Essential Strategies for Teaching Integrated Behavioral Health in Graduate and Clinical Settings
Andrea Burgoa: Welcome! Welcome, everyone, to our webinar on teaching integrated behavioral health with the authors. Andrea Burgoa: of Integrated Behavioral Health and Primary Care, please feel free to share where you’re joining from in the chat as everyone logs in and gets settled. My name is Andrea Burgoa. I am, Andrea Burgoa: the Higher Ed Marketing Manager here at APA Publishing. I’m going to start today with a few housekeeping items while everyone is joining and getting settled, so… Andrea Burgoa: Number one, all attendees are muted to prevent accidental noises and distraction, but we have provided multiple modes of communication and interaction for today’s session. Auto captioning is enabled and can be accessed via the closed caption button. Andrea Burgoa: Chat is open and available for all attendees to use and to communicate with your other attendees and share your own experiences and thoughts. 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Andrea Burgoa: Now I’d like to welcome you again to our webinar on teaching integrated behavioral health, and I’d like to introduce our panelists. Andrea Burgoa: Dr. Jeffrey L. Goodie is a professor in the Department of Family Medicine with a secondary appointment in the Department of Medical and Clinical Psychology. A board-certified clinical health psychologist and retired U.S. public health service captain, Dr. Goodie brings more than two decades of leadership advancing the integration of behavioral health into primary care systems. Andrea Burgoa: He has taught integrated primary care at the graduate, internship, and professional levels, both nationally and internationally, and has led training, research, and implementation efforts in the primary care behavioral health model to access… to enhance readiness, access, and health outcomes across diverse populations. Andrea Burgoa: And Dr. Christopher Hunter is currently the co-director of CNC Hunter Consulting, with an interest in applying his experience and expertise to health systems and clinics that want to establish, expand, or improve their integrated behavioral health services and primary care, with a focus on whole-person and team-based care. Andrea Burgoa: Prior to his current position, he led the development, implementation, dissemination, and quality improvement efforts for primary care behavioral health services in the military health system over a 14-year period. Andrea Burgoa: I want to thank you both for being here, and I’m going to go ahead and turn it over to you. Jeffrey Goodie: Great. Jeffrey Goodie: Well, thank you. It is a pleasure to be here with everyone, and today we’re going to be talking about teaching integrated behavioral health in today’s graduate and clinical settings, and really specifically focusing in on how Jeffrey Goodie: you might use, the book that both Chris and I are co-authors on, Integrated Behavioral Health and Primary Care, Step-by-Step Guidance for Assessment and Intervention, how we’ve used that for teaching, particularly at the graduate level, but also talking maybe a little bit, within other kind of clinical settings. Just as we get started here. Jeffrey Goodie: First and foremost, I, my job is within the Department of War, but, I… nothing that we’re saying here, none of these opinions, are representative of, Jeffrey Goodie: where I work, or the Department, Department of War, the Defense Health Agency. These are all, my own comments, as well as Chris’s. Jeffrey Goodie: So, we’re going to start out… Chris is going to start out just giving an overview of, sort of, the integrated primary care landscape, talking a little bit about why this topic is valuable and important, not only within our healthcare system, but also why it’s important to teach about that. Jeffrey Goodie: He’s going to be talking about some of the key topics and competencies that are related to integrated primary care education. Jeffrey Goodie: And then I’ll talk, more specifically about, sort of, practical teaching strategies, how, how I’ve gone about talking about it. But then, really, we want to make sure that we leave time for questions at the end where we can Jeffrey Goodie: Kind of address questions that you might have that, in case you’re thinking about teaching in your own setting, and we can talk about ways that you might be able to adapt, kind of what we’ve done, to, where you’re at. Jeffrey Goodie: And so with that, I’m going to turn it over to Chris, and to talk about this overview of integrated primary care. Christopher Hunter: Yeah, thanks, Jeff, I appreciate that, and thank you all for taking time out of your busy schedules to join us. We hope that you’ll be able to have some good takeaways that you can apply to the things that you’re interested in doing. Christopher Hunter: Currently. Just as some additional context, I’ve been… Christopher Hunter: working in integrated primary care settings for the last 25 years, not only as an integrated behavioral health provider, I’m a clinical health psychologist by training, but I have also worked in APA-accredited internships and have Christopher Hunter: taught and trained psychology interns to work in primary care. So, you know, one of the things that we think about in terms of why in the world would we ever want to integrate into primary care, right? We spend all this time training to be, you know, doctoral level psychologists or master’s level mental health people. Why would we ever want to do this? Christopher Hunter: And I think part of the reason is Christopher Hunter: That only a very small percentage of the folks that would benefit Christopher Hunter: From seeing a mental health provider are gonna ever get that care. Christopher Hunter: And I think, as we’ve seen, especially as the pandemic rolled out. Christopher Hunter: access to qualified mental health providers in the specialty setting is less and less. It’s even more difficult in rural areas. People don’t necessarily want to make those steps to go to see this mental health person that’s over here that I don’t know. Christopher Hunter: And so when we look at those who are actually getting good, evidence-based informed care. Christopher Hunter: compared to those who might benefit from it, we’re really only hitting the tip of the iceberg, and most people that could benefit from good behavioral health services Christopher Hunter: either don’t have access to it, won’t go to it, it gets delayed, or they don’t even know it exists. So, that’s part of the reason to integrate into primary care. Christopher Hunter: You put the resources where we know people are gonna go. Christopher Hunter: It’s not uncommon for people to have a primary care or a go-to physician. Christopher Hunter: In the perfect world, they get to know that team, they stay there. Christopher Hunter: And those teams, when they’re operating at their best, it’s not just a primary care provider and it’s a nurse, but it’s also other people that round out that team. So not only an integrated behavioral health provider, but in my perfect world, you know, do we have a physical therapist that’s also part of the primary care team? Christopher Hunter: Do we have a PharmD who’s part of that team? Do we have an acupuncturist? So. Christopher Hunter: the patient can actually get one-stop shopping. They’ve got one store to go to, they go to the Super Walmart, they know that they can get almost anything they want there, but if they need something specialized that Super Walmart doesn’t carry, they can go to a specialized store to get that. Next slide. Christopher Hunter: So, really, the idea here is how do we start to deliver behavioral health services that are more of a population health focus? How can we provide Christopher Hunter: Less care, less intensive care, to a greater number of people. Christopher Hunter: who, by the sheer volume, you’ll end up helping more people, even if you’re less effective. And we don’t really have time to go into what a population health approach is to healthcare, but if you Google that, you’ll get some pretty good definitions of what that’s like. So, it’s basically, how can we Christopher Hunter: have better access and deliver these kinds of services to the most people that we can, in a way that can be effective. Next slide. Christopher Hunter: So, why teach integrated primary care? And I can see this. I’m trying to put myself into people that are, you know, grad school professors, and, you know, your whole program, or much of your program, is designed around, let’s just say generically, to produce people that are going to go do specialty work. Christopher Hunter: certainly you have, different specialties people can go into, or different tracks people can go into, but why would I want to bother, you know. Christopher Hunter: I hear about integrated care, APA talks about integrated care, but I’m having trouble just, sort of, kind of meeting my goals here. And I think there’s a couple of reasons. One is that by being able to produce… introduce integrated care Christopher Hunter: Principals to graduate level, and or clinical kinds of training. Christopher Hunter: It allows those people to have more flexibility about what they choose to do. Christopher Hunter: Some of them may not have any interest in going into primary care at all right now. That may change down the road. And what we do know is if you take somebody who’s just trained to deliver specialty Christopher Hunter: behavioral health services, and you drop them in a primary care clinic, and they haven’t been trained to do that, they will quickly fail. I’ve seen it over and over and over again in multiple systems. So. Christopher Hunter: The other thing that I think was sort of surprising to me when Christopher Hunter: I was at, faculty on an ATA internship. I was in charge of the primary care, integrated primary care rotation, and it was mandatory for our psychology interns to go through, and it was a month-long Christopher Hunter: clinical experience where they observed me for a week doing this, we discussed all the patients, I observed them for a week doing all the patients, then they saw all my patients with me next door, then I followed back up again with them on that. So, they had to learn, I trained them to a very specific set of core competencies. Christopher Hunter: And the consistent feedback that we got was, even for people that didn’t really want to go to the primary care training, they found it Christopher Hunter: beneficial Christopher Hunter: And it made them more efficient and more effective in their especially outpatient behavioral health work. So in 60-minute appointments, they felt like they were better able to Christopher Hunter: Assess what the problem was. Come up with a shared decision about what are the goals for treatment. Christopher Hunter: write that treatment plan out with specific things that patient can start doing that day, and because I helped… I trained the interns to write their note as they’re in the appointment with the, with the patient. Christopher Hunter: When that patient walked out of the specialty mental health clinic, their specialty mental health note was 80-85% benched. And that patient walked out that day Christopher Hunter: with an evidence-based informed treatment plan that they could start doing then. So they said it made them… it gave them a greater breadth and depth of skill that they could do more efficiently and more effectively. That’s something we hadn’t really thought of, but we were really pleased to find that, because most of the providers, most of the Christopher Hunter: Interns we were training were initially gonna go to specialty outpatient mental health. Christopher Hunter: And now we knew that they could really crush it when they went out there. So… Next slide. Christopher Hunter: So, when we think about Christopher Hunter: kind of where people get behavioral health, mental health services, or care. It really kind of falls into a stepped care approach, right? A lot of people who are struggling, will read a self-help book, they’ll talk to a spouse, a clergy member. Christopher Hunter: friend. Some people, nowadays, it’s a lot easier to go online. You know, you can have AI-based or web-based things. There are a range of products that are available to folks at no or minimal cost. Christopher Hunter: And then, sort of like, if we took this into kind of a medical problem, let’s say somebody had a cough, right? Christopher Hunter: And they’re gonna kind of treat their cough at home, and their cough’s getting a little worse, so they go ahead and they do some online stuff, and they get an idea about what they might do, and so they do some more stuff, but their cough’s getting worse, it’s not getting any better. Well, their next step is to go to primary care, right? Because they’ve tried to address it on their own, and I think that similar Christopher Hunter: trajectory can happen with people that have a behavioral health concern or a biopsychosocially influenced concern or problem. You know, they go to primary care. Christopher Hunter: And hopefully, most of those people that go to primary care are able to assess and address and resolve that problem, that cough, with the primary care provider, right? Christopher Hunter: But what happens if it doesn’t get resolved? Well, most of it can get resolved at primary care, but then there may be a small number of people that go on, and they’re gonna go see a specialist. They’re gonna go see some other specialist that the primary care provider wants. Not unlike Christopher Hunter: Somebody who was being helped for behavioral health or a biopsychosocially influenced problem in primary care, if they don’t seem to be functionally improving or symptom improving. Christopher Hunter: Well, maybe they do need specialty services. It’s sort of like, also, the person that comes to primary care for a headache that doesn’t get resolved. Well, now let’s go see a neurologist, right? Christopher Hunter: Some people absolutely do and need specialty behavioral health services. Christopher Hunter: We want to make sure that we give people the right care at the right time for the level of problem they have. So we don’t want, necessarily, people with adjustment disorders going to see specialty behavioral health, because we know we can address those. We know we can address… and there’s a growing, Christopher Hunter: mound of research to support this. We know that we can Christopher Hunter: Help assess, treat, intervene, and improve health, function, and quality of life for a range of behavioral health presentations and biopsychosocially influenced problems in primary care. Christopher Hunter: If they’re not getting better, let’s get them to specialty behavioral health, and then for a tiny number of people, they need inpatient care, right? So we think about this as behavioral health on a stepped care. Christopher Hunter: the right treatment at the right time for the right person, given what their current situation is. Jeff, next slide. Christopher Hunter: So… Christopher Hunter: Two of the primary models of integrated care delivery are a care management model, also known as a collaborative care model, and a primary care behavioral health model of service delivery. And then there are Christopher Hunter: some clinics or systems that will blend those two models together. So let’s take a little deeper dive of what these are. Christopher Hunter: So, care management model, or collaborative care model, is really a clinical care pathway. Christopher Hunter: It’s set up so that people are screened for a particular problem. The most common one, and the most… the one that was the earliest studied was for depression. Christopher Hunter: People are screened for depression in primary care. If they pop positive on the PHQ2, they get a PHQ-9. If they score in a certain range there, the primary care provider talks about bringing in a care manager to assist them with treatment. Christopher Hunter: primary care… the care manager is typically going to be a nurse, but it could be a social worker, it could be a master’s level person, it could be a doctoral level person. They’re delivering a very Christopher Hunter: prescribed assessment at each follow-up. How are you doing? They have very specific modules or strategies that they can do. If they have particular Christopher Hunter: challenging patients, or they want particular medication recommendations, the primary care provider and care manager can bring in a psychiatrist. A psychiatrist is also part… a consulting psychiatrist is part of this model. Christopher Hunter: And then, when it’s available. Christopher Hunter: and this tends to be more in those blended models. They can also bring in psychologists if they wanted to add additional skills in on other problems. Now, a care management model is also being expanded for other things, like anxiety, post-traumatic stress disorder. It’s really a well-defined Christopher Hunter: Clinical care pathway, where everybody knows what their role is, what the other people on the team, what their role is, and what the outcome is that they’re looking for. Christopher Hunter: Next slide. Christopher Hunter: So, when I hear people say, well, we’re doing integrated care, or we’re doing collaborative care. Christopher Hunter: I like to ask them, well, specifically tell me what you mean, because there is a real continuum of what that looks like, and Jeff, I think this is the slide that we’ve got movement on, right? Christopher Hunter: Go ahead and hit the next one. Christopher Hunter: So, we’ve got coordinated care, which is, okay, your primary care folks are talking with mental health providers who are maybe not in the building, they could be in the building, Christopher Hunter: Or somewhere in the building, probably not in the clinic. And that can be helpful, but it’s still, you know, it’s trying to, like, spray a fire hose through the opening of a Coke bottle. You’re not going to get much flow that way. Patients end up not… no-showing or canceling their appointments. Go ahead, next, Jeff. Christopher Hunter: Co-located care is where you have a behavioral health Christopher Hunter: provider who is in the primary care clinic. Now, that doesn’t mean they’re doing good integrated care. Christopher Hunter: Co-located care only means you have a behavioral health provider in the primary care clinic. Christopher Hunter: It doesn’t mean that they’re necessarily having a shared medical record. It doesn’t necessarily mean they’re not doing just 60-minute appointments, and while this makes it easier for a patient to get Christopher Hunter: What’s typically happening in especially care. Christopher Hunter: these specialists quickly fill up, there becomes a backlog, there’s a long wait list, and then they start to become irrelevant to the primary care team, because they’re just not able to help their patients. So, when people talk to me about doing co-located care, my question is, is the return on investment really worth it? Christopher Hunter: You know, I’d rather see you do this and explain to them their options, because I think you’re going to get this kind of return on investment, if that’s your goal. Next. Christopher Hunter: So, on the far end of this continuum is primary care behavioral health. Christopher Hunter: Our primary care behavioral health model of service delivery. Christopher Hunter: Okay, Jeff, go to the next slide, and we’ll talk about what a PCBH model of service delivery is. Christopher Hunter: So, the primary care behavioral health model, or PCBH model of service delivery, is where you have a behavioral health consultant that could be a doctor-level person, it could be a master’s level person, Christopher Hunter: It could, at this point now, be an LPC, Christopher Hunter: Because there’s some ways for that to get reimbursed that varies a little bit. But you are there to help the primary care provider and the rest of the team improve the services that they can deliver for behavioral health, mental health, unhealthy substance use, and biopsychosocially influenced problems, like… Christopher Hunter: Chronic pain, diabetes, asthma, Christopher Hunter: Go to the next slide, and we’ll talk a little bit… get a little bit more into details of what this model looks like. And so. Christopher Hunter: Jeff Ryder and Dotmeyer and I, at one point, there were a lot of different ways a PCBH model of Christopher Hunter: Service delivery was being defined, so we went ahead, and in this article, went through a process and actually Christopher Hunter: specifically defined what a PCBH model of service delivery is. Christopher Hunter: This is some of the highlights. If you go to that article, it goes into great detail. We’ll give you an acronym here in a second. But really what a PCBH model is, is it’s a team-based approach to primary care, where it’s not just the primary care provider’s job to Christopher Hunter: help the patient, but it’s the entire team’s job to help the patient. So that behavioral health consultant or provider is there to work with the primary care provider, the nurses, anybody else that’s on the team. And the goal is to help the entire team manage the full range of behavioral health concerns or biopsychosocially influenced conditions Christopher Hunter: That people are bringing into the clinic. Christopher Hunter: And to improve their ability to manage that. Christopher Hunter: those particular problems. Even if that BHC doesn’t happen to be in the clinic that day, or somebody’s moved on and quit that job, I mean, I knew when I was first started doing this, I think this was in, like, 2001, Christopher Hunter: I knew I was doing my job well as a BHC. I mean, anybody who’s worked in a primary care clinic, or Christopher Hunter: I’ve been to primary care clinics. Christopher Hunter: The ones I’ve been into, the walls can be really thin. Christopher Hunter: And so, when I heard the family physician that was in the exam room next to me. Christopher Hunter: saying to their patient exactly the same things I have discussed, and treatment plan recommendations that I’ve recommended, and saying, here’s what I think’s going on, this is what I want to see happen, I want to bring Dr. Hunter in to help us get a plan and monitor that and get it going on. I knew I was doing my job. Christopher Hunter: In terms of helping to Christopher Hunter: Helping that team learn how to improve or enhance their skills, but not doing it in a way that Christopher Hunter: provided an extra burden on them. The goal is really to help provide services for the entire population of that… whoever’s going in that clinic, so it’s… it’s that population health perspective. Christopher Hunter: you’re a generalist, you see everybody, everything, there’s no patient you can’t see. Doesn’t mean you can necessarily do anything with them, but you see all patients, and you see a lot of them. Go to the next slide, Jeff. Jeffrey Goodie: Great. And Chris, just so you know. Christopher Hunter: Yes, sir. Jeffrey Goodie: there’s a question in the chat about billing codes, so as you’re describing things, I don’t know if you want to just comment on billing. Christopher Hunter: What I’ll say about billing codes is that that is an ever-shifting landscape, and if you’re interested in billing codes for integrated behavioral health, there are very specific ones for the collaborative care or coordinated care model. Christopher Hunter: There are ones that may or may not be accepted, depending on what state you are and who’s funding those. I would encourage you to Google that, or go to other websites. If you go to the American Psychological Association website, Psychiatry Association website, the Collaborative Family Healthcare Association website. Christopher Hunter: there are discussions and products that will tell you more about that, but that changes frequently, so I wouldn’t even begin to make comments on that. That’s not my area of expertise, but there’s a lot of people out there that have been doing this, and the information is out there. Christopher Hunter: So… To try to make this… Christopher Hunter: really long primary care behavioral health model of service delivery definition a little easier to remember. We came up, we put it in the gather, Christopher Hunter: acronym, which was first put out by Patty Robinson and Jeff Ryither. And so, this helps you look at what a PCBH model of service delivery is. Like we talked about, you want to be able to see all patients, all ages, with whatever they’re coming in with. In a perfect world, you want to see them the same day. We call that a warm handoff. Christopher Hunter: If you see them on the same day, it eliminates a cancellation and a no-show. And you give a patient one-stop shopping, if they can stay and do that. You’re part of the team. Christopher Hunter: So, if you don’t have… so, you’re going to, you know, the clinic morning huddles, you should be in them. Christopher Hunter: Clinic meetings, you should be in them. Christopher Hunter: clinic trainings, you should be doing them. I took it to the extent where I was, Christopher Hunter: working in an active duty clinic, and their clinic was having their PT tests. I was not active duty at this point. Christopher Hunter: I went out and did their PT test with them. Christopher Hunter: Because that’s part of what a team does, and I had the ability to do that. If they’re having parties, you go to them. Christopher Hunter: high productivity. Christopher Hunter: And sometimes people say, oh my god, how can I see 10 to 14 patients a day? So… Christopher Hunter: That’s part of what training providers to work in primary care teaches them how to do efficient and effective Christopher Hunter: Functional assessments, functional biopsychosocial assessments. Christopher Hunter: What’s driving the problem? What’s making it worse? What’s making it better? What are the functional impairments? What are the quality of life of parents? Based on the best evidence that we have, what can we possibly lay out in terms of treatment plans? Christopher Hunter: What does the patient want to do? Get them going on that treatment plan, and they’re out the door. So, if you have 10-30 minute appointments today. Christopher Hunter: That’s only 5 hours out of an 8-hour day. Christopher Hunter: And when we train the provider to actually write the note, they’re facing the patient, they’re asking questions, they’re filling out that medical record note as they’re doing this. Christopher Hunter: There’s still additional administrative stuff to do, sure. Christopher Hunter: But even if I’m just, just seeing 10 patients a day, that’s still only 5 hours of clinical time out of an 8-hour day. I still have 3 plus hours, because nobody just does an 8-hour day, it’s usually an 8 and a half or a 9-hour day. Christopher Hunter: I still have all that time to go talk to docs, give feedback, finish up notes, finish my coding, and like I talked about, part of the educator thing is, as you’re giving feedback to providers, telling them. Christopher Hunter: we set up a plan for the patient to do this, this is what I expect. They start to learn from those conversations. Christopher Hunter: And you can also do Lunch and Learns. Christopher Hunter: you do a 5 or 10 minute thing about, here are the… here are the main behavioral treatments for insomnia. When you send your patients to me, as you’ve probably already seen, generally, here’s what we’re gonna do, here’s the evidence behind that, and these things you can do as well, if you wanted to. Here’s some information, here’s some handouts that would allow you to do that. Christopher Hunter: And you start to be seen as a routine member of the team. You’re not this outsider that’s a visitor. Christopher Hunter: you’re there as part of the team, and you start to become a really valued team member, and when you’re out, the rest of the team doesn’t like it. When you’re on vacation, they want you back. Christopher Hunter: There was one clinic that had a full-time behavioral health consultant. Christopher Hunter: That behavioral health consultant job was eliminated, and the chief of that clinic Christopher Hunter: converted one of their PA slots Christopher Hunter: So they could have a full-time behavioral health consultant. That’s how valuable that team player became to that team. Next slide. Christopher Hunter: I was fortunate enough to be part of this task force with Susan McDaniel, and one of the authors on this American Psychologist article, where we laid out what are sort of the core competencies for people you’re training for integrative primary care. Christopher Hunter: And… Christopher Hunter: You know, the article goes into much more detail in Chapter 2 of our books. We extensively go into core competencies and clinical practice and management skills, but we want people to be… Christopher Hunter: critical thinkers. We want them to know the science behind this for specialty, what’s been evaluated in primary care. Christopher Hunter: And how can you adapt things based on theory, based on critical thinking, based on the goals you’re looking for? Christopher Hunter: How do you interact with leadership, administration. Christopher Hunter: how do you make sure you’re talking the same language? When you go to another country. Christopher Hunter: And you’re gonna live there, it’s to your benefit to learn to speak the language, right? Christopher Hunter: You want to be accepted and be part of that team. How do you… Christopher Hunter: kind of coordinate or merge things like ethics. Well, I have these ethics, especially mental health. Primary care has this. Am I being unethical if I do this? The ethics problem comes up over and over again, and we’ve addressed it in our system. Christopher Hunter: for the last 25 years, and still, every once in a while, we run into somebody that doesn’t truly understand what HIPAA involves. So, you know, what is the culture of primary care? Well, the culture of primary care, at least the ones I’ve worked in, is you don’t call the doctors Christopher Hunter: Dr. So-and-so, at least not face-to-face, I’m gonna call you Frank, or Tim, or Lisa. And when they call me Dr. Hunt, I say, please call me Chris. And so, that’s not something you know unless somebody trains you to do it. Christopher Hunter: How do you build those relationships? I talked about that. How do you manage your time? How in the world Christopher Hunter: in a 30-minute appointment, can I get good, actionable information, summarize that to the patient. Christopher Hunter: Lay out things based on that functional assessment that make sense based on what they want. Get them to agree to choose one, and then start them on that program, and have them walk out of there at a 27-minute mark. Christopher Hunter: So they can go out to the waiting room, and I can bring up my next patient, and I can go out to the waiting room and grab that person. You can do that. Christopher Hunter: But it’s helpful if you have somebody who’s training you to do that, and training you towards a set of observed competencies. So it’s not just read a journal article, it’s not just, we’re going to look at this PowerPoint, we’re going to take a test. Christopher Hunter: I used to do this with my psychology interns. I’d say. Christopher Hunter: I want you to read these book chapters, these journal articles, and we’re gonna have, during our supervision, we’re gonna have a discussion about them. Christopher Hunter: And they’d come in clearly that they… and I’d ask them questions. And after one embarrassing session, they knew, hey, no kidding, this guy’s gonna ask me very specific questions, and I need to know this information. And then once they had that information, I had a clinical core competencies checklist. Christopher Hunter: Here’s what you’re going to be evaluated on. Here are your behavioral benchmarks that I’m going to be looking at. So it’s not just, can you say it? I’m going to observe you doing it. Christopher Hunter: And people will say they can do it, and say they know it, and that’s very different than them being in a situation with either a standardized, mock patient, or real-world patient, where they’re having to deal with patients showing up late. Christopher Hunter: the medical record not coming up, and you having to reboot your computer. That creates a whole different Christopher Hunter: set of clinical learning experiences. But if you’re in the clinic as a supervisor and you’re there, you can always step in and model the appropriate behavior and rescue them so patient care isn’t being compromised. Christopher Hunter: And then we talked about the teaching and supervision. Next slide. So, why we wrote this book? Christopher Hunter: So… I first started in the clinic in 2000. Christopher Hunter: And before going to the clinic, this was brand new, Christopher Hunter: the Air Force brought in Kirk Strassel to… to train us. Christopher Hunter: They had just had a draft of Christopher Hunter: Kind of the manual for primary care, behavioral health. Christopher Hunter: The reason I wanted this book is because prior to this job, at this point, I had a very good, librarian. I pulled, as far as I could tell, every journal article and every book chapter written on integrated care. Christopher Hunter: And a lot of it was based on… Christopher Hunter: The theory, best guesses, because there weren’t a lot of people working in primary care. Christopher Hunter: So, I had a… that knowledge base. I had a… I had a… I think, a strong knowledge base of what’s good, evidence-based informed care for your general mental health presentations. Christopher Hunter: As well as, you know, I’m boarded in health psych. I mean, I really loved working with people with all kinds of chronic diseases, so I had that base. But what I had to do is I had to figure out Christopher Hunter: Probably break a 30-minute appointment into digestible pieces that I can do over and over again in an efficient way. Christopher Hunter: So the reason I wrote this book, or that I asked people to come collaborate with me on this book, is because I wanted people that are starting to work in primary care to have an off-the-shelf book that they could pick Christopher Hunter: That was rooted in science, Based, also, or influenced on clinical experience and Christopher Hunter: When you look at, you know. Christopher Hunter: Here’s a… here’s how you might say this. Here are the questions and how you might ask this. Christopher Hunter: That’s how I would say it in the clinic, right? I wasn’t making it up to just be good reading. That’s how I would actually say it to a patient. And we structured the book so that it was written in certain sections, so, oh my god, you know? Christopher Hunter: I’m gonna see somebody with diabetes today. I’ve never seen some diabetes. Let me turn to the diabetes chapter. Okay, here are patient handouts, here are the assessment questions I can ask them, here are the interventions. I wanted it to be a user-friendly way, an off-the-shelf book, that anybody could pick up. And if you’ll just do the things in the book, at the very least, you’re… at the very least, you’re on an evidence-based, evidence-informed way of how you can do this. Christopher Hunter: And so, you know, now, you know, we’ve… we’re ending up in the third edition. You know, I think the book has evolved. I mean, this was a book that… Christopher Hunter: was sort of my brainchild. I wanted to do it, I got rejections from… Christopher Hunter: different publishers, I even… I’ll share just a little secret. APA rejected this book proposal at first. Christopher Hunter: And they said, well, we already have lots of books like this. Christopher Hunter: And being who I am, I said, that’s not true. I said, I would like to know why you rejected this, and I’d like to know why the reviewer said this, because this book Christopher Hunter: prospectus isn’t like any other book. I even know Mark Ort, who… you say that book’s like this one. It’s nothing like this book. Christopher Hunter: And so, what I heard was, evidently, people that can make Christopher Hunter: the call on this, had some discussions at APA and said, oh, you know what? I think we missed this. I think we do need to publish this book. So that’s my plug on, if people are rejecting you and telling you no. Christopher Hunter: Kind of be like a small child and say, why? Christopher Hunter: It can lead to good outcomes. Christopher Hunter: Okay, Jeff, I think… You’re up. Jeffrey Goodie: Great, thanks so much, Chris. So, I hope, we hope, you know, that for those of you on the call who maybe were less familiar with PCBH and really what we mean when we’re talking about integrated primary care, that you have at least a starting place. Jeffrey Goodie: in terms of understanding that, and you can dive deeper into some of the resources that we shared. I did want to point out, as Chris was talking about the book here, one of the features of the book that we have is Jeffrey Goodie: All of the handouts that we talk about in the book are available for download. Jeffrey Goodie: And you can take those, you can edit it, in order… unfortunately, I think they’re downloadable as PDFs, so it’ll take a little bit of work to edit them, but you… but we’re hopeful that you would take them and adapt them for your environments, for your situation, so that, it’s really usable. I think when we wrote this book. Jeffrey Goodie: We really had learners in mind, and we wanted folks to be able to essentially pick this up and be able to use it, use the information that was presented in each of these chapters with the next patient that you saw who might be presenting with some of those conditions. Jeffrey Goodie: And so, I’m going to take just a little bit of time here to give you a quick overview of how I’ve used this book in teaching graduate students. Jeffrey Goodie: you’ve heard a little bit already how Chris has been involved in training residents and interns, and we can, you know, talk a little bit more about that with the questions as we go forward. Jeffrey Goodie: Just to give you a little bit of context, I teach in a graduate program, where it’s a graduate program in clinical psychology, usually takes 4 to 5 years at the school, and then a year of internship. Jeffrey Goodie: I have taught this course as an elective. It has lasted anywhere from 8 to 16 weeks, so I adapt what I’m teaching based on how long it is, and right now, in its most recent iteration, it’s being offered as a 2-credit, but it’s been as a 3-credit course. Jeffrey Goodie: Most of the students who are taking this are doing it after they’ve had foundational courses in psychology, so… Jeffrey Goodie: These are… Jeffrey Goodie: foundations in understanding, you know, what psychology is, what clinical psychology is. They’ve had, foundations in, you know, conducting interviews. Jeffrey Goodie: doing assessments. Most often, they’ve had a class in CBT, at least, and some have had a background in health psychology. Jeffrey Goodie: And I really do think having these courses, while I don’t make it always required as a prerequisite, I do think that having this background makes it a lot easier for students to be able to, kind of learn Jeffrey Goodie: How to adapt what they have learned in those classes, and to be able to Jeffrey Goodie: Apply them within the context of primary care. Jeffrey Goodie: So I’m gonna go through and just, give you kind of a, you know, give you a sense of how I’ve, Jeffrey Goodie: how I’ve organized the course, and then we can talk a little bit about, how, how there might be some adaptations to this. So, when we start out, in the first, first, first class or so. Jeffrey Goodie: I find that it’s important to just sort of lay a foundation about sort of what is primary care, helping folks understand what that is. Some folks, you know, again, may not have had direct experience with primary care kind of growing up. Many have, but on occasion, we have some that have not. Jeffrey Goodie: And certainly don’t understand the different specialties within primary care, whether it’s family medicine, internal medicine, pediatrics, or Jeffrey Goodie: OBGYN care. And then we, just as we started out today’s class, talk about, you know, why we should do, integrated care, providing that rationale. Jeffrey Goodie: And then going over core concepts like a biopsychosocial model, what it means to, Jeffrey Goodie: deliver, step care, and then we didn’t talk about it in here, but, talking about what the patient-centered medical home is, and, the quadruple aim, which are all drivers within, primary care that, really, really drive, ultimately, the ways in which, care is provided. Jeffrey Goodie: In the, you know, and so, Jeffrey Goodie: You know, we sort of build on that Jeffrey Goodie: Foundation, and so we use kind of the first two chapters in our book to really kind of talk a little bit about what are some of the competencies, talk… Chris alluded to, the idea of ethics and how ethics can be different, in, primary care settings. And we also talk about specific cultural considerations, both the culture of Jeffrey Goodie: primary care, and how you adapt to that, but also how you might adapt to the types of care that you’re providing, or the ways in which you’re assessing to the cultures of the individuals who are Jeffrey Goodie: coming in. Jeffrey Goodie: We go over, Chris alluded to, sort of these core competencies for BHCs, and so, this is really talking about sort of that, that prac… the competencies that are involved in the practice. Jeffrey Goodie: of, of, the PCBH model. And so we go through and, and we have, Jeffrey Goodie: We have a document that kind of lays each of these out and talks about very specific behavioral anchors associated with, ultimately what clinical practice looks like, practice management skills, what consultation skills look like, documentation, you know, as you can imagine. Jeffrey Goodie: Moving from specialty behavioral health care to primary care has very different expectations for documentation, and so we do talk about that in those first few classes. Jeffrey Goodie: And then we talk about things like administrative and knowledge skills and team performance, and Chris has highlighted, I think, just how important it is Jeffrey Goodie: For, for individuals who are working to be integrated in primary care, to become part of the team, and how to integrate with that. Jeffrey Goodie: So we cover that, in the first few classes, but very early on. Jeffrey Goodie: again, to kind of emphasize this idea of, you know, kind of what is primary care, one of the things that I do is I have, in my case, a family physician come into the class. Usually, they’ll take the entire class to really kind of talk about primary care from their perspective, what it is that they’re doing and seeing in their daily life, and really talk about Jeffrey Goodie: The value of having a behavioral health provider within primary care, and how they would hope to be able to use that person. Jeffrey Goodie: And I can tell you, out of all the classes that I teach in the context of this course, this is one of the favorite classes of the students, really being able to hear and understand what primary care is, and Jeffrey Goodie: and how they can contribute to it. One of the things that I do, I have a link here. Because I work in a family medicine department, I do focus primarily on family medicine. Jeffrey Goodie: And there’s a really nice video here. It’s intended for medical students who might be considering family medicine, but it does a really nice job of really describing the specialty of family medicine and some of the core values that exist within that specialty. Jeffrey Goodie: So a lot… so those first few classes are really foundational, really trying to give the perspective of, again, why this is important. But then we start, moving in the course to, really the practical skills of, of, Jeffrey Goodie: filling the role as a behavioral health consultant. And so we introduced this idea of the introductory script, which is a script that we have, all behavioral health consultants say before they start an appointment, which really lays out, Jeffrey Goodie: what the purpose of that, of the appointment is. How this appointment is likely going to be different from any specialty behavioral health care that they might have experienced before this. Jeffrey Goodie: And so it sort of lays that out. Our students learn how to kind of confirm the purpose of that visit. And then our book is really, organized around the idea of the five A’s, and we talk about, you know, how you do a functional assessment using the five A’s. Jeffrey Goodie: We don’t have time in this lecture to really kind of talk about, you know, each of these aspects, but just very briefly, you know, the five A’s that we’re talking about here are this idea of doing an assessment, and then based on that assessment, kind of developing Jeffrey Goodie: Some ideas for a personalized treatment plan, describing those possibilities of the treatment plan with the patient, getting the patient to agree to how they want to move forward, and then actually delivering those interventions, to the patient. Jeffrey Goodie: And then once the patient has received those interventions, whether it’s after the first appointment or after you’ve seen them, you know, 2 or 3 times, you know, thinking about, you know, how are you going to follow up? Jeffrey Goodie: You know, what is that patient going to do? And maybe you’re talking about sort of the follow-up with you as a behavioral health consultant, maybe it’s following up with their primary care provider, or maybe it’s following up with specialty care. And all of these things really Jeffrey Goodie: drive into developing this personal act, personal action plan, where, Jeffrey Goodie: you know, both you and the patient have a clear sense of what is going to be changed. But we also have sort of the goal when we develop this personal action plan that somebody who wasn’t sitting in the room with you would be able to pick up, what this plan is, and know how to help that patient kind of move forward. Because within primary care. Jeffrey Goodie: one of the real benefits is that individuals are likely coming back to that place, and so it may not be the BHC that’s helping that patient move forward with their plan, but it may be other providers, maybe it’s nurses, or even admin staff that’s helping them to move forward. Jeffrey Goodie: We talk about, in Chapter 4, we kind of lay out, the kind of common, intervention strategies, that, really almost regardless of what individuals are presenting with, Jeffrey Goodie: might be valuable, interventions. So, more often, you know, the expectation is students have already been exposed to most of these. We do talk about how you might, adapt that for a primary care setting. Jeffrey Goodie: But we do talk about, kind of, what each of these are, making sure that students understand, you know, these types of interventions. Jeffrey Goodie: And then we move into, really talking about how you apply that, within different, types of presenting problems. We don’t necessarily take time and go into depth for all of these things, but I’ll pick out, you know, some that, I think are particularly relevant. So, in Chapter 5, we talk about, sort of, depression, anxiety. Jeffrey Goodie: PTSD and insomnia. We might break that up into one or two classes talking about how to do interventions, assessments and interventions for that. Jeffrey Goodie: We also take time to talk about health behaviors. This is spread out across a few chapters, within the book, and so that might be tobacco targeting weight, physical inactivity, substance use, and sexual problems. Jeffrey Goodie: And then we, also talk about, kind of, chronic disease, and again, we don’t usually have time to talk about each of these, but, but we’re likely going to talk about things like cardiovascular disease or pain disorders, and how we might, target those. Jeffrey Goodie: And then we also talk about how we adapt this to special populations, and other concerns, like managing suicide, working with older adults. Jeffrey Goodie: Working with children, adolescents, and parenting, or couple distress. Jeffrey Goodie: Sometimes we will take some time to talk about shared medical appointments, which kind of goes beyond kind of today’s lecture, but the idea is that you’re sort of bringing individuals in together in almost as a class. They’re getting their medical appointment while also getting education about how to make behavior changes. Jeffrey Goodie: The class is set up so that we… I will usually have folks do either debate in class or write a brief paper about the pros and cons of integrated primary care versus specialty care, because I really want folks to hone in on what those differences are, and to have a really clear understanding, and I want to make sure that they have a clear understanding about how the care is different Jeffrey Goodie: in each of those settings. Really, the big part about this course is writing this 20- to 30 page paper, and essentially what I ask them to do is to write a book chapter, like what we have in the book. So they format, the paper based on that, so they’re doing a brief, Jeffrey Goodie: review of the literature, but really kind of focusing on how they may take what we know in the literature and be able to apply it in primary care. I do require that they’re take… that they’re taking on a topic that we haven’t covered in the book, or isn’t really covered in other books that might be out there, and so… and so it’s nice for them to, you know, kind of take something that they’re interested in beyond Jeffrey Goodie: what’s already been done, and create, essentially, the book chapter. And, you know, for me, I think that really helps them to kind of hone in on, ultimately, you know, what we’re trying to teach, which is how do you adapt what you do in specialty care for the primary care environment. I also have them record a role play of an initial assessment, so get to see them kind Jeffrey Goodie: doing the 5As, Jeffrey Goodie: In, for the assessment of the presenting problem, that they had, written about. And so, they work with a classmate or someone else, and of course, you know, want to make sure that they do that in less than 30 minutes. Jeffrey Goodie: We incorporate, in terms of pre-class assignments, I have readings beyond kind of book chapters, having them respond to reflections and questions. There’s videos that I’ll have them watch that kind of give them a sense of what this looks like, and may have them do some special assignments, like memorizing that introductory script, and then kind of testing them on that. Jeffrey Goodie: within the class. Jeffrey Goodie: This is where I get some of my videos from. Division 38 has actually a very nice, Jeffrey Goodie: course that they’ve developed where they have some videos. Those videos don’t always exactly fit into the PCBH model, but, it is, it gives, students a sense of what, Jeffrey Goodie: what this can look like. There’s, APA has a YouTube channel with some, if you do a search for, sorry, it should say Integrated Primary Care, you’ll see, some of the videos that they have there. And then Beach & Bellman Consulting, they have a lot of great videos on there talking about Integrated Primary Care. Kent Corso has a few videos, and then. Jeffrey Goodie: Really encourage folks to also look at the Collaborative Family Health Care Association, which has a lot of great resources related to integrated primary care. Jeffrey Goodie: Our co-author, Ann Dobmeyer, has recorded a video, you can get, from, Jeffrey Goodie: from the APA. It’s about 100 minutes. It, again, it provides a really nice example of a PCBH interview, but then also shows what it’s like to then consult with a physician based on what they’ve learned, from that, from that interview. Jeffrey Goodie: In class, we’ll talk about their reflections, talk about the chapters and the readings, review assessment questions, and we’ll do some role plays in the class as well. And Chris has already talked a little bit about how we do this in clinical settings, and so Jeffrey Goodie: Here’s some other resources, again, in terms of finding out about integrated primary care, and we’ll leave a few minutes here for questions. Andrea Burgoa: Thank you so much! If anyone has questions that they have not, submitted to the Q&A panel, please, please do so now. Andrea Burgoa: Chris, you’ve done an excellent job just flying through those, answering them via text. Are there any that you would like to speak more on live? Christopher Hunter: Not in particular. If somebody has something else they want to discuss, or if I gave them an answer that was unsatisfactory, we would try to address that. Andrea Burgoa: Yeah. But yeah, doing this is complex. It involves a lot… I mean. Christopher Hunter: The questions you’re asking are questions that are common kinds of questions, and a lot of them are concerned with the business side of this aspect. Christopher Hunter: And there’s an absolute business side, and it depends on what system you’re in, what building you’re in, are you in an FQHC, are you in a clinic? Are you in a hospital? What state are you in? Who’s the payer? It’s complex. Christopher Hunter: It’s gotten better than it was 25 years ago, but it’s still… Christopher Hunter: Not where I would hope it would be. Andrea Burgoa: I would also like to say that I appreciated your anecdote about how you made this book happen. Christopher Hunter: Unknown truths. Andrea Burgoa: Always ask why, always ask why. Even if it is APA, we are not untouchable. So, Andrea Burgoa: Thank you so much for that. That was an amusing moment for me, so I appreciate it. Andrea Burgoa: Again, some great questions asked in Q&A. Thank you, Chris, for answering those. If anyone has any remaining questions, please let me know now, but just a couple, like, brief housekeeping things before we wrap it up. Andrea Burgoa: A recording of this will be available. It will be in your inbox, in about 24 hours from now. And then, if… Andrea Burgoa: you’re waiting for an attendance certificate, please just be patient with us. It’s a manual process, so that does take us a week or so to get that done, but I want to thank Andrea Burgoa: all of our attendees for your great participation and questions, and a special thank you to Dr. Goody and Dr. Hunter for being here and sharing all of your expertise with us today. We really appreciate it. Christopher Hunter: So I think we have 3 minutes left, and I’m gonna try to answer some of these questions live, so the first one… Christopher Hunter: what resources do you suggest for creating a PCBH form from scratch? Christopher Hunter: Well, our book’s a good place to go, and it depends on what kind of form you’re talking about. Are you talking about patient education handouts? I encourage you to have those to be… to have… be one page, be bulleted pieces that you can interact with the patient on, and, you know. Christopher Hunter: We created our own forms, you know? Christopher Hunter: What’s our need? What’s our education need? What’s our training need? I had a behavioral prescription pad that was blank, that I’d write out the treatment plan on, or that had pre-positioned text where I could circle or cross out common things so it would take me less time to do that. Jeffrey Goodie: And Chris, I don’t… I think it’s just about PCBH, not necessarily a form, but just kind of in terms of, like, creating PCBH from scratch, yeah. Christopher Hunter: So, if that’s correct, then I would say the biggest thing that you want to do is you need to get buy-off from primary care leadership that has the ability to make decisions and hold people accountable to those. Christopher Hunter: If you don’t have buy-off from that person, then you’re just one personality in there trying to make things happen. Somebody who can say, our primary care clinic is going to do this, this is why I bought off on this, this is what I want people to do, and can hold them accountable for doing what the clinic has decided to do, I think is Christopher Hunter: necessary if you’re going to be successful in primary care behavioral health. Jeff and I did a presentation at Collaborative Family Health Care Association two years ago on that. It’s what I saw in the Department of Defense. Christopher Hunter: Other using BHCs in primary care. Typically, I find that that is because the primary care provider has not been fully informed about what this is. Nobody spent the time doing that with them. So part of that is going around to each one of those primary care providers in either 5 minutes Christopher Hunter: Personally, when it’s time, when they have time, we’re doing a 10-minute, you know, lunch and learn presentation, giving them a handout on here’s the things that we can do, and Christopher Hunter: Getting the nurses and medical assistants that same information, because they are going to help Christopher Hunter: They’re seeing the patient, they’re seeing what the patient is presenting with. Christopher Hunter: They can say, hey, Dr. Smith, should we bring Dr. Hunter on? Oh, yeah, that’s a great idea. I didn’t even think about that. So that’s… that’s one of the ways that you can do that. But that has been my experience. There’s just a lack of understanding, especially if you get new physicians on board, and they don’t have any in-processing with what is the behavioral health consultant. Nobody told me we had this, I didn’t even know it, this is great. Well, I’m gonna send all my depressed patients to them. Christopher Hunter: Well, that’s… could start, but what about all these other folks, right? Jeffrey Goodie: And as I… as Chris knows, you know, oftentimes we would send out, like, weekly reminders about, like, we would do a weekly special, about, you know, here, you know, we can help with hypertension, we can help with smoking, we can help with sleep, and so, so each week, kind of sending them something new, you know, to remind them and to keep us top of mind, in terms of. Jeffrey Goodie: You know, when they’re seeing a patient, how we might be able to be integrated with them. Christopher Hunter: Yeah, one, one, one example is, Christopher Hunter: I had gone to a specific family medicine doc, had given them my handout on what I could do. They had that handout pressed on their bulletin board in their administrative office, and they were there for 6 months. And I went around with… mine was a monthly special on overweight and obesity, and she looks at me, she says. Christopher Hunter: You can help me with my patients who are overweight and obese. Christopher Hunter: It’s a repeating message. It’s not that she hadn’t heard this before. It’s not that the one-pager that she looked at every day didn’t have that on it. Christopher Hunter: she was just so inundated with everything that just those… those weekly specials, hey, if you’re seeing people with overweight or obesity, I can… I can help you with that. Happy to see them. Oh, fantastic! Then, what you’ll see is you do that, give that to them in the morning. In the afternoon, they see people that are overweight and obese, and all of a sudden, you have 3 referrals from that. Christopher Hunter: So, it’s that constant messaging piece that I think is important. Christopher Hunter: Now we’re at 1 minute over. Andrea Burgoa: We are, but that’s perfectly fine. Thank you for everyone who’s stuck with us. The majority of people have, so… appreciate you. Andrea Burgoa: And thank you again to our authors for being here today. We appreciate you. Andrea Burgoa: Yeah, thank you. Any final parting words? Jeffrey Goodie: This can be a very rewarding area to go into, to both… to both practice and to teach about, and, you know, there are a lot of great resources. Our book is one of them, and, you know, certainly encourage folks, we had our emails up there. Either one of us would be happy to talk with you, and, you know. Jeffrey Goodie: Keep this conversation going, and really appreciate everybody joining us today. Christopher Hunter: I’d echo that. Christopher Hunter: This is hard. Christopher Hunter: Doing this well is hard. Christopher Hunter: Doing it well has also been… Christopher Hunter: one of, if not the most rewarding experiences of my life. To be able to train over well over 100 providers to do this, and create a bunch of, I know this is narcissistic, a bunch of little mini-me’s who I know are out there and are providing great care in primary care clinics that patients wouldn’t otherwise get. Christopher Hunter: I don’t know if there’s a better reward for that, and it’s hard. I mean, slogging it out as a clinician is hard. Figuring out what are the financial pathways, getting leadership buy-off. I mean, that’s why all these core competencies aren’t important. The cool thing is, you don’t have to do it by yourself. Christopher Hunter: There’s plenty of information, there’s plenty of experts, there’s plenty of associations where you don’t have to reinvent the wheel. Andrea Burgoa: Great. Andrea Burgoa: Thank you so much. Thank you to everyone for being with us today, and sounds like we will be continuing some of these conversations offline. So, love that. Christopher Hunter: Right. Andrea Burgoa: Alright, everyone have a great day! Christopher Hunter: Thanks, bye.
This webinar provides essential strategies for teaching integrated behavioral health in today’s graduate and clinical training settings. Designed for educators, the session focuses on effectively preparing students to deliver behavioral health services in primary care environments. The authors of Integrated Behavioral Health in Primary Care, Drs. Jeffrey Goodie and Christopher Hunter, share how their text serves as a foundational resource grounded in both scientific evidence and real-world clinical experience. The book offers a comprehensive guide to collaborative care models, clinical competencies, and team-based approaches for integrated practice.
To learn more about this title and request a free digital exam copy, please visit this link: https://bit.ly/47qbztm
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