Primary Care Mental Health Integration

Primary Care Mental Health Integration
Dr. Anna Cassel |  Anna.Cassel@va.gov

Residents training in the Primary Care Mental Health Integration (PCMHI) track actively participate on the Primary Care Behavioral Health (PCBH) team. The PCBH program was established to promote effective treatment of common mental health and physical health conditions commonly seen in the primary care environment. With a high level of stigma associated with seeking specialty mental health services, PCMHI allows patients to receive short-term therapy and psychiatric medication management within the comfort of the primary care environment. This includes ability to provide early interventions when Veterans present to primary care in the early stages of symptomatology. In addition, our team is trained in helping to address psychological aspects that impact medical conditions (i.e. life-style behaviors, effective use of coping strategies, impact of stress on the body, & adjustment to medical conditions). PCMHI services are delivered by a team consisting of psychologists, a psychiatrist, clinical nurse specialists, social workers, residents in each of these respective disciplines, and peer specialists. The postdoctoral residents will be an integrated member of the PCBH team, and will learn to provide treatment for mental and physical health concerns that are commonly seen within the primary care setting and the Women’s Health Clinic. This experience will provide the postdoctoral residents with the knowledge and understanding in applying the biopsychosocial model and the mind-body approach to providing whole-person care.

Referrals to the program are generated from primary care providers either by their discretion and/or positive responses to routine screens for depression, PTSD, substance use, weight, or chronic pain. If the Veteran is interested in PCMHI services, then a member of our team joins the end of the primary care visit as a warm handoff. This allows us to get a brief sense of the Veteran’s needs, and to help reduce stigma and open up access to mental health services. The team completes a brief psychological evaluation during a warm handoff, and triages for appropriateness of fit for the program based on level and type of care needed. This feedback is sent back to the primary care providers to facilitate the collaboration between these services or to coordinate with programs that would best meet the needs of the Veteran. Brief interventions are provided in PCMHI through use of CBT, ACT, mindfulness-based approaches, and the use of biofeedback. The postdoctoral residents will learn to provide the full spectrum of care provided by the program.

In addition to working as an integrated member of PCMHI and primary care, postdoctoral residents also complete sub-rotations working within our pain self-management clinic and in the MOVE! weight management program. These opportunities allow for further depth in behavioral health training experiences. Similar to their experience in PCMHI, trainees will serve as members of interdisciplinary teams within both of these clinics (including opportunities to co-facilitate groups and provide consultative services across multiple disciplines within our healthcare system). Training in these sub-rotations also includes provision of individual therapy targeting management of chronic pain (CBT for Chronic Pain (CBT-CP), Brief CBT-CP, ACT for Chronic Pain, Biofeedback, etc.) and support for health behavior changes such as weight management. Additional opportunities are also available to complete pre-surgical evaluations for bariatric surgery and organ transplant as well as to increase exposure to Health Promotion/Disease Prevention principles. With all of our services, our residents are able to become specialists in collaborative care, pain management, and weight management.

Below are further details on some of the components of our training track.

Warm handoffs
Post-doctoral residents each cover 1 to 2 half days of warm handoff coverage to primary care/week. For each ½ day of coverage, we also have staff back-up coverage to always ensure needed supervision is available.

Individual therapy
Post-doctoral residents follow a caseload of individual therapy cases in primary care for both physical and mental health concerns. PCBH tends to follow Veterans with mild to moderate level of symptoms, and then higher risk Veterans are referred to the Mental Health Clinic.

Consultation to primary care
Postdoctoral residents complete curbside consultations to primary care providers. Team members also join the various PACT pre-planning meetings, which allows our team to be fully integrated into the PACT groups.

Biofeedback 
Biofeedback is a way to tune into the body’s physiological response to stress, and to see how one’s body is responding physiologically to relaxation and mindfulness coping strategies. When working with a medical population, biofeedback is a critical way to help individuals understand the importance of the mind/body connection. Biofeedback services are used both in PCBH and pain self-management.

Pain self-management
Post-doctoral residents will learn to complete Psychology pain evaluations, comprehensive mental health evaluations, and engage in collaborative treatment planning with Veterans diagnosed with chronic pain conditions. The residents will also rotate as a team member on the interdisciplinary pain teams.

Individual therapy (chronic pain)
Post-doctoral residents will gain experience in providing individual therapy for Veterans with chronic pain conditions. Treatment may include Cognitive Behavioral Therapy for Chronic Pain (CBT-CP), which is identified by VA as an Evidence Based Practice, as well as Acceptance and Commitment Therapy for Chronic Pain, Biofeedback, Motivational Interviewing, and interventions for chronic pain and comorbid mental health concerns such as joint treatment for pain and PTSD.

MOVE! Weight Management
MOVE! evaluations: Postdoctoral residents will learn to complete comprehensive mental health evaluations for weight management.
Individual therapy: Postdoctoral residents will gain experience in providing behavioral health strategies for weight management through the MOVE! program.
MOVE! class: Post-doctoral residents will have the opportunity to help facilitate a weekly MOVE! weight loss management class. This class is co-led with other disciplines including nutrition, pharmacy, and recreation therapy.

Pre-surgical evaluations: Trainees will learn to complete comprehensive pre-surgical mental health evaluations for Veterans seeking an organ transplant and bariatric surgery.

Other Training Opportunities

Whole Health: Whole Health is a mission of the VA system to help Veteran’s bring a mindful awareness to their values and lives. Trainees will co-facilitate a 9-week Whole Health group with our Whole Health peer specialists.

Mindfulness: Trainees will have ample opportunity to learn about mindfulness during the residency. Trainees have the optional opportunity to co-facilitate a weekly mindful moment to primary care, a 6-week Introduction to Mindfulness group, or a 12-week Mindfulness Based Wellness group.

Training of family medicine residents: PCBH trains a family medicine resident each month while they complete 4-week rotations in our program to learn about mental health. This offers an amazing opportunity to both teach and learn from medical residents on our team.

Weekly peer consultation: Our post-doctoral residents and NP fellows rotate with providing weekly peer consultation to our family medical resident. This can range from discussing topics related to integration, providing peer consultation on cases, or educating the residents on areas of interest.

Learning objectives
1. Understand the underpinnings of the various evidence-based models of integrated care.

2. Understand at advanced level how to work in the medical culture.

3. Conceptualize cases from mental health and medical perspective.

4. Develop and implement evidence-based programs for integrated care.

5. Proficiency in performing quick assessments within the primary care setting.

6. Proficiency in motivational interviewing in clinical work to promote engagement in treatment and/or health behavioral change.

7. Proficiency in delivering brief interventions for mental health conditions commonly seen in primary care setting.

8. Proficiency in delivering focused treatment for psychological factors related to medical conditions.

9. Proficiency in delivering care management for at risk mental health conditions.

10. Proficiency in providing care in dual fashion with primary care providers.

11. Acquire skill to work collaboratively with primary care providers with shared treatment plan and curbside consultations.

12. Demonstrate proficiency in flexibility to manage high caseload with short session durations within primary care setting (20–30-minute visit vs traditional 50-minute session).

13. Contribute on multidisciplinary medical teams from behavioral health perspective.

14. Ability to work as team member in primary care.

Target professional experiences
1. Manage primarily short-term cases with evidence-based brief interventions for common mental health and medical conditions in primary care clinic.

2. Develop and deliver groups for self-management of medical conditions and health behaviors.

3. Provide at least 5 co-visits with PCBH prescribers (psychiatrist, NP, NP fellow, and medical residents).

4. Maintain open access to primary care medical staff for warm hand-offs and curb-side consultation.

5. Effectively communicate with PCBH team and primary care staff to coordinate good care.

6. Provide consultation to Bedford and affiliated CBOC programs on principles of integrated care.

7. Identify relevant topics in primary care and present to primary care staff at least once.

8. Collaborate in dual fashion with peer specialists in PCBH and pain program.

9. Identify a need in the primary care system and develop at least one research or program development project for quality improvement.

10. Actively participate in weekly PCBH team meeting and primary care staff meetings.

11. Assume administrative duties in delivery and development of programs for PCBH.