severity of impairment significantly accounted for variability in clinical outcome, with trajectories of change varying across appointments as a function of baseline severity. Patients with more severe impairment at baseline improved faster than patients with less severe baseline impairment. CONCLUSIONS: Patients treated within an integrated primary care behavioral health service demonstrate significant improvements in clinical status, even those with the most severe levels of distress at baseline.

Longitudinal outcomes after brief behavioral health intervention in an integrated primary care clinic.

The primary aim of the current study was to obtain information about the longitudinal clinical functioning of primary care patients who had received care from behavioral health consultants (BHCs) integrated into a large family medicine clinic. Global mental health functioning was measured with the 20-item self-report Behavioral Health Measure (BHM), which was completed by patients at all appointments with the BHC. The BHM was then mailed to 664 patients 1.5 to 3 years after receipt of intervention from BHCs in primary care, of which 70 (10.5%) were completed and returned (62.9% female; mean age 43.1 ± 12.7 years; 48.6% Caucasian, 12.9% African American, 21.4% Hispanic/Latino, 2.9% Asian/Pacific Islander, 10.0% Other, 4.3% no response). Mixed effects modeling revealed that patients improved from their first to last BHC appointment, with gains being maintained an average of 2 years after intervention. Patterns of results remained significant even when accounting for the receipt of additional mental health treatment subsequent to BHC intervention. Findings suggest that clinical gains achieved by this subset of primary care patients that were associated with brief BHC intervention were maintained approximately 2 years after the final appointment.