Session #A4
October 6, 2012, 10:30 AM
The Behavioral Health Consultant:
Defining the value, working conditions, training
requirements and professional boundaries of the BHC
Neftali Serrano, PsyD
Director, Behavioral Health Services, Access Community Health Centers
Jeff Reiter, PhD, ABPP
Co-Director, Behavioral Health Services
HealthPoint Community Health Centers
M. Hunter Hansen, PsyD
Medical Psychologist,
Southeast Community Health Systems
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012
Austin, Texas U.S.A.
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Faculty Disclosure
• I/We currently have or have had the following relevant
financial relationships (in any amount) during the past 12
months:
• Consultants, primarycareshrink.com
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Objectives
1.Identify the key issues which remain undefined in
developing the role of the Behavioral Health
Consultant as a member of the primary care medical
home team
2.Identify the workforce development needs which are
needed to sustain a suitably trained workforce and a
role which is attractive for mental health
professionals
3.Understand the historical development of the
Behavioral Health Consultant role in comparison to
other healthcare specialties
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Learning Assessment
• A learning assessment is required for CE credit.
• Attention Presenters:
• Please incorporate audience interaction through a
brief Question & Answer period during or at the
conclusion of your presentation.
• This component MUST be done in lieu of a written
pre- or post-test based on your learning objectives to
satisfy accreditation requirements.
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Presuppositions
• Behavioral health consultants (BHC) utilize a consultation
model in primary care (Robinson & Reiter, 2006)
• BHC work requires different qualifications, work setting
requirements, training and professional identity
• There is no prevailing standard for any of these issues
currently
• Billing is an important issue but is not the focus of this
presentation
• We (presenters) are or have been BHCs in FQHC settings
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BHC Model at a Glance
• Consultant orientation
• Member of primary care team, seamless integration
• Goal is to improve PCP mgmt of behavioral issues
• Wide variety of interventions and goals
• High-volume, low-intensity care provided longitudinally
• Immediate feedback to PCP, goal is to affect PCP behavior
• Any behaviorally-based problem, any age
• On-demand availability, fluid schedule
• Rooted in population health principles
• Small changes in large numbers
• Aim to affect PCP behavior and the care milieu
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Brief History of a New Identity
• We are not alone: Parallels to the emergence of Emergency Medicine
in the 1970s
–- How to credential generalist providers
–- How to create sustainable work conditions
–- Parallels in the modes of employment of EMPs to BHCs
• Our own history: pioneers born of need in practice settings1
–- Lack of strong connections with academic centers
–- Cross-disciplinary group (LCSWs, LPCs, Psychologists)
–- The PCBH model emerged concurrent with a variety of “integration”
– models
–- Only now developing stronger ties with academic centers
•
•
So, now what?
1Behavioral Health Consultation and Primary Care: Lessons Learned, Patricia J. Robinson and Kirk D. Strosahl. JOURNAL OF CLINICAL
PSYCHOLOGY IN MEDICAL SETTINGS, Volume 16, Number 1 (2009), 58-71, DOI: 10.1007/s10880-009-9145-z
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The Current State Of BHC
• Ad hoc certification provided by
educational institutions
• Workforce development groups
and independent consultants
providing supervision, consultation
to new BHCs and their clinics
• These do not meet the needs of
workforce development and do not
have the consistency of a specialty
discipline
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Quality Control: Key Concerns
•
Can we compare a BHC in one clinic to that in another? Could we drop a
BHC from Oregon into a clinic in Wisconsin and have them be able to do
the same job?
•
At present there is a great degree of variation between integrated care
models and with implementation of the BHC model based on how
programs are developing, how BHCs are selected, how they are trained
and how they are paid.
•
To what degree do we want to standardize training and expectations
since "all healthcare is local"?
•
Can we claim consensus with the development of certificate programs,
internships and post-doctoral training sites, and a growing body of
literature/ books? If not now, when?
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Should BHC Work be a "Specialty"?
•
•
"Specialties" are defined differently by different organizations:
o APA's Committee for Recognition of Specialties and
Proficiencies in Professional Psychology (CRSPPP)
o Council of Specialties (CoS)
o American Board of Professional Psychology (ABPP)
CRSPP definition of a "specialty":
o a defined area of professional psychology practice
characterized by a distinctive configuration of competent
services for specified problems and populations. Practice in a
specialty requires advanced knowledge and skills acquired
through an organized sequence of education and training in
addition to the broad and general education and core scientific
and professional foundations acquired through an APA or CPA
accredited doctoral program.* Specialty training may be
acquired either at the doctoral or postdoctoral level as defined
by the specialty.
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Or Perhaps BHC Work Should be a "Proficiency"
•
CRSPP definition of a "proficiency":
o a defined area of professional psychology practice
characterized by a distinctive configuration of competent
services for specified problems and populations. Practice in
a specialty requires advanced knowledge and skills acquired
through an organized sequence of education and training in
addition to the broad and general education and core
scientific and professional foundations acquired through an
APA or CPA accredited doctoral program.* Specialty training
may be acquired either at the doctoral or postdoctoral level
as defined by the specialty.
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What it Takes to Become a Specialty
•
•
•
Petition the CRSPP to show fulfillment of criteria
"Specialty" criteria of the CRSPPP:
o Administrative Organizations
o Public Need for the Specialty Practice
o Diversity
o Distinctiveness
o Advanced Scientific and Theoretical Preparation
o Advanced Preparation in the Parameters of Practice
o Structures and Models of Education and Training in the
Specialty
o Continuing Professional Development and Continuing
Education
o Effectiveness
o Quality Improvement
o Guidelines for Specialty Service Delivery
o Provider Identification and Evaluation
Similar criteria for a "proficiency"
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Examples of Specialties and
Proficiencies
• Specialties
– Clinical Health Psychology
– School Psychology
– Counseling Psychology
– Industrial-Organizational Psychology
– Behavioral and Cognitive Psychology
– Forensic Psychology
– Clinical Neuropsychology
Ideal Components of Curricula
o
Key components for graduate-level curricula:

Current (general) curricula, plus:

Population health

Basics of the U.S. healthcare system

Primary Care Service and Culture

Care Management Models

Brief Screening, Intervention: MI, CBT, Brief Psychodynamic,
Brief Couples, Behavioral Modification)

Record Keeping, Billing

Practical psychopharmacology

Treatment algorithms

Functional/ strategic patient care

Program development skills

Health-related and specialty population concerns

Ethical Issues
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Examples of Specialties and
Proficiencies
• Proficiencies
– Police Psychology
– Biofeedback
– Psychopharmacology
– Sport Psychology
– Treatment of Alcohol and Psychoactive
Substances
– Personality Assessment
Why Obtain Specialty
Designation?
• Promotes standardization of practices
• Improved quality control
• More opportunities for collective and
comparative research
• Clear training goals for graduate schools,
training sites and CE offerings
• Better differentiation from specialty care
for consumers and healthcare partners
Obstacles to Specialty
Designation
• No agreement on what constitutes “primary
care psychology” (vs “specialty”)
• Lack of current “Guidelines” (as required by
CRSPP) for BHC work
• Paucity of faculty prepared to teach BHC
work
• Few training sites conducting BHC work
– Many are not university-affiliated
– Need for APA accreditation is an obstacle
How To Pay BHCs
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What Does A BHC Add To The Primary Care Service?
•Patient encounters is just one of several value-added services that BHCs provide and
as such is an imprecise way of measuring value
•curbside consultation and cross-pollination of skills impact a broader swath of the population
•telephone consultation and task-sharing (e.g. suicidal patients, efficiency of managing patient issues inbetween visits, assumption of common PCP tasks)
•program development/ leadership in the areas of mental and behavioral health
•BHC should be considered an embedded aspect of primary care, not a separate
service akin to medical assistants and nursing
•Efficiencies introduced by BHCs is still an open question
•unlikely that across the board PCP efficiency increases are one of the impacts
•systemic utilization of healthcare resources such as emergency department utilization is still an open
question
•access to care efficiency is the most obvious efficiency but it is not a direct financial efficiency
•staffing efficiency vs. specialty mental health, but again not often an incentive for HMOs unless they are
both provider and insurer
•Most likely measurable impact is on quality and provider (team) satisfaction (do-ability
of primary care)
•Quality: improved outcomes, improved adherence to evidence-based pathways
•Satisfaction: provider retention, provider willingness to treat mental health issues
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How To Pay BHCs
•
We believe it makes the most sense to pay BHCs a salary based on two
levels of demonstrated competency and/or job description: "ProviderOnly BHC" and "Provider-Leader BHC"
•
Provider-Only BHC
•
BHC who adds the clinical value discussed above but either lacks
experience with or is not charged with program development or
evaluation and who may need to develop psychopharmacology skills.
•
Provider-Leader BHC
•
BHC who adds both clinical value and has experience with and is
charged with program development/ evaluation responsibilities and can
demonstrate leadership in the area of psychopharmacology.
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Payscale Exemplar
• Access Community Health Centers:
–Director
–Team Leads
–Psychologist Staff
–Social Work Staff
• Regional Variations In Payscale:
–Midwest, northeast, south
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Designing A Sustainable
Specialty
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Mirroring But Not Duplicating Primary Care
• • Primary care is a difficult place to work for many PCPs and
has had some difficulty with attracting and retaining its most
valued workers. We don't want to replicate this.
• - Many PCPs choose to work part-time as a result of the
•strain or are provided with protected time.
– - Burnout is a key threat to the development of the
•primary care workforce.
• • On the other hand in an integrated environment we want to
'fit in' and live the primary care life as members of the team.
There are many patients needing our services.
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Productivity Expectations
• We need to mirror the primary care pace always and achieve the ultimate goal of
full accessibility
• Redefine productivity as encompassing all of the activities of a successful BHC
including telephone-based interventions, curbside consultations, participation in
care teams, population monitoring, clinic leadership for specific areas and visits.
• Still patient visits will be the heart of the BHCs work. In most clinics this means
that a mature BHC in a mature program should be able to consistently see 8-12
patients per day with variation determined by factors such as overall clinic
efficiency and other program/clinic related factors.
• To be sustainable this degree of productivity can usually be maintained in a 4-day
work week. We believe it is not sustainable to work 5 day works weeks over years
with this kind of pace. Correlates exist in similar high volume professions such as
emergency medicine.
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Making Use of Administrative Time
• Encouraging leadership is key in creating a stimulating and balanced
work role for BHCs
- pediatrics
- quality
- special populations
- care management
- consulting psychiatry
- liason to specialty care services
• Routine activities such as catching up on note writing and other
paperwork is also a piece of administrative time, but should not
dominate it
• Flex time: High pace, high stress jobs are best tolerated when flex
time is allowed, such as doing administrative work from home
(leverage technology)
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Our Recommendations
•
BHC work meets criteria for a distinct specialty and would benefit from
recognition as such to build a coherent, sustainable workforce
•
Uniform curricula specific to BHC work should be integrated into training
programs along with requisite training experiences in primary care settings to
qualify a person for designation as a Behavioral Health Consultant
•
Our hope is that specialization does not result in more barriers to the
development of a BHC workforce that is needed in mass to meet the needs
of the U.S. population but rather stimulates growth
•
Salary-based payment is the most logical method of paying BHCs due to the
broad nature of the role but is region-specific and specific to the value
provided to the BHC to the organization
•
We recommend ideal standards for working conditions that foster long-term
viability including 4 day work weeks or other methods of job diversification
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Session Evaluation
• Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
• Thank you!
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