Quality Control and Fidelity to Primary Care Behavioral Health Model of Service Delivery:

Programmatic Behavioral Health Consultant Training in a Large Federal Healthcare System

Christopher L. Hunter, PhD ABPPKent A. Corso, PsyD, BCBA-D

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session # B2aFriday October 17, 2014

Faculty Disclosure

• We have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• List the core competencies behavioral health consultants need for consistent primary care appropriate behavioral health service delivery.

• Described the types of policies/standard operating procedures needed to ensure consistent training and monitoring of service delivery over time.

• Describe the competencies and skills needed for expert trainers.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Quality Control and Fidelity to Service DeliveryBottom Line Up Front

Primary Care Behavioral Health Model *

2014 Annual Conference

“ Here he is Edward Bear (aka Winnie-the-Pooh), coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it…”

A. A. Milne

Quality Control and Fidelity to Service Delivery

Why should anyone care?

Primary Care Behavioral Health Model *

2014 Annual Conference

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

▪ Background/Context▪ History, Funding/Policy, Workforce Development

-Hunter, C. L., Goodie, J. L., Dobmeyer A. C., & Dorrance, K. A. (2014). Tipping points in the Department of Defense’s experience with psychologists in primary care. American Psychologist, 69, 388-398.

-Hunter C. L., & Goodie, J. L., (2012). Behavioral health in the department of defense patient-centered medical home: History, finance, policy, work force development and evaluation. Journal of Translational Behavioral Medicine, 2, 355-363.

Primary Care Behavioral Health Model *

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Primary Care Behavioral Health Model *

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Age Total % Female % Active Duty % Retired % Family Members

0-4 307,188 49% N/A N/A 100%

5-14 478,689 49% N/A N/A 100%

15-17 121,014 49% N/A N/A 100%

18-24 559,098 39% 60% 0% 40%

25-34 723,752 41% 67% 0% 33%

35-44a 444,297 49% 56% 6% 37%

45-64a 571,348 46% 11% 45% 43%

65+ 145,792 52% 0% 49% 51%

Total 3,351,178 aTotal % of Active Duty, Retired and Family Members does not equal 100% due to rounding

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System3.3 million enrolled to a primary care provider

▪ Policy/Standards – DoD Instruction 6490.15– Program Standards

▪Model of Service Delivery▪Staffing Ratios▪Expert Trainers▪Training Standards▪Program Managers▪Oversight Committee

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www.dtic.mil/whs/directives/corres/pdf/649015p.pdf

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

▪ Primary Care Behavioral Health (PCBH) Model Focused on all enrolled patients

▪BHP is a primary care (PC) team member ▪BHPs & PCPs share patient information▪Brings a team-based management approach ▪Helps team improve BH assessment & intervention▪Sees patients in 15-30 minute appointments ▪Same day as well as scheduled appointment availability▪Focuses on full range of BH presentations

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BH: is being used as a generic term to include services for health behavior change like weight loss, substance dependence/abuse/misuse, behavioral medicine interventions like chronic pain management, and general mental health services like panic disorder.

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

▪ Blended Model of CareCombining PCBH model and care management model service delivery components in the same clinic. -One BHP and one care manager in clinics with 7500+ enrollees

Primary Care Behavioral Health Model *

2014 Annual Conference

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

Expert Behavioral Health Care Facilitator TrainersEXPERIENCE COMPETENCIES:

a. Successfully completed BHCF training and meet all core BHCF core competencies

b. Has 3 years of full-time clinical experience in a primary care setting.

c. Is designated as an expert trainer by his or her Service designation authority.

KNOWLEDGE COMPETENCIES:

a. Performance criteria for BHCF competencies and administrative and clinical standards.

b. Service practice standards and all related policies and procedures related to training.

TEACHING COMPETENCIES:

a. Train to criterion-based core competency benchmarks for evaluating trainee performance.

b. Use behaviorally-based feedback and modeling.

c. Provide corrective feedback in a constructive skill-building manner.

ADMINISTRATIVE COMPETENCIES:

a. Model the development of cooperative relationships with the local PCMs, IBHCs, and patients.

b. Aid BHCFs in assessing customer satisfaction, clinical outcomes and other performance measures related to their service.

Primary Care Behavioral Health Model

2014 Annual Conference

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

Expert Behavioral Health Consultant (BHC) TrainersLICENSURE AND EXPERIENCE:

a. Will hold a professional mental health-related license, have successfully completed the initial IBHC training and met all core IBHC competencies.

b. Will have accrued at least 200 clinical IBHC patient contacts in primary care and have at least 3 months of full-time equivalent IBHC primary care clinic experience.

2. KNOWLEDGE COMPETENCIES:

a. Performance criteria for IBHC competencies and administrative and clinical standards.

b. Service practice standards and all policies and procedures related to training.

3. CLINICAL COMPETENCIES.

IBHC expert trainers will demonstrate skill in applying the PCBH model of service delivery with a wide variety of primary care patient problems using evidence-based interventions.

4. TEACHING COMPETENCIES:

a. Train criterion-based core competency areas and benchmarks for evaluating trainee performance.

b. Use behaviorally-based feedback, modeling, and guided rehearsal.

c. Provide corrective feedback in a constructive skill-building manner.

5. ADMINISTRATIVE COMPETENCIES.:

a. Contribute to program design built on population-based care principles, with the aim of targeting IBHC services to population needs.

b. Model the development of cooperative relationships with the local clinic chief, the primary care team leader & other primary care staff

c. Aid IBHCs in assessing customer satisfaction, clinical outcomes and other performance measures related to their service.

6. EXPERT TRAINER DESIGNATION. The Service will designate individuals as expert trainers…before the publication of this instruction

Primary Care Behavioral Health Model

2014 Annual Conference

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

▪ Training Standards for BHCs and BHCFs▪Must be trained by expert trainers▪Must be trained to clinical/administrative benchmark competencies▪Must demonstrate knowledge of policy/standards▪Must demonstrate benchmark clinical/administrative core competencies

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Training and demonstration of knowledge and competencies must occur prior to the BHC or BHCF starting work in primary care.

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

▪ BHC TrainingPHASE I: Self-study (8 hours)

PHASE II: didactic and role plays of core competency skills (32 hours)

PHASE III: chart review, site visit, direct observation, chart review, re-administration of core competency skills assessment

Primary Care Behavioral Health Model *

2014 Annual Conference

Quality Control and Fidelity to Service DeliveryDepartment of Defense Military Health System

Primary Care Behavioral Health Model *

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Challenges/Lessons Learned

1. Develop agreed upon clinical/administrative standards that are observable/can be enforced. -Develop methods to ensure workforce is trained to clinical & administrative standards-Fidelity to service delivery model for desired outcomes to have a chance to be realized

2. Develop manuals addressing clinical, administrative, operational & financial components.- Guide practitioners/administrators on what services will & will not do

3. Develop, implement and enforce system level policy as well as clinic level SOPs

Future Directions

∎Program improvement project:

PCBH model fidelity ❑Clinical outcomes❑Formal instrument❑Chart review❑Assign fidelity score❑Regression equation examining relationship between fidelity and clinical

outcomes irrespective of demographic variables❑Provide Feedback to BHCs

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Future Directions

∎Program improvement project:

Inter-observer agreement between trainers in training settings❑Use of Simulation Center❑Use of Standard Core Competency Forms (CCFs)❑Multiple trainers review same video role play❑Calculate inter-observer agreement in CCF ratings❑Provide feedback to trainers; discuss results and develop concensus around

solutions

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Bibliography / Reference1. Hunter, C. L., Goodie, J. L., Dobmeyer A. C., & Dorrance, K. A. (2014). Tipping

points in the Department of Defense’s experience with psychologists in primary care. American Psychologist, 69, 388-398.

2. Hoge M.A., Morris J.A., Laraia M., Pomerantz A., & Farley, T. (2014). Core Competencies for Integrated Behavioral Health and Primary Care. Washington, DC: SAMHSA - HRSA Center for Integrated Health Solutions.

3.McDaniel, S. H., Grus, C. L., Cubic, B., Hunter, C. L., Kearney, L. K., Schuman C., Kessler, R. S.,…Johnson S. B. (2014). Competencies for psychology practice in primary care. American Psychologist, 69, 409-429.

4.Hunter C. L., & Goodie, J. L., (2012). Behavioral health in the department of defense patient-centered medical home: History, finance, policy, work force development and evaluation. Journal of Translational Behavioral Medicine, 2, 355-363.

5. Hunter C. L., & Goodie, J. L., (2010). Operational and clinical components for integrated-collaborative behavioral health care in the patient centered medical home. Journal of Families Systems and Health, 28:308-321.

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