Neftali Serrano, PsyD Director, Behavioral Health Services, Access Community Health Centers

1. 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.

2. 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 2

3. Objectives • 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 • Identify the workforce development needs which are needed to sustain a suitably trained workforce and a role which is attractive for mental health professionals • Understand the historical development of the Behavioral Health Consultant role in comparison to other healthcare specialties 3

4. 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. 4

5. 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 5

6. 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

7. 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 7

8. 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

9. 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? 9

10. Should BHC Work be a "Specialty"? • "Specialties" are defined differently by different organizations: • APA's Committee for Recognition of Specialties and Proficiencies in Professional Psychology (CRSPPP) • Council of Specialties (CoS) • American Board of Professional Psychology (ABPP) • CRSPP definition of a "specialty": • 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. 10

11. Or Perhaps BHC Work Should be a "Proficiency" • CRSPP definition of a "proficiency": • 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. 11

12. What it Takes to Become a Specialty • Petition the CRSPP to show fulfillment of criteria • "Specialty" criteria of the CRSPPP: • Administrative Organizations • Public Need for the Specialty Practice • Diversity • Distinctiveness • Advanced Scientific and Theoretical Preparation • Advanced Preparation in the Parameters of Practice • Structures and Models of Education and Training in the Specialty • Continuing Professional Development and Continuing Education • Effectiveness • Quality Improvement • Guidelines for Specialty Service Delivery • Provider Identification and Evaluation • Similar criteria for a "proficiency" 12

13. Examples of Specialties and Proficiencies • Specialties • Clinical Health Psychology • School Psychology • Counseling Psychology • Industrial-Organizational Psychology • Behavioral and Cognitive Psychology • Forensic Psychology • Clinical Neuropsychology

14. Ideal Components of Curricula • 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 14

15. Examples of Specialties and Proficiencies • Proficiencies • Police Psychology • Biofeedback • Psychopharmacology • Sport Psychology • Treatment of Alcohol and Psychoactive Substances • Personality Assessment

16. 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

17. 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

18. How To Pay BHCs

19. 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 in-between 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 19

20. 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: "Provider-Only 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. 20

21. Payscale Exemplar • Access Community Health Centers: • Director • Team Leads • Psychologist Staff • Social Work Staff • Regional Variations In Payscale: • Midwest, northeast, south 21

22. Designing A Sustainable Specialty

23. 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. 23

24. 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. 24

25. 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) 25

26. 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 26

27. Session Evaluation • Please complete and return theevaluation form to the classroom monitor before leaving this session. • Thank you! 27