Department of Defense Integrated Behavioral Health in the Patient-Centered Medical Home

Abstract

The Department of Defense (DoD) is integrating 470 full-time behavioral health personnel in every military treatment facility patient-centered medical home with 1,500 or more enrollees. This chapter provides an overview of the DoD military health system’s integrated behavioral health efforts. Areas including staffing and service delivery model, population served, finance, policy, and program evaluation are discussed. DoD efforts have broad applicability to other systems and can serve as a guide to developing and implementing integrated behavioral health care services in primary care.

Disclaimer: The views expressed herein are those of the author and do not necessarily represent the official policy or position of the Department of Defense (DoD), the Military Health System, TRICARE Management Activity, the United States Department of Health and Human Services, or the United States Government.

Appendix A: Training Core Competency Tool

Dimension	Element	Attribute	Skill rating (1 = low; 5 = high)
			1	2	3	4	5	Comments
I. Clinical Practice Knowledge and Skills	1. Role definition	Says introductory script smoothly, conveys the BHC role to all new patients, and answers patient’s questions
	2. Problem identification	Identifies and defines the presenting problem with the patient within the first half of the initial 30-min appointment
	3. Assessment	Focuses on current problem, functional impact, and environmental factors contributing to/maintaining the problem; uses tools appropriate for primary care
	4. Problem focus	Explores whether additional problems exist, without excessive probing
	5. Population-based care	Provides care along a continuum from primary prevention to tertiary care; develops pathways to routinely involve BHC in care of chronic conditions; understands the difference between population-based and case-focused approach
	6. Biopsychosocial approach	Understands relationship of medical and psychological aspects of health
	7. Use of empirically supported interventions	Utilizes evidence-based recommendations/interventions suitable for primary care for patients and PCPs
	8. Intervention design	8.a. Bases interventions on measurable, functional outcomes and symptom reduction
		8.b. Uses self-management, home-based practice
		8.c. Uses simple, concrete, practical strategies based on empirically supported treatments for primary care
	9. Multi-patient intervention skills	Works with PCMs to provide classes and/or groups in format appropriate for primary care (e.g., drop-in stress management class, group medical visit for a chronic condition)
	10. Pharmacotherapy	Can name basic psychotropic medications; can discuss common side effects and common myths; abides by recommendation limits for nonprescribers
II. Practice Management Skills	1. Visit efficiency	30-min visits demonstrate adequate introduction, rapid problem identification and assessment, and development of intervention recommendations and a plan
	2. Time management	Stays on time when conducting consecutive appointments
	3. Follow-up planning	Plans follow-up for 2 weeks or 1 month, instead of every week (as appropriate); alternates follow-ups with PCMs for high-utilizer patients
	4. Intervention efficiency	Completes treatment episode in four or fewer sessions for 85 % or more of patients; structures behavioral change plans consistent with time-limited treatment
	5. Visit flexibility	Appropriately uses flexible strategies for visits: 15 min, 30 min, phone contacts, secure messaging
	6. Triage	Attempts to manage most problems in primary care, but does triage to mental health, chemical dependency, or other clinics or services when necessary
	7. Case management	Utilizes patient registries (if they exist); takes load off PCM (e.g., returns patient calls about behavioral issues); advocates for patients
	8. Community resource referrals	Is knowledgeable about and makes use of community resources (e.g., refers to community self-help groups, Airmen and Family Readiness Center resources)
III. Consultation Skills	1. Referral clarity	Is clear on the referral questions; focuses on and responds directly to referral questions in PCM feedback
	2. Curbside Consultations	Successfully consults with PCMs on-demand about a general issue or specific patient; uses clear, direct language in a concise manner
	3. Assertive follow-up	Ensures PCMs receive verbal and/or written feedback on patients referred; interrupts PCM, if indicated, for urgent patient needs
	4. PCM education	Delivers brief presentations in primary-care staff meetings (PCM audience; focus on what you can do for them, what they can refer, what to expect, how to use BHC optimally, etc.)
	5. Recommendation usefulness	Recommendations are tailored to the pace of primary care (e.g., interventions suggested for PCMs can be done in 1–3 min)
	6. Value-added orientation	Recommendations are intended to reduce physician visits and workload (e.g., follow-up with BHC instead of PCM)
	7. Clinical pathways	Participates in team efforts to develop, implement, evaluate, and revise pathway programs needed in the clinic
IV. Documentation Skills	1. Concise, clear charting	Clear, concise notes detail:
		• Referral problem specifics
		• Functional analysis
		• Pertinent history
		• Impression
		• Specific recommendations and follow-up plan
	2. Prompt PCM feedback	Written and/or verbal feedback provided to PCM on the day the patient was seen
	3. Appropriate format	Chart notes use SOAP format
V. Administrative Knowledge and Skills	1. BHOP policies and procedures	Understands scheduling, templates, MEPRS codes for PC work, criticality of accurate ADS coding
	2. Risk-management protocols	Understands limits of existing BHOP practices; can describe and discuss how and why informed consent procedures differ, etc.
	3. KG ADS (coding) documentation	Routinely and accurately completes coding documentation
VI. Team Performance Skills	1. Fit with primary care culture	Understands and operates comfortably in fast-paced, action-oriented, team-based culture
	2. Knows team members	Knows the roles of the various primary care team members; both assists and utilizes them
	3. Responsiveness	Readily provides unscheduled services when needed (e.g., sees patient during lunch time or at the end of the day, if needed)
	4. Availability	Provides on-demand consultations by beeper or cell phone when not in the clinic; keeps staff aware of whereabouts

1. Use a rating scale of 1 = low skills to 5 =high skills to assess current level of skill development for all attributes within each dimension. Check in the column corresponding to the rating that best describes the trainee’s current skill level. Competency Tool: Behavioral Health Consultant (BHC) mentor rates the BHC trainee based on their observations for each dimension (verbal feedback is also strongly recommended). A rating of 3 or higher is considered satisfactory for training