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Integrate Clinical and Business Thinking for a New Level of Care
Editor’s note: This is the third in a 3-part series on the concept of Primary Behavioral Care. | Part I and Part II
If the primary care setting is to help resolve our crisis in care access, a fresh approach is needed. Early care integrators were psychiatrists and psychologists driven more by a desire to improve primary care treatment than expand care access. Psychiatrists initially focused on managing psychotropic medications, and psychologists addressed health behaviors (e.g., smoking, diet).
The psychiatric integration effort, the Collaborative Care Model (CCM), and the psychologist-driven one, Primary Care Behavioral Health (PCBH), have expanded their focus while remaining grounded in the medical model. Experts are split on whether therapy-based solutions should be framed as medical in nature—is psychotherapy best understood as a medical treatment, or is it a psychosocial solution?
How do these clinical issues concern executives? Today’s leading integration models promote primary care physician (PCP) consultations and preserve the status quo. Yet, to impact care access, we must transform primary care into a distinct level of behavioral care. We need many more therapists working there, reliant on a data-driven infrastructure, and their approach must be grounded in psychotherapy research.
Common Factors of Psychotherapy
Executives will need monumental changes to end the behavioral care access crisis. A new level of care is such a change. The key is having multiple therapists (roughly 1 therapist per PCP) using their abilities as change agents. Therapy research points to the therapist as driving clinical change more than therapy techniques. Unfortunately, today’s integration models overvalue techniques.
A medical orientation prioritizes a technical focus. The goal is to eliminate subjectivity from treatment. Consequently, many clinicians focused on techniques presume they personify being evidence-based. However, decades of research disagree. It is the “common factors” (e.g., therapeutic alliance, empathy) that research consistently finds driving outcomes across psychotherapy models.
Some medically oriented approaches take training in therapy techniques to an extreme. Advocates of PCBH want clinicians to get extensive post-licensure training in techniques. This misguided focus is based on misunderstanding key lessons from therapy research. Also, such rigid technical demands could reduce professional interest in this setting.
Therapists must adjust to working in a medical environment, but this does not mean an entirely different skill set is needed to help people change. Therapists who effectively help people in their offices can effectively help them in exam rooms. Yet, we should monitor all results to ensure quality.
Tech Infrastructure
Measurement-based care (MBC) is a powerful alternative to focusing on clinical techniques. A preference for diagnosis-specific treatments is the essence of the medical model, but psychotherapy research does not validate this belief for psychosocial services. MBC offers a better option. It addresses the client-specific question of whether this intervention is working for this client.
MBC is a way to trust the clinician while verifying a client’s response. We need executives to install this empirical support system to aid therapists. As clinicians learn to use feedback from MBC, they especially value its support in risk management. Digital therapeutics are also needed as part of the tech infrastructure—together, they help establish the primary care setting as a level of behavioral care.
Technology questions do not end there. The PCBH approach rightly supports a shared medical record and care plan, which may only be embraced in some practices. MBC must initially be an independent system for its unique data collection and analyses. However, the ultimate goal for all workflows and systems is integration, with clinicians sharing everything from check-in and scheduling to exam rooms.
It is to be expected that PCPs will routinely make warm hand-offs to therapists when behavioral issues emerge, but such PCP referrals epitomize a consulting approach to integration rather than a staffing one. The Primary Behavioral Care model relies on clinical flags in the MBC system and reporting from the electronic health record to identify clients needing behavioral work.
A New Behavioral Home
Are PCPs ready for the influx of therapists envisioned under the Primary Behavioral Care model? Many physicians (especially in Federally Qualified Health Centers) understand the need, but staffing levels would be much higher than for PCBH (one-fifth to half the staffing). Staffing aside, PCPs will see an emotional shift for therapists as they move from being primary care consultants to inhabiting a new level of care as their home.
This reflects broader changes in primary care. The setting has long been synonymous with the primary care physician, but this view needs updating. PCPs may still manage the setting, but there has been a steady growth of physician assistants and nurse practitioners in addition to psychotherapists. The setting is changing as professions and teams evolve. PCPs are not the sole clinical “owners” of the setting.
A Conceptual Integration
This series of articles describes a new approach to primary care integration. It asks executives to know the data—both from therapy research and MBC—and focus on both client and population-level goals. Yet the most critical combination resides at a higher level of abstraction—that between clinical and business viewpoints. This conceptual integration may be needed to solve many big problems in our field.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
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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