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Innovations in primary care behavioral health: a pilot study across the U.S. Air Force

Innovations in primary care behavioral health: a pilot study across the U.S. Air Force Implications Integrated primary care services have grown in popularity Practice: Primary care behavioral health (PCBH) in recent years and demonstrated significant benefits to the 1 programs should consider utilizing technicians to patient experience, patient health, and health care opera- Department of Family Medicine, extend the reach of behavioral health consultant. tions. However, broader systems-level factors for health care Uniformed Services University, Bethesda, MD, USA organizations, such as utilization, access, and cost, have been Mike O’Callaghan Military Medical understudied. The current study reviews the results of quality Center, Las Vegas, NV, USA improvement project conducted by the U.S. Air Force, which Policy: Health care systems should consider a 35th Medical Group, Misawa Air has practiced integrated primary care behavioral health for over stepped care approach to mental health care Base, Misawa, Japan 20 years. This study focuses on exploring how shifting the using PCBH and specialty clinics. 81st Medical Group, Keesler Air access point for behavioral from specialty mental health clinics Force Base, Biloxi, MS, USA to primary care, along with the use of technicians in patient care, can improve a range of health outcomes. Retrospective Research: Larger scale, controlled studies should data analysis was conducted on an internal Air Force quality evaluate alternative delivery models and use of improvement project implemented at three military treatment provider extenders based on pilot findings. facilities from October 2014 to September 2015. Positive preliminary support for these innovations was seen in the form of expanded patient populations, decreased time to first appointment, increased patient encounters, and decreased (PCBH) model. Although the field is continuing purchased community care compared with non-participating Correspondence to: Ryan to refine and build consensus, PCBH is defined by sites. Incorporation of behavioral health technicians further R. Landoll, ryan.landoll@usuhs. several key components [10]. PCBH emphasizes increased number of patient encounters while maintaining high edu levels of patient satisfaction across diverse clinical settings; in a team-based approach to the health care using fact, patients preferred appointments with both technicians and Cite this as: TBM 2019;9:266–273 a biopsychosocial model of health. The PCBH doi: 10. 1093/tbm/iby046 behavioral health providers, compared with appointments with model incorporates a behavioral health consultant behavioral health providers only. These findings encourage fur - (BHC) into the primary care team to serve as a gen- Published by Oxford University Press ther systematic review of systems-level factors in primary care on behalf of the Society of Behavioral eralist and strives to intervene on the day they are behavioral health and adoption of the use of provider extenders Medicine 2018. This work is written by referred (via use of the “warm handoff”) [11]. The in primary care behavioral health clinics. (a) US Government employee(s) and is in the public domain in the US. goal is to incorporate biopsychosocial assessment and intervention into everyday care, accomplished Keywords via focused, time-limited visits (≤4 total, each lasting Primary care behavioral health, Integrated care, 15–40  min) and coordinated follow-up with other Access to care, Military health primary care team members [10, 12]. Although lim- ited research to date directly compares various mod- As the need for mental health care in the USA con- els of integrated care, PCBH has been associated with strong outcomes under the Triple Aim [3]. For tinues to rise, there has become increased interest in innovative service delivery models [1–3]. In example, PCBH has been found to reduce functional impairment [6] and successfully treat post-traumatic particular, the field of integrated care has rapidly grown, with a wide variety of particular care mod- stress disorder [7], insomnia [8], and suicidal idea- tion [13]. els being developed and evaluated [3]. These inte- grated care models have shown significant benefits The U.S. Air Force (USAF) has utilized PCBH for over 20  years, expanding from one to over 70 for improving patient access [4], patient satisfaction [5], and patient outcomes [6–8]—all critical compo- military treatment facilities (MTFs) across the world [14]. The USAF has invested considerable resources nents embedded within the Institute for Healthcare Improvement’s (IHI) “Triple Aim”—improved popu- in training and developing BHCs—clinical psycholo- gists and social workers—evaluating both patient lation health, experience of care, and reduced health care costs [9]. experience and health outcomes in this model [5, 6]. The military health system (MHS) provides care One particular model of care in this literature is referred to as the primary care behavioral health to over 9.4 million beneficiaries, across all ages and page 266 to 273 TBM Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH demographic groups, including active duty and current manning of mental health personnel, mental retired military members and their children and health clinic access to care rates, and ability of clin- partners [15]. Thus, innovations within this diverse ics to support this project while maximizing diver- and complex health care system may have critical sity of sites to promote generalizability. The three parallels to civilian health care. MTFs selected as pilot sites were chosen by AFMS program managers to provide variety in geographi- cal location and empanelment size to allow for gen- Air Force PCBH eralizability across the MHS. The USAF was one of the first larger health care organizations to practice PCBH and continues to Procedure emphasize many of its hallmark features [16]. BHCs are directly located in primary care clinics, provid- ing the aforementioned focused, timely encounters Overall program management through a consultative fashion to a primary care pro- The QI initiative involved two main adjustments to vider (PCP). This involves warm-handoffs (directly current program standard operating procedures. meeting with a patient following his or her PCP visit) One, providers and behavioral health technicians and routine feedback to the PCP via daily huddles, (BHTs) originally assigned to provide full-time one-on-one feedback, and use of a shared electronic specialty mental health services were reallocated health record. The BHC and PCP consult on a to primary care to supplement the existing BHCs. shared treatment plan, and the BHC is expected to Two, mental health clinic staff were trained to tri- use the biopsychosocial model to work with individ- age and book patients an initial PCBH appointment uals experiencing a wide range of conditions (e.g., unless certain criteria were met, described in Fig. 1 anxiety, depression, chronic pain, sleep, weight (with dotted lines indicating process change). The management) [17]. Patients who need a higher level current military insurance provider, TRICARE, of care are subsequently referred to specialty mental allows all beneficiaries to self-refer to a community health treatment. TRICARE network provider without a referral. The USAF PCBH model has been associated This policy was not changed, although primary with high levels of patient satisfaction [5], patient– care and administrative staff were encouraged to provider rapport [18], and improved patient book appointments directly into PCBH for patients functioning [6]. It has relied on a structured, com- self-referring for mental health–related care. In add- petency-based phased training approach for new ition, no changes were made to the USAF PCBH BHCs, involving a combination of experiential program’s clinical and operational policies (e.g., learning, didactic instruction, and on-the-job obser- regular consultations with a patient’s PCP; referring vation and mentoring [19]. However, challenges to appropriate cases to specialty mental health; brief, this model remain, paralleling that of the civilian solution-focused visits). Finally, while access pro- health care system. Underutilization of behavioral cedures were put in place designed to encourage health care can limit the active engagement of BHCs this stepped care approach, patient preference was in patient outcomes. The reasons for underutiliza- respected and if a patient insisted on being seen in tion are multifaceted and may include practice the specialty mental health clinic, this request was behaviors of the BHC [20], patient stigma [21], and granted. It should be emphasized that this QI pro- PCP misconceptions [22], among others. In an effort gram did not involve any change to total personnel to address this challenge of underutilization, the Air manning or funding—simply a reallocation of their Force Medical Service (AFMS) recently piloted sev- clinical time as described above (“zero-sum”). Any eral innovations in its long-standing PCBH program. personnel changes at these clinics were determined by higher headquarters consistent with the broader METHOD Air Force mission and without consideration of this Data in the present study are based on a 1-year pilot program. quality improvement (QI) initiative approved by the Wilford Hall Institutional Review Board (IRB) for BHT utilization internal program evaluation and conducted from BHT roles were not specified by overall program October 2014 to September 2015 [23]. This cur- management. Furthermore, as previously men- rent study was a retrospective data analysis of this tioned, technicians were reassigned from the spe- program evaluation project and was reviewed and cialty mental health clinic to primary care to assist approved by the Uniformed Services University IRB. with the anticipated increase in services. These BHTs were enlisted personnel who receive exten- Participating sites sive training in psychological assessment and inter- Solicitation for MTF participation in the pilot study vention as part of their technical school education was sought in June and July 2014. Six MTFs con- (approximately 3–4  months). This includes rig- firmed interest in participating in the study. Each orous evaluation and on-the-job training over the MTF was ranked based on empanelment size, first several years of employment. Although there TBM page 267 of 273 Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH Paent presents to Paent completes full Paent completes A week or more specialty mental psychological triage intake and begins health clinic and intake scheduled specialty care Paent presents to Paent completes brief triage and if BHC treats paent in specialty mental condions below not met, offered PCBH or refers to health clinic same day appointment in PCBH specialty clinic Paent given specialty mental health appointment, if… -Danger to self or others -Substance abuse or domesc violence at acuity level requiring specialty care -Previous treatment in specialty care and desire to connue -Requires special duty evaluaon (e.g., command- directed, special assignment) Fig 1 | Patient flow diagram for quality improvement project. BHC behavioral health consultant; PCBH primary care behavioral health. are no specific educational requirements beyond a not delay access for subsequent appointments and high school diploma or equivalent, many of these availability of PCBH personnel for warm-handoffs, technicians obtain associate’s, bachelor’s, or other maintaining the population health focus of PCBH professional degrees, ultimately becoming certified [11, 12]. Although other behavioral health models alcohol and drug abuse counselors and providing a of care have used provider extenders for telephonic full range of psychological care under supervision in care management and structured screening [26], a deployed setting [24]. technicians in this model participated in the face-to- The technicians employed in this study had al- face functional assessment of the patient’s concerns. ready passed the certification required by the Air Force for involvement in patient care, practiced only Strategic messaging under the scope of a licensed provider, and received Before the pilot study began, the medical facilities pay commiserate with their enlisted rank. For this launched a comprehensive strategic messaging cam- project, they received additional competency-based paign to alert the population and military leadership phased training designed to parallel USAF training about the changes to accessing mental health care. for BHCs [18]. Mental health and PCBH staff briefed commanders At one facility, the technician was trained to be and their personnel about these changes, created directly involved in full-time patient care and oper- base newspaper articles, and informed patients about ated in this capacity approximately 50% of the utili- PCBH services via online secure messaging. Examples zation year. Due to successful feedback and results, are provided in the Supplementary Material. that technician trained technicians at other sites. This included providing a patient with informed con- Measures sent, reviewing screening measures, and conducting a focused biopsychosocial, functional assessment Process metrics (essentially, the first 15–20 min of a patient encoun- ter in PCBH). Afterward, the technician would brief The following data were collected for PCBH and the BHC on the case, who would then meet with mental health clinics for both participating (n  =  3) the patient for treatment planning for the remaining and nonparticipating (n  =  69) MTFs: number of 5–10 min. Such operations were designed to parallel patient encounters per PCBH and mental health the traditional use of medical technicians in primary clinics, number of unique patients per PCBH and care while remaining consistent with the PCBH mental health clinics, access to care (days it took to be seen for initial appointment), and the amount model of brief, solution-focused appointments [25]. An advantage of this model included f lexibility (i.e., of money reimbursed by TRICARE for outpatient mental health therapy spent in the local community. an atypical deviation in length of visit), which did page 268 of 273 TBM Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH These process metrics were made available to the to previous naturalistic collection of patient satisfac- project manager overseeing this QI study for the tion within the MHS [22]. This revised survey was fiscal year prior to implementation of the pilot pro- only used during implementation of the technician gram and the fiscal year during implementation. training program from July to September 2015. Data were provided on a quarterly basis as part of Data analytic plan ongoing and standard AFMS program evaluation The use of retrospective data limited certain statis- practices for behavioral health care operations. tical analysis. Due to the significantly unequal cell sizes in comparing participating with nonparticipat- Patient satisfaction ing sites, analysis of variance (ANOVA) for process The Anonymous Patient Satisfaction Survey for Internal metrics was not recommended [27]. In addition, the Behavioral Health Consultant Services has been used limited degrees of freedom available for time-series for program evaluation within the USAF for many designs precluded formal testing of pre- and post- years and found to show good internal consistency changes [28]. Thus, the limited descriptive data and concurrent validity [5, 22]. It has been revised available are presented for these process metrics. and edited to include additional aspects of patient Because each site differed in empanelment size and satisfaction and increase the range of response because total number of encounters for three partici- options due to noted concerns about ceiling effects pating sites versus 69 nonparticipating sites involved [22]. Five items measured patients’ satisfaction significantly different frames of reference, changes with the BHC on various clinical skills (e.g., effort from pre- to post-implementation were converted to to listen, perceived knowledge of concern, likeli- aggregated percentage change scores. hood of recommending services) and two additional In regard to patient satisfaction data, more ro- questions measured the patient’s overall satisfaction bust statistical analyses could be performed. and willingness to recommend services. Questions Unfortunately, due to the small number of partici- were measured on a seven-point Likert scale with pating sites, comparisons across sites could not be responses ranging from 0  =  extremely dissatisfied to statistically tested. All data were analyzed for miss- 6 = extremely satisfied, 0 = definitely would not to 6 = def- ingness and normality. Independent samples t-tests initely would, and 0  =  extremely poor to 6  =  extremely were conducted to examine differences in patient good. The current version was further revised for this satisfaction when a technician was involved in care study to allow patients to indicate whether or not a versus when one was not. A  Bonferroni correc- technician was involved in the encounter, and if so, tion was applied given multiple planned analysis to evaluate their satisfaction with the technician’s (p  <  .05/8  =  .006). Hierarchical linear regression assessment of the presenting concern and effort to was employed to understand factors of patient sat- listen. Internal consistency in the current sample isfaction with both their BHC and technician that was α = .95. influenced their overall satisfaction and willingness This survey was collected as part of standard to recommend services. clinical operations throughout the process improve- ment initiative. At each site, the Family Health RESULTS Clinic front desk staff were instructed to give the surveys to each patient who had a PCBH appoint- Basic information on staff and empanelment size for selected sites is listed in Table 1. As mentioned ment to reduce social desirability (i.e., avoiding the provision of feedback directly to their BHC). The previously, additional staff was not recruited for this participating site; instead, sites managed their completed surveys, excluding patient identifying information, were returned to the PCBH adminis- personnel to support additional resources in pri- mary care consistent with implementation guid- trative staff after a sufficient number of surveys had been collected to prevent identification of specific ance described above. It should also be noted that overall, staffing across all three locations decreased respondents. These responses were then entered by administrative staff and sent to the process improve- over 20%, with only one individual site report- ing an increase in staffing across both PCBH and ment project manager. These procedures are similar Table 1 | Pilot site characteristics Mental health clinic providers PCBH providers Empanelment size (Full-time equivalents) (Full-time equivalents) Site population FY2014 (Pre) FY2015 (Post) density FY2014 (Pre) FY2015 (Post) FY2014 (Pre) FY2015 (Post) 13,579 13,347 (−2%) 1,113 5.12 5.12 (0%) 1.0 1.38 (+38%) 25,624 24,861 (−3%) 1,270 8.5 4.5 (−47%) 2.45 2.34 (−5%) 54,624 46,997 (−13%) 2,944.6 9.38 6.55 (−30%) 0.88 2.5 (+284%) Percentage change from pre- to post-intervention listed in FY2015 (Post) columns. Per 2010 U.S. Census (population per square mile). TBM page 269 of 273 Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH specialty mental health clinics—and of less than 0.4 community health care costs accounts for a potential full-time equivalent providers (6% increase). As a savings of nearly $7 million across the entire AFMS fidelity check, all sites reported adherence to pro- per year [23]. In regard to technician involvement, gram implementation guidance as feasible, showing the initial site in which a technician was involved an increase in PCBH providers, with the exception in direct patient care had a 61% increase in average of one site where there was a decrease in provid- daily patient visits when comparing the quarter pro- ers. However, this decrease was at a considerably ceeding technician training (4.73) with the quarter smaller rate (5%) than seen in the specialty mental following technician training (7.6). health clinic at the same location (47%), representing In regard to patient satisfaction, during the a prioritization of maintaining manning in PCBH. 3-month collection period, there were approxi- Descriptive results for key process metrics are mately 2,078 encounters and 329 patients returned shown in Table  2. As shown, results were positive completed surveys. Although this response rate is but limited by the exploratory nature of available low (16%), it is on par with other primary care set- data analysis and percentage change was used due tings [22, 29]. Patient satisfaction was analyzed com- to unequal facility sizes. Participating sites saw an paring encounters with a technician compared with increase in both total patient encounters and total those without a technician aggregated across all patients served during the implementation year. three sites due to sample size within specific sites. Furthermore, they had a much greater increase by Three cases were missing data on key study varia- percentage volume compared with non-participat- bles; after eliminating these cases, data were missing ing sites. Pilot sites also saw a decrease in no-show in only 3% of cases and data were considered miss- rates for both PCBH and specialty mental health ing completely at random (n = 326; Little’s MCAR clinics, and this decrease in rates again exceeded test all ns for key study variables); thus, expectation those in nonparticipating sites. In regard to access to maximization imputation methods were utilized to care, specialty mental health clinics at participating handle missing data consistent with prudent statis- sites saw a slight decrease in access to care (longer tical techniques [30]. Of the 326 patient encounters, wait times, equivalent to less than 10% of a day) patients indicated technician involvement in 77 while nonparticipating sites saw shorter wait times. (24%) encounters. As shown in Table 3, patients who However, the opposite effect was observed for PCBH worked with a BHT rated their willingness to recom- clinics. Participating sites, while already increasing mend services as greater than those patients who did patient volume, experienced improved access to not meet with a BHT. care and nonparticipating PCBH sites saw longer Hierarchical linear regression was used to under- wait times. In addition, where nonparticipating sites stand the impact of specific aspects of patient satis- experienced a 16% increase in community purchased faction (e.g., amount of time spent with the BHC, care costs (the amount of money that TRICARE provider or technician’s effort to listen) on overall spends on behavioral health care outside the MTF) patient satisfaction for those encounters with a tech- between pre- and post-implementation fiscal years, nician. All aspects of patient satisfaction for the pro- pilot sites saw a 4% decrease in purchased care costs vider were entered on an initial step and two items during this same time period. This 20% difference in assessing the technician’s role (their effort to listen Table 2 | Key process metrics for PCBH enhancement pilot Pilot sites Nonparticipating sites a a Process metric Pre-pilot Post-pilot %Δ Pre-pilot Post-pilot %Δ Total encounters PCBH 4,219 8,511 +99 48,856 59,726 +22 Mental health 23,214 24,952 +12 348,053 357,275 +3 Total patients PCBH 2,683 6,464 +140 30,116 34,209 +14 Mental health 6,132 12,865 +138 53,248 52,844 −1 No-show rate (%) PCBH 14.3 10.6 −4 8.9 8.8 −1 Mental health 12.1 8.3 −30 7.2 7.0 −3 Access to care PCBH 6.88 5.22 −12 4.09 4.24 +4 Mental health 6.06 6.13 +1 6.04 5.71 −6 Purchased care ($M) 3.30 3.17 −4 36.1 41.7 +16 PCBH primary care behavioral health. Average percentage across pilot sites. Percentage change rounded to nearest hundredth reported as whole number. page 270 of 273 TBM Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH and assessment of the problem) were entered on a specialty mental health may also have contributed second step. Results are shown in Table 4. Inclusion to a decrease in no-show rates and promote patient of the BHT items accounted for an additional 3% engagement. Reduced no-shows and improved of the variance in patient satisfaction, F change access, combined with increased population pene- (2, 70) = 7.76, p = .001; of note, their effort to listen tration, were also accompanied by large cost savings was significantly associated with patient satisfaction, by reducing the use of outside community providers β = .36, p < .001. with higher per-encounter reimbursement costs. In this regard, the findings provide initial, but poten- DISCUSSION tially compelling evidence for cost-saving models The results of this preliminary pilot are promising which may influence the insurance market land- and have implications for civilian health care organ- scape in health care to encourage further systematic izations. Findings reinforce the benefits of PCBH, research in this understudied area of systems-level with a focus on understudied practice-level factors factors. Sites incorporating PCBH into their patient [31–33]. Specifically, findings demonstrate the flow for specialty mental health referrals saved ability of PCBH to reduce specialty mental health money during a time when costs continued to burden, improving population reach and access. increase at other facilities and while experiencing This appears to have the added benefit of increas- greater demand for services. Cost savings were even ing patient compliance through improved appoint- stronger in the final two fiscal quarters of the imple- ment attendance. These benefits were seen not mentation project, suggesting that as clinic popula- only in PCBH, but also in specialty mental health tions become more familiar with new procedures clinics at participating sites, suggesting advantages and increase their service uptake, costs may decline of a stepped care approach that improved com- even further. munication, coordination, and reach of behavio- The positive findings associated with technicians ral health services within health care operations. are also promising preliminary results. Although Improved coordination between primary care and there may be some apprehension about a patient Table 3 | Patient satisfaction in technician-involved versus nontechnician-involved encounters Technician Nontechnician mean (SD) mean (SD) t 1. Amount of time for appt 5.23 (0.93) 5.29 (0.94) 0.49 2. BHC’s effort to listen 5.47 (0.85) 5.55 (0.76) 0.77 3. BHC’s knowledge of presenting concern 5.29 (0.96) 5.46 (0.81) 1.58 4. Quality of care/intervention 5.16 (0.99) 5.39 (0.82) 2.09 5. Overall treatment plan 5.00 (1.14) 5.32 (0.86) 2.26 6. Overall patient satisfaction 5.25 (1.00) 5.36 (0.88) 0.90 7. Likelihood to recommend IBHC services 5.32 (0.91) 4.94 (1.29) 2.94* 8. Patient health rating 3.54 (1.23) 3.61 (1.33) 0.36 BHC behavioral health consultant. Degrees of freedom adjusted due to heterogeneity of variances. *p < .05 using Bonferroni correction for planned analysis. Table 4 | Hierarchical linear regression predicting patient satisfaction from provider and technician factors 2 2 R ΔR β Final β Step 1 (Provider factors) .82 .82** Amount of time for appt .43* .35* BHC effort to listen .13 .02 Knowledge of presenting concern −.03 −.05 Quality of care/intervention .12 .17 Overall treatment plan .34* .31* Step 2 (Technician factors) .85 .03* Technician effort to listen .36** .36** Assessment of presenting concern −.15 −.15 Final model F(7, 70) = 56.92** BHC behavioral health consultant. *p < .01, **p < .001. TBM page 271 of 273 Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH having to meet with yet another individual to preserve “real-world” practices, few additional describe their presenting concern, findings were not constraints were placed on pilot sites. Although consistent with this being seen as a barrier. Given this improves generalizability, it also significantly the parallel process to typical primary care opera- increases heterogeneity of the intervention sample. tions, patients may not have been acutely aware of Thus, it is quite possible that a number of other the difference. This was likely reinforced by train- variables (e.g., fidelity to model, staff training and ing the BHC to provide a biopsychosocial concep- expertise, population demographics) may have tualization to the patient when entering the room, contributed to the positive findings. Without direct reaffirming that the technician had fully briefed the measures of these confounds, the ability to draw provider on the case, allowing the patient to validate causal inferences is more limited. that report, and then move immediately into inter- Despite these constraints, we feel these results vention. In this way, the patient would not need to offer important encouragement for further re- “tell their story” yet again while still feeling heard. In search in the field of PCBH at the systemic level. It fact, patient satisfaction was improved by a techni- is important to emphasize that these changes were cian’s effort to listen—and this survey was completed incorporated in a system where there are clearly at the end of the entire encounter; thus, it is likely defined competency-based expectations for PCBH that the ability of the BHC to convey the techni- providers and clinics. These expectations are easily cians’ report reinforced a feeling of team-based care. translatable to new facilities, as the Department of Results further indicated that the quality of care Defense has expanded many of these clinics only in with both a technician and BHC is perceived as simi- the past few years [18]. As discussed above, these lar or perhaps preferred to care with that same BHC MTFs have considerable variability in size, staffing, only, while providing potential benefits that may and resources and are in locations with significant indirectly lead to improved utilization. In particular, diversity in patient empanelment, environment, and incorporating technicians in patient care appears presenting concerns. The MHS provides care not to provide opportunities to increase provider effi- only for service members, but also for family mem- ciency and patient access—resulting in at least three bers and retirees, whose diversity mirrors the ci- extra appointments daily in the current study—while vilian population. Thus, the USAF’s PCBH training maintaining the experience of care. Several possibil- and implementation program provides a “roadmap” ities may explain these findings, although these links for both civilian and military health care settings to have not been empirically tested. The first is that by allow for further testing and evaluation. having this model whereby someone from the PCBH In addition, this study utilized a pre- and post-test team is always available, even if an appointment has intervention design with control group comparison been scheduled, allows for both the warm-hand- for analyzing results. Although statistical analysis offs and the scheduled follow-ups to occur without is limited by the small intervention sample size decreasing either patient or PCP access, which can and limited time points, these preliminary findings be a barrier to referral [22]. Second, this model are reinforced by prudent methodological design. may increase comfort with PCBH as “routine” for Although these facilities are heterogeneous and patients and PCPs, as we know that individuals were not selected entirely at random, it is important bring certain schemas to various situations and that to highlight that results were compared against these influence their perceptions and expectations the population of 69 other MTFs who also vary in these environments [34]. Finally, research sug- in fidelity to the model on measures such as staff gests barriers to BHC service utilization are higher training and expertise, population demographics, among nonprovider members of the primary care and a host of other potential variables of interest. team [22]. Having a technician available may also Thus, these positive findings across this naturalistic facilitate more interactions between team members variability speak to the potential generalizability of by promoting relationships between team members these findings. Finally, these benefits were achieved with similar levels of training and responsibility at “zero cost” to the existing PCBH and specialty (e.g., BHT to medical technician, BHCs to PCPs). mental health clinics. No additional personnel were Future research should directly test these potential recruited or hired across all three sites; manning explanations. decreased while it was reallocated. No additional This preliminary study is not without limitations. compensation was provided to these sites to support The sample size and time points for which data were these changes. Thus, there is little net cost to imple- collected limit the ability to utilize more advanced menting these changes relative to the significant po- statistical analysis. Furthermore, the low response tential benefit demonstrated by these preliminary rate for patient satisfaction may limit our ability to positive findings, which may seek to encourage fur- evaluate the representativeness of the sample, des- ther systematic research in this area. pite its consistency with response rates in previous Future research should seek to address the limi- studies in similar settings. It also introduces the po- tation of the small intervention sample by further tential for selection and nonresponse biases in the expanding this QI initiative based on these prom- sample. It is important to note that in an effort to ising preliminary findings. Furthermore, efforts page 272 of 273 TBM Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH 8. Goodie JL, Isler WC, Hunter C, Peterson AL. Using behavioral health con- should be made to incorporate these changes into J Clin sultants to treat insomnia in primary care: a clinical case series. new PCBH programs and to parallel civilian-in- Psychol. 2009; 65(3): 294–304. 9. Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and tegrated health care settings. This will not only cost. Health Aff (Millwood) . 2008; 27(3): 759–769. improve generalizability, but many of the same 10. Mauksch L, Peek CJ, Fogarty CT. Seeking a wider lens for scientific rigor observed benefits in this setting are directly translat- in emerging fields: The case of the primary care behavioral health model. Fam Syst Health. 2017; 35(3): 251–256. able outside of a military setting. Focusing on these 11. Horevitz E, Organista KC, Arean PA. Depression treatment uptake in inte- practice-level decisions has the potential to shape grated primary care: How a “Warm Handoff” and other factors affect Psychiatr Serv. 2015; 66(8): 824–830. decision making by Latinos. the opportunities for success in the area of inte- 12. Reiter JT, Dobmeyer AC, Hunter CL. The primary care behavioral health grated behavioral health care. (PCBH) model: An overview and operation definition. J Clin Psychol Med Settings. 2018. doi: 10.1007/s10880-017-9531-x. [Epub ahead of print]. SUPPLEMENTARY MATERIAL 13. Bryan CJ, Corso KA, Corso ML, Kanzler KE, Ray-Sannerud B, Morrow CE. Therapeutic alliance and change in suicidal ideation during treatment Supplementary material is available at Translational Arch Suicide Res. 2012; 16(4): in integrated primary care settings. Behavioral Medicine online. 316–323. 14. Hunter CL, Goodie JL. Behavioral health in the Department of Defense Patient-Centered Medical Home: History, finance, policy, work force Acknowledgments: This project would not have been possible with the Transl Behav Med. 2012; 2(3): 355–363. development, and evaluation. clinical team responsible for executing the quality improvement pro- 15. Defense Health Agency. Evaluation of the TRICARE Program: Fiscal Year ject at local facilities. Listed in alphabetical order: Capt (Dr.) Adam Dell, 2017 Report to Congress. Falls Church, VA: Defense Health Agency; Capt (Dr.) Abby Fields, SrA Romia Jones, Mr. Michael Jordan, SSgt Ebony Santiago, SrA Samantha Webber, and SSgt Natalie Yarbrough. We also 16. Funderburk JS, Dobmeyer AC, Hunter CL, Walsh CO, Maisto SA. Provider extend our sincere thanks to Dr. Jisuk Park who assisted with preliminary practices in the primary care behavioral health (PCBH) model: An initial review of the study findings. There was no funding associated with this examination in the Veterans Health Administration and United States Air project. This article was authored by employees of the U.S. government. Fam Syst Health. 2013; 31(4): 341–353. Force. Any views expressed herein are those of the authors and do not neces- 17. Air Force Medical Operations Agency. Primary Care Behavioral Health sarily represent the views of the U.S. government or the Department of Services: Behavioral Health Optimization Program Field Manual. Joint Defense. Base San Antonio – Lackland: Air Force Medical Service; 2014. 18. Corso KA, Bryan CJ, Corso ML, et al. Therapeutic alliance and treatment Fam Syst Health. outcome in the primary care behavioral health model. Compliance with Ethical Standards 2012; 30(2): 87–100. 19. Dobmeyer AC, Hunter CL, Corso ML, et al. Primary care behavioral Primary Data: This manuscript is not under consideration at another health provider training: Systematic development and implementation J Clin Psychol Med Settings. 2016; 23(3): journal and has not been previously published. Portions of these data in a large medical system. 207–224. have been presented at various conferences, including the Society of 20. Robinson PJ, Strosahl KD. Behavioral health consultation and primary Behavioral Medicine. As above, we are employees of the U.S. Department J Clin Psychol Med Settings. 2009; 16(1): care: Lessons learned. of Defense, but we have control of the primary data presented for review 58–71. if desired. 21. Shim R, Rust G. Primary care, behavioral health, and public health: Am J Public Health. 2013; Partners in reducing mental health stigma. Conflict of Interest: The authors report no conflicts of interest. 103(5): 774–776. 22. Landoll RR, Nielsen MK, Waggoner KK. 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Int J 3. Vogel ME, Kanzler KE, Aikens JE, Goodie JL. Integration of behavioral Epidemiol. 2016; 46: 348–355. health and primary care: Current knowledge and future directions. J 29. Panattoni L, Stone A, Chung S, Tai-Seale M. Patients report better satis- Behav Med. 2017; 40(1): 69–84. faction with part-time primary care physicians, despite less continuity of 4. Ayalon L, Areán PA, Linkins K, Lynch M, Estes CL. Integration of mental J Gen Intern Med. 2015; 30(3): 327–333. health services into primary care overcomes ethnic disparities in access care and access. 30. Kline R. Principles and Practice of Structural Equation Modeling. New to mental health services between black and white elderly. Am J Geriatr York, NY: Guilford; 2005. Psychiatry. 2007; 15(10): 906–912. 31. Cummings NA, O’Donohue WT, Cummings JL. The financial dimension of 5. Runyan CN, Fonseca VP, Meyer JG, Oordt MS, Talcott GW. A novel J Clin Psychol Med Settings. 2009; approach for mental health disease management: The Air Force integrated behavioral/primary care. 16(1): 31–39. Medical Service’s interdisciplinary model. Dis Manag. 2003; 6(3): 32. Miller BF, Mendenhall TJ, Malik AD. Integrated primary care: An inclusive 179–188. 6. Bryan CJ, Corso ML, Corso KA, Morrow CE, Kanzler KE, Ray-Sannerud B. three-world view through process metrics and empirical discrimination. Clin Psychol Med Settings. 2009; 16(1): 21–30. Severity of mental health impairment and trajectories of improvement 33. Muse AR, Lamson AL, Didericksen KW, Hodgson JL. A systematic review in an integrated primary care clinic. J Consult Clin Psychol. 2012; 80(3): of evaluation research in integrated behavioral health care: Operational 396–403. Fam Syst Health. 2017; 35(2): 136–154. 7. Cigrang JA, Rauch SA, Mintz J, et al.; STRONG STAR Consortium. and financial characteristics. 34. Zacks JM, Speer NK, Swallow KM, Braver TS, Reynolds JR. Event percep- Treatment of active duty military with PTSD in primary care: A follow-up tion: A mind-brain perspective. Psychol Bull. 2007; 133(2): 273–293. report. J Anxiety Disord. 2015; 36: 110–114. TBM page 273 of 273 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

Innovations in primary care behavioral health: a pilot study across the U.S. Air Force

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Copyright © 2022 Society of Behavioural Medicine
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1869-6716
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1613-9860
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10.1093/tbm/iby046
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Abstract

Implications Integrated primary care services have grown in popularity Practice: Primary care behavioral health (PCBH) in recent years and demonstrated significant benefits to the 1 programs should consider utilizing technicians to patient experience, patient health, and health care opera- Department of Family Medicine, extend the reach of behavioral health consultant. tions. However, broader systems-level factors for health care Uniformed Services University, Bethesda, MD, USA organizations, such as utilization, access, and cost, have been Mike O’Callaghan Military Medical understudied. The current study reviews the results of quality Center, Las Vegas, NV, USA improvement project conducted by the U.S. Air Force, which Policy: Health care systems should consider a 35th Medical Group, Misawa Air has practiced integrated primary care behavioral health for over stepped care approach to mental health care Base, Misawa, Japan 20 years. This study focuses on exploring how shifting the using PCBH and specialty clinics. 81st Medical Group, Keesler Air access point for behavioral from specialty mental health clinics Force Base, Biloxi, MS, USA to primary care, along with the use of technicians in patient care, can improve a range of health outcomes. Retrospective Research: Larger scale, controlled studies should data analysis was conducted on an internal Air Force quality evaluate alternative delivery models and use of improvement project implemented at three military treatment provider extenders based on pilot findings. facilities from October 2014 to September 2015. Positive preliminary support for these innovations was seen in the form of expanded patient populations, decreased time to first appointment, increased patient encounters, and decreased (PCBH) model. Although the field is continuing purchased community care compared with non-participating Correspondence to: Ryan to refine and build consensus, PCBH is defined by sites. Incorporation of behavioral health technicians further R. Landoll, ryan.landoll@usuhs. several key components [10]. PCBH emphasizes increased number of patient encounters while maintaining high edu levels of patient satisfaction across diverse clinical settings; in a team-based approach to the health care using fact, patients preferred appointments with both technicians and Cite this as: TBM 2019;9:266–273 a biopsychosocial model of health. The PCBH doi: 10. 1093/tbm/iby046 behavioral health providers, compared with appointments with model incorporates a behavioral health consultant behavioral health providers only. These findings encourage fur - (BHC) into the primary care team to serve as a gen- Published by Oxford University Press ther systematic review of systems-level factors in primary care on behalf of the Society of Behavioral eralist and strives to intervene on the day they are behavioral health and adoption of the use of provider extenders Medicine 2018. This work is written by referred (via use of the “warm handoff”) [11]. The in primary care behavioral health clinics. (a) US Government employee(s) and is in the public domain in the US. goal is to incorporate biopsychosocial assessment and intervention into everyday care, accomplished Keywords via focused, time-limited visits (≤4 total, each lasting Primary care behavioral health, Integrated care, 15–40  min) and coordinated follow-up with other Access to care, Military health primary care team members [10, 12]. Although lim- ited research to date directly compares various mod- As the need for mental health care in the USA con- els of integrated care, PCBH has been associated with strong outcomes under the Triple Aim [3]. For tinues to rise, there has become increased interest in innovative service delivery models [1–3]. In example, PCBH has been found to reduce functional impairment [6] and successfully treat post-traumatic particular, the field of integrated care has rapidly grown, with a wide variety of particular care mod- stress disorder [7], insomnia [8], and suicidal idea- tion [13]. els being developed and evaluated [3]. These inte- grated care models have shown significant benefits The U.S. Air Force (USAF) has utilized PCBH for over 20  years, expanding from one to over 70 for improving patient access [4], patient satisfaction [5], and patient outcomes [6–8]—all critical compo- military treatment facilities (MTFs) across the world [14]. The USAF has invested considerable resources nents embedded within the Institute for Healthcare Improvement’s (IHI) “Triple Aim”—improved popu- in training and developing BHCs—clinical psycholo- gists and social workers—evaluating both patient lation health, experience of care, and reduced health care costs [9]. experience and health outcomes in this model [5, 6]. The military health system (MHS) provides care One particular model of care in this literature is referred to as the primary care behavioral health to over 9.4 million beneficiaries, across all ages and page 266 to 273 TBM Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH demographic groups, including active duty and current manning of mental health personnel, mental retired military members and their children and health clinic access to care rates, and ability of clin- partners [15]. Thus, innovations within this diverse ics to support this project while maximizing diver- and complex health care system may have critical sity of sites to promote generalizability. The three parallels to civilian health care. MTFs selected as pilot sites were chosen by AFMS program managers to provide variety in geographi- cal location and empanelment size to allow for gen- Air Force PCBH eralizability across the MHS. The USAF was one of the first larger health care organizations to practice PCBH and continues to Procedure emphasize many of its hallmark features [16]. BHCs are directly located in primary care clinics, provid- ing the aforementioned focused, timely encounters Overall program management through a consultative fashion to a primary care pro- The QI initiative involved two main adjustments to vider (PCP). This involves warm-handoffs (directly current program standard operating procedures. meeting with a patient following his or her PCP visit) One, providers and behavioral health technicians and routine feedback to the PCP via daily huddles, (BHTs) originally assigned to provide full-time one-on-one feedback, and use of a shared electronic specialty mental health services were reallocated health record. The BHC and PCP consult on a to primary care to supplement the existing BHCs. shared treatment plan, and the BHC is expected to Two, mental health clinic staff were trained to tri- use the biopsychosocial model to work with individ- age and book patients an initial PCBH appointment uals experiencing a wide range of conditions (e.g., unless certain criteria were met, described in Fig. 1 anxiety, depression, chronic pain, sleep, weight (with dotted lines indicating process change). The management) [17]. Patients who need a higher level current military insurance provider, TRICARE, of care are subsequently referred to specialty mental allows all beneficiaries to self-refer to a community health treatment. TRICARE network provider without a referral. The USAF PCBH model has been associated This policy was not changed, although primary with high levels of patient satisfaction [5], patient– care and administrative staff were encouraged to provider rapport [18], and improved patient book appointments directly into PCBH for patients functioning [6]. It has relied on a structured, com- self-referring for mental health–related care. In add- petency-based phased training approach for new ition, no changes were made to the USAF PCBH BHCs, involving a combination of experiential program’s clinical and operational policies (e.g., learning, didactic instruction, and on-the-job obser- regular consultations with a patient’s PCP; referring vation and mentoring [19]. However, challenges to appropriate cases to specialty mental health; brief, this model remain, paralleling that of the civilian solution-focused visits). Finally, while access pro- health care system. Underutilization of behavioral cedures were put in place designed to encourage health care can limit the active engagement of BHCs this stepped care approach, patient preference was in patient outcomes. The reasons for underutiliza- respected and if a patient insisted on being seen in tion are multifaceted and may include practice the specialty mental health clinic, this request was behaviors of the BHC [20], patient stigma [21], and granted. It should be emphasized that this QI pro- PCP misconceptions [22], among others. In an effort gram did not involve any change to total personnel to address this challenge of underutilization, the Air manning or funding—simply a reallocation of their Force Medical Service (AFMS) recently piloted sev- clinical time as described above (“zero-sum”). Any eral innovations in its long-standing PCBH program. personnel changes at these clinics were determined by higher headquarters consistent with the broader METHOD Air Force mission and without consideration of this Data in the present study are based on a 1-year pilot program. quality improvement (QI) initiative approved by the Wilford Hall Institutional Review Board (IRB) for BHT utilization internal program evaluation and conducted from BHT roles were not specified by overall program October 2014 to September 2015 [23]. This cur- management. Furthermore, as previously men- rent study was a retrospective data analysis of this tioned, technicians were reassigned from the spe- program evaluation project and was reviewed and cialty mental health clinic to primary care to assist approved by the Uniformed Services University IRB. with the anticipated increase in services. These BHTs were enlisted personnel who receive exten- Participating sites sive training in psychological assessment and inter- Solicitation for MTF participation in the pilot study vention as part of their technical school education was sought in June and July 2014. Six MTFs con- (approximately 3–4  months). This includes rig- firmed interest in participating in the study. Each orous evaluation and on-the-job training over the MTF was ranked based on empanelment size, first several years of employment. Although there TBM page 267 of 273 Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH Paent presents to Paent completes full Paent completes A week or more specialty mental psychological triage intake and begins health clinic and intake scheduled specialty care Paent presents to Paent completes brief triage and if BHC treats paent in specialty mental condions below not met, offered PCBH or refers to health clinic same day appointment in PCBH specialty clinic Paent given specialty mental health appointment, if… -Danger to self or others -Substance abuse or domesc violence at acuity level requiring specialty care -Previous treatment in specialty care and desire to connue -Requires special duty evaluaon (e.g., command- directed, special assignment) Fig 1 | Patient flow diagram for quality improvement project. BHC behavioral health consultant; PCBH primary care behavioral health. are no specific educational requirements beyond a not delay access for subsequent appointments and high school diploma or equivalent, many of these availability of PCBH personnel for warm-handoffs, technicians obtain associate’s, bachelor’s, or other maintaining the population health focus of PCBH professional degrees, ultimately becoming certified [11, 12]. Although other behavioral health models alcohol and drug abuse counselors and providing a of care have used provider extenders for telephonic full range of psychological care under supervision in care management and structured screening [26], a deployed setting [24]. technicians in this model participated in the face-to- The technicians employed in this study had al- face functional assessment of the patient’s concerns. ready passed the certification required by the Air Force for involvement in patient care, practiced only Strategic messaging under the scope of a licensed provider, and received Before the pilot study began, the medical facilities pay commiserate with their enlisted rank. For this launched a comprehensive strategic messaging cam- project, they received additional competency-based paign to alert the population and military leadership phased training designed to parallel USAF training about the changes to accessing mental health care. for BHCs [18]. Mental health and PCBH staff briefed commanders At one facility, the technician was trained to be and their personnel about these changes, created directly involved in full-time patient care and oper- base newspaper articles, and informed patients about ated in this capacity approximately 50% of the utili- PCBH services via online secure messaging. Examples zation year. Due to successful feedback and results, are provided in the Supplementary Material. that technician trained technicians at other sites. This included providing a patient with informed con- Measures sent, reviewing screening measures, and conducting a focused biopsychosocial, functional assessment Process metrics (essentially, the first 15–20 min of a patient encoun- ter in PCBH). Afterward, the technician would brief The following data were collected for PCBH and the BHC on the case, who would then meet with mental health clinics for both participating (n  =  3) the patient for treatment planning for the remaining and nonparticipating (n  =  69) MTFs: number of 5–10 min. Such operations were designed to parallel patient encounters per PCBH and mental health the traditional use of medical technicians in primary clinics, number of unique patients per PCBH and care while remaining consistent with the PCBH mental health clinics, access to care (days it took to be seen for initial appointment), and the amount model of brief, solution-focused appointments [25]. An advantage of this model included f lexibility (i.e., of money reimbursed by TRICARE for outpatient mental health therapy spent in the local community. an atypical deviation in length of visit), which did page 268 of 273 TBM Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH These process metrics were made available to the to previous naturalistic collection of patient satisfac- project manager overseeing this QI study for the tion within the MHS [22]. This revised survey was fiscal year prior to implementation of the pilot pro- only used during implementation of the technician gram and the fiscal year during implementation. training program from July to September 2015. Data were provided on a quarterly basis as part of Data analytic plan ongoing and standard AFMS program evaluation The use of retrospective data limited certain statis- practices for behavioral health care operations. tical analysis. Due to the significantly unequal cell sizes in comparing participating with nonparticipat- Patient satisfaction ing sites, analysis of variance (ANOVA) for process The Anonymous Patient Satisfaction Survey for Internal metrics was not recommended [27]. In addition, the Behavioral Health Consultant Services has been used limited degrees of freedom available for time-series for program evaluation within the USAF for many designs precluded formal testing of pre- and post- years and found to show good internal consistency changes [28]. Thus, the limited descriptive data and concurrent validity [5, 22]. It has been revised available are presented for these process metrics. and edited to include additional aspects of patient Because each site differed in empanelment size and satisfaction and increase the range of response because total number of encounters for three partici- options due to noted concerns about ceiling effects pating sites versus 69 nonparticipating sites involved [22]. Five items measured patients’ satisfaction significantly different frames of reference, changes with the BHC on various clinical skills (e.g., effort from pre- to post-implementation were converted to to listen, perceived knowledge of concern, likeli- aggregated percentage change scores. hood of recommending services) and two additional In regard to patient satisfaction data, more ro- questions measured the patient’s overall satisfaction bust statistical analyses could be performed. and willingness to recommend services. Questions Unfortunately, due to the small number of partici- were measured on a seven-point Likert scale with pating sites, comparisons across sites could not be responses ranging from 0  =  extremely dissatisfied to statistically tested. All data were analyzed for miss- 6 = extremely satisfied, 0 = definitely would not to 6 = def- ingness and normality. Independent samples t-tests initely would, and 0  =  extremely poor to 6  =  extremely were conducted to examine differences in patient good. The current version was further revised for this satisfaction when a technician was involved in care study to allow patients to indicate whether or not a versus when one was not. A  Bonferroni correc- technician was involved in the encounter, and if so, tion was applied given multiple planned analysis to evaluate their satisfaction with the technician’s (p  <  .05/8  =  .006). Hierarchical linear regression assessment of the presenting concern and effort to was employed to understand factors of patient sat- listen. Internal consistency in the current sample isfaction with both their BHC and technician that was α = .95. influenced their overall satisfaction and willingness This survey was collected as part of standard to recommend services. clinical operations throughout the process improve- ment initiative. At each site, the Family Health RESULTS Clinic front desk staff were instructed to give the surveys to each patient who had a PCBH appoint- Basic information on staff and empanelment size for selected sites is listed in Table 1. As mentioned ment to reduce social desirability (i.e., avoiding the provision of feedback directly to their BHC). The previously, additional staff was not recruited for this participating site; instead, sites managed their completed surveys, excluding patient identifying information, were returned to the PCBH adminis- personnel to support additional resources in pri- mary care consistent with implementation guid- trative staff after a sufficient number of surveys had been collected to prevent identification of specific ance described above. It should also be noted that overall, staffing across all three locations decreased respondents. These responses were then entered by administrative staff and sent to the process improve- over 20%, with only one individual site report- ing an increase in staffing across both PCBH and ment project manager. These procedures are similar Table 1 | Pilot site characteristics Mental health clinic providers PCBH providers Empanelment size (Full-time equivalents) (Full-time equivalents) Site population FY2014 (Pre) FY2015 (Post) density FY2014 (Pre) FY2015 (Post) FY2014 (Pre) FY2015 (Post) 13,579 13,347 (−2%) 1,113 5.12 5.12 (0%) 1.0 1.38 (+38%) 25,624 24,861 (−3%) 1,270 8.5 4.5 (−47%) 2.45 2.34 (−5%) 54,624 46,997 (−13%) 2,944.6 9.38 6.55 (−30%) 0.88 2.5 (+284%) Percentage change from pre- to post-intervention listed in FY2015 (Post) columns. Per 2010 U.S. Census (population per square mile). TBM page 269 of 273 Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH specialty mental health clinics—and of less than 0.4 community health care costs accounts for a potential full-time equivalent providers (6% increase). As a savings of nearly $7 million across the entire AFMS fidelity check, all sites reported adherence to pro- per year [23]. In regard to technician involvement, gram implementation guidance as feasible, showing the initial site in which a technician was involved an increase in PCBH providers, with the exception in direct patient care had a 61% increase in average of one site where there was a decrease in provid- daily patient visits when comparing the quarter pro- ers. However, this decrease was at a considerably ceeding technician training (4.73) with the quarter smaller rate (5%) than seen in the specialty mental following technician training (7.6). health clinic at the same location (47%), representing In regard to patient satisfaction, during the a prioritization of maintaining manning in PCBH. 3-month collection period, there were approxi- Descriptive results for key process metrics are mately 2,078 encounters and 329 patients returned shown in Table  2. As shown, results were positive completed surveys. Although this response rate is but limited by the exploratory nature of available low (16%), it is on par with other primary care set- data analysis and percentage change was used due tings [22, 29]. Patient satisfaction was analyzed com- to unequal facility sizes. Participating sites saw an paring encounters with a technician compared with increase in both total patient encounters and total those without a technician aggregated across all patients served during the implementation year. three sites due to sample size within specific sites. Furthermore, they had a much greater increase by Three cases were missing data on key study varia- percentage volume compared with non-participat- bles; after eliminating these cases, data were missing ing sites. Pilot sites also saw a decrease in no-show in only 3% of cases and data were considered miss- rates for both PCBH and specialty mental health ing completely at random (n = 326; Little’s MCAR clinics, and this decrease in rates again exceeded test all ns for key study variables); thus, expectation those in nonparticipating sites. In regard to access to maximization imputation methods were utilized to care, specialty mental health clinics at participating handle missing data consistent with prudent statis- sites saw a slight decrease in access to care (longer tical techniques [30]. Of the 326 patient encounters, wait times, equivalent to less than 10% of a day) patients indicated technician involvement in 77 while nonparticipating sites saw shorter wait times. (24%) encounters. As shown in Table 3, patients who However, the opposite effect was observed for PCBH worked with a BHT rated their willingness to recom- clinics. Participating sites, while already increasing mend services as greater than those patients who did patient volume, experienced improved access to not meet with a BHT. care and nonparticipating PCBH sites saw longer Hierarchical linear regression was used to under- wait times. In addition, where nonparticipating sites stand the impact of specific aspects of patient satis- experienced a 16% increase in community purchased faction (e.g., amount of time spent with the BHC, care costs (the amount of money that TRICARE provider or technician’s effort to listen) on overall spends on behavioral health care outside the MTF) patient satisfaction for those encounters with a tech- between pre- and post-implementation fiscal years, nician. All aspects of patient satisfaction for the pro- pilot sites saw a 4% decrease in purchased care costs vider were entered on an initial step and two items during this same time period. This 20% difference in assessing the technician’s role (their effort to listen Table 2 | Key process metrics for PCBH enhancement pilot Pilot sites Nonparticipating sites a a Process metric Pre-pilot Post-pilot %Δ Pre-pilot Post-pilot %Δ Total encounters PCBH 4,219 8,511 +99 48,856 59,726 +22 Mental health 23,214 24,952 +12 348,053 357,275 +3 Total patients PCBH 2,683 6,464 +140 30,116 34,209 +14 Mental health 6,132 12,865 +138 53,248 52,844 −1 No-show rate (%) PCBH 14.3 10.6 −4 8.9 8.8 −1 Mental health 12.1 8.3 −30 7.2 7.0 −3 Access to care PCBH 6.88 5.22 −12 4.09 4.24 +4 Mental health 6.06 6.13 +1 6.04 5.71 −6 Purchased care ($M) 3.30 3.17 −4 36.1 41.7 +16 PCBH primary care behavioral health. Average percentage across pilot sites. Percentage change rounded to nearest hundredth reported as whole number. page 270 of 273 TBM Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH and assessment of the problem) were entered on a specialty mental health may also have contributed second step. Results are shown in Table 4. Inclusion to a decrease in no-show rates and promote patient of the BHT items accounted for an additional 3% engagement. Reduced no-shows and improved of the variance in patient satisfaction, F change access, combined with increased population pene- (2, 70) = 7.76, p = .001; of note, their effort to listen tration, were also accompanied by large cost savings was significantly associated with patient satisfaction, by reducing the use of outside community providers β = .36, p < .001. with higher per-encounter reimbursement costs. In this regard, the findings provide initial, but poten- DISCUSSION tially compelling evidence for cost-saving models The results of this preliminary pilot are promising which may influence the insurance market land- and have implications for civilian health care organ- scape in health care to encourage further systematic izations. Findings reinforce the benefits of PCBH, research in this understudied area of systems-level with a focus on understudied practice-level factors factors. Sites incorporating PCBH into their patient [31–33]. Specifically, findings demonstrate the flow for specialty mental health referrals saved ability of PCBH to reduce specialty mental health money during a time when costs continued to burden, improving population reach and access. increase at other facilities and while experiencing This appears to have the added benefit of increas- greater demand for services. Cost savings were even ing patient compliance through improved appoint- stronger in the final two fiscal quarters of the imple- ment attendance. These benefits were seen not mentation project, suggesting that as clinic popula- only in PCBH, but also in specialty mental health tions become more familiar with new procedures clinics at participating sites, suggesting advantages and increase their service uptake, costs may decline of a stepped care approach that improved com- even further. munication, coordination, and reach of behavio- The positive findings associated with technicians ral health services within health care operations. are also promising preliminary results. Although Improved coordination between primary care and there may be some apprehension about a patient Table 3 | Patient satisfaction in technician-involved versus nontechnician-involved encounters Technician Nontechnician mean (SD) mean (SD) t 1. Amount of time for appt 5.23 (0.93) 5.29 (0.94) 0.49 2. BHC’s effort to listen 5.47 (0.85) 5.55 (0.76) 0.77 3. BHC’s knowledge of presenting concern 5.29 (0.96) 5.46 (0.81) 1.58 4. Quality of care/intervention 5.16 (0.99) 5.39 (0.82) 2.09 5. Overall treatment plan 5.00 (1.14) 5.32 (0.86) 2.26 6. Overall patient satisfaction 5.25 (1.00) 5.36 (0.88) 0.90 7. Likelihood to recommend IBHC services 5.32 (0.91) 4.94 (1.29) 2.94* 8. Patient health rating 3.54 (1.23) 3.61 (1.33) 0.36 BHC behavioral health consultant. Degrees of freedom adjusted due to heterogeneity of variances. *p < .05 using Bonferroni correction for planned analysis. Table 4 | Hierarchical linear regression predicting patient satisfaction from provider and technician factors 2 2 R ΔR β Final β Step 1 (Provider factors) .82 .82** Amount of time for appt .43* .35* BHC effort to listen .13 .02 Knowledge of presenting concern −.03 −.05 Quality of care/intervention .12 .17 Overall treatment plan .34* .31* Step 2 (Technician factors) .85 .03* Technician effort to listen .36** .36** Assessment of presenting concern −.15 −.15 Final model F(7, 70) = 56.92** BHC behavioral health consultant. *p < .01, **p < .001. TBM page 271 of 273 Downloaded from https://academic.oup.com/tbm/article/9/2/266/4992907 by DeepDyve user on 13 July 2022 ORIGINAL RESEARCH having to meet with yet another individual to preserve “real-world” practices, few additional describe their presenting concern, findings were not constraints were placed on pilot sites. Although consistent with this being seen as a barrier. Given this improves generalizability, it also significantly the parallel process to typical primary care opera- increases heterogeneity of the intervention sample. tions, patients may not have been acutely aware of Thus, it is quite possible that a number of other the difference. This was likely reinforced by train- variables (e.g., fidelity to model, staff training and ing the BHC to provide a biopsychosocial concep- expertise, population demographics) may have tualization to the patient when entering the room, contributed to the positive findings. Without direct reaffirming that the technician had fully briefed the measures of these confounds, the ability to draw provider on the case, allowing the patient to validate causal inferences is more limited. that report, and then move immediately into inter- Despite these constraints, we feel these results vention. In this way, the patient would not need to offer important encouragement for further re- “tell their story” yet again while still feeling heard. In search in the field of PCBH at the systemic level. It fact, patient satisfaction was improved by a techni- is important to emphasize that these changes were cian’s effort to listen—and this survey was completed incorporated in a system where there are clearly at the end of the entire encounter; thus, it is likely defined competency-based expectations for PCBH that the ability of the BHC to convey the techni- providers and clinics. These expectations are easily cians’ report reinforced a feeling of team-based care. translatable to new facilities, as the Department of Results further indicated that the quality of care Defense has expanded many of these clinics only in with both a technician and BHC is perceived as simi- the past few years [18]. As discussed above, these lar or perhaps preferred to care with that same BHC MTFs have considerable variability in size, staffing, only, while providing potential benefits that may and resources and are in locations with significant indirectly lead to improved utilization. In particular, diversity in patient empanelment, environment, and incorporating technicians in patient care appears presenting concerns. The MHS provides care not to provide opportunities to increase provider effi- only for service members, but also for family mem- ciency and patient access—resulting in at least three bers and retirees, whose diversity mirrors the ci- extra appointments daily in the current study—while vilian population. Thus, the USAF’s PCBH training maintaining the experience of care. Several possibil- and implementation program provides a “roadmap” ities may explain these findings, although these links for both civilian and military health care settings to have not been empirically tested. The first is that by allow for further testing and evaluation. having this model whereby someone from the PCBH In addition, this study utilized a pre- and post-test team is always available, even if an appointment has intervention design with control group comparison been scheduled, allows for both the warm-hand- for analyzing results. Although statistical analysis offs and the scheduled follow-ups to occur without is limited by the small intervention sample size decreasing either patient or PCP access, which can and limited time points, these preliminary findings be a barrier to referral [22]. Second, this model are reinforced by prudent methodological design. may increase comfort with PCBH as “routine” for Although these facilities are heterogeneous and patients and PCPs, as we know that individuals were not selected entirely at random, it is important bring certain schemas to various situations and that to highlight that results were compared against these influence their perceptions and expectations the population of 69 other MTFs who also vary in these environments [34]. Finally, research sug- in fidelity to the model on measures such as staff gests barriers to BHC service utilization are higher training and expertise, population demographics, among nonprovider members of the primary care and a host of other potential variables of interest. team [22]. Having a technician available may also Thus, these positive findings across this naturalistic facilitate more interactions between team members variability speak to the potential generalizability of by promoting relationships between team members these findings. Finally, these benefits were achieved with similar levels of training and responsibility at “zero cost” to the existing PCBH and specialty (e.g., BHT to medical technician, BHCs to PCPs). mental health clinics. No additional personnel were Future research should directly test these potential recruited or hired across all three sites; manning explanations. decreased while it was reallocated. No additional This preliminary study is not without limitations. compensation was provided to these sites to support The sample size and time points for which data were these changes. Thus, there is little net cost to imple- collected limit the ability to utilize more advanced menting these changes relative to the significant po- statistical analysis. Furthermore, the low response tential benefit demonstrated by these preliminary rate for patient satisfaction may limit our ability to positive findings, which may seek to encourage fur- evaluate the representativeness of the sample, des- ther systematic research in this area. pite its consistency with response rates in previous Future research should seek to address the limi- studies in similar settings. It also introduces the po- tation of the small intervention sample by further tential for selection and nonresponse biases in the expanding this QI initiative based on these prom- sample. It is important to note that in an effort to ising preliminary findings. 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Journal

Translational Behavioral Medicine – Oxford University Press

Published: Mar 1, 2019

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