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Are We Essential Providers of Primary Care or Consulting Specialists?
Enthusiasm is growing for team-based healthcare. It improves care coordination for people with multiple conditions. Many teams in primary care embrace whole-person care and include specialists like behavioral healthcare clinicians. Yet some of these behavioral clinicians serve as consultants, while others work as essential care providers. It is worth considering the differences between these two roles.
Primary care has tried a variety of team structures. In two common models, behavioral clinicians act as specialty consultants. They may consult on psychotropic medications (collaborative care) or address behavioral disorders and unhealthy behaviors (primary care behavioral health, or PCBH). Yet a new approach, universal behavior model, or UBM, views our clinicians as essential primary care providers.
What is UBM?
UBM is like other models that integrate behavioral clinicians into the primary care setting, but it starts from the premise that consulting models fall short. PCPs need us to address the behavioral dimension of health and illness. Behavioral needs are vast, and consulting models are inadequate based on their staffing levels and advisory nature. To be clear, our field designed this consulting approach, not PCPs.
Primary care creates a time problem. Placing our clinicians in this setting increases behavioral healthcare access, but full therapy sessions are impractical. Therapy is remarkably efficacious, largely due to therapist skill. UBM relies on effective therapists, not the techniques employed by them. As therapists deliver clinical value in less time, UBM comes alive as a vital new type of primary care.
Given the wide scope of needs, from behavioral disorders to unhealthy behaviors and dysfunctional ways of coping, UBM estimates needing 1 behavioral clinician per PCP. Clinicians use their therapy skills and a biopsychosocial perspective, while not formally providing psychotherapy. They listen well, plant seeds for change, and refer as needed for digital therapeutic services and external psychotherapy.
The final, critical way to differentiate UBM from consulting roles like PCBH is its impact on our field. While PCBH offers a niche role for a small subset of our clinicians, UBM contemplates shifting most of our outpatient therapists from isolated, specialty settings into primary care. This is where most patients already seek care. It is a move that will immediately address the dismal access rates in our field.
Reconfiguring Health Benefits
It is time to move fragmented behavioral benefits to primary care using UBM as the platform. We know that employee assistance/EAP services help people with pre- and non-clinical problems, disease management (DM) addresses behavioral drivers of chronic illnesses, and wellness programs focus on health improvement. These valuable services would be far more accessible in a primary care setting.
It has been easier for payers to manage separate benefits and infrastructures than to consolidate them. Yet access to these discrete benefits has been totally inadequate. Employers have browbeaten and incentivized their vendors for EAP, DM, and wellness to boost access rates. Disappointment will remain until bold remedies are tried. UBM’s unique integration of behavioral and primary care is one such idea.
What stands in the way of consolidating benefits into primary care under UBM? It is mainly entrenched interests and resistance to change. Many employers privately bemoan their continued funding of these independent benefits. If they decide to consolidate benefit plans and move service delivery into primary care, they will find fully staffed behavioral teams ready to increase utilization under UBM.
Yet staffing is another challenge to be faced honestly. We need behavioral clinicians eager to do this work, but many doing similar work today find it stressful. We must understand why and address it. Clinicians see more patients each day in primary care, but another key driver of their stress is tied to job responsibilities. A key question here is whether clinicians are consultants or care providers.
Consulting to a Team vs. Caring for a Patient
Consulting models are geared to limit accountability for clinicians, but they ironically can intensify stress. The scope of work can expand and overwhelm—the hope to set limits and reduce pressure by removing direct care responsibility evaporates. Job listings reveal this. Some roles have grown to include almost every behavioral issue. This range of responsibilities, whether consultative or not, is stressful.
UBM asks one thing of behavioral clinicians—be a force for positive behavior change. The goal is to help patients, not the care team. There may be stress in leaving some issues unresolved during brief visits, but this is part of long-term, intermittent work. A clinician’s focus is self-determined, not set by a team. While consultants are asked to satisfy a team’s needs, UBM clinicians primarily address patient needs.
Consultants may lack a sense of ownership for settings where they consult. UBM clinicians know that primary care is their home. In fact, UBM helps fulfill the health home concept—if health homes are to be comprehensive and effective, behavioral clinicians are needed as essential care providers. Along the way, UBM also helps fulfill our field’s mission to make care accessible for those who need it.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health. Norm Ryan, MD is a primary care physician who has held senior medical executive roles with Alere Health, UnitedHealthcare, and Humana.
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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