Brief Intervention Models for Behavioral Health
Building a BH Toolkit
Screening Tools

Screening tools are an important part of an integrated program as they help support the program in a few ways. It is documented that two-thirds of primary care visits have a psychosocial basis and that 50-80% of these visits do not result in the identification of a physical health problem (Chiles, Lambert, & Hatch, 1999). Screening tools promote early detection of possible mental health and substance abuse issues that may warrant further investigation. One of the more common tools is the PHQ-9 screening for depression, which can also be used to re-screen the patient for longitudinal improvement following a period of intervention. The screening tools also serve to identify patient referrals for the BHP while keeping the IC program as a visible component of the continuum of services. This provides some cross training that can strengthen the team value of the integrated programming. Many screening tools can be completed by the patient and/or by a host of different providers within the practice, and some are even brief enough to be used in the context of conversation between a clinician and the patient. Physical health institutions are familiar with the use of screening tools and have experience in determining when they can be incorporated into patient interactions without overwhelming the patient during his or her visit, or the staff. Some options when considering frequency of use and identifying patients are to use the tool if a provider suspects a condition, to aid in discussion with a patient, for new patients or for random patients.

Resources:

  • ICARE provides a list of common behavioral health screening tools.
  • ICARE provides a list of additional screening tools and military-related information on posttraumatic stress disorder and traumatic brain injury.
  • The Health Services/Technology Assessment Text is an online resource that discusses factors to consider when selecting a screening instrument.
  • Harvard Medical School –“Adult ADHD Self-Report Scale”
Using screening tools in practice

This patient flow diagram is borrowed from the Buncombe County Health Center in Asheville, NC and serves as a good example of how screening tools can be used by clinicians in the clinic to collaboratively identify and treat behavioral health concerns (Cate, Gregory, Martin, Mims, & Tettambel, 2004, sect. “Definition of Project”, figure 2).

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Some clinics may decide to incorporate brief screens such as the CAGE, PHQ-2, or BHQ-18 (which was the screening tool used at the Buncombe County Health Center) in their initial or yearly self-completed patient information update/questionnaire. The self-completed information usually consists of patient demographics, emergency contact information, allergies, health history, and can incorporate a few brief screens. This allows clinics to screen their entire population and possibly identify patients who have low to moderate risk levels that might otherwise go undetected, and who could benefit from proactive strategies. The PHQ-2 is a quick “first-step” approach to screen patients who may be depressed. The two questions focus on mood and ahedonia. If the total of the two questions is 3, than the Positive Predictive Value (PPV) of having any depressive disorder is 75%, while the PPV of having major depressive disorder is 38.4% (Kroenke, Spitzer, & Williams, 2003). If totals are higher than 3, the PPVs are higher. The nurse in the diagram above may use a PHQ-9 to further investigate the results of the patient’s answers on the PHQ-2. Note: The description above is just one example of how screening tools can be incorporated into a treatment algorithm. The sample diagram in this case is a formal part of the services provided by the Buncombe County Health Center, described below in the first resource.

Resources:

  • Buncombe County Health Center: A program Integrating Behavioral Health Care into Public Health – Document illustrates how screening tools play a part in treating the patient population. View PDF
  • The Health Services/Technology Assessment Text is an online resource with a diagram showing patient flow through the primary care screening and referral process.
    • The need for information about depression is common and examples of these materials can be found under the MacArthur Foundation Initiative link.
    • The Bio-Medical Library at the University of Minnesota has a comprehensive list of resources for the creation of patient education materials.
    • The Mountainview Consulting Group has numerous examples of patient education content for various conditions, which can be used to generate pamphlets.
    • In addition to providing patient education materials for specific conditions, it may be helpful to supply information about the behavioral health program. This information can consist of a brochure incorporating a couple of patient scenarios, a list of conditions that may improve through BHP interventions, and perhaps some information about the BHP. Furthermore, an exam room poster may be appropriate as it can serve to illustrate the clinic’s understanding of behavioral mental health and interest in serving patients who have these needs. The Mountain Area Health Education Center has examples of these documents.
    • The Mountain Area Health Education Center’s Integrated Care web page has examples of Green Light Prompts: condition and patient acuity-specific prompts for PCPs to consider the engagement of the BHP in the care of their patient. A pocket card can be developed as reminder of the assistance the BHP can provide.
    • Annotated bibliography: Robinson and Reiter, 2007, Behavioral Consultation and Primary Care: a Guide to Integrating Services, Chapter 8, “Start-up: What to Do and How to Influence PCPs”
    • Agendas for primary care staff meetings
      The BHP and his or her program should be a regular agenda item discussed at staff meetings. Some items to discuss in routine meetings can be: problems with patient and clinician flow, barriers too referral, concerns, praise, examples of collaboration and integration benefitting PCPs and patients.
  • Patient Handouts, Education Materials, and Brochures
    Patient handouts and brochures can serve multiple functions including informing patients about different health conditions, increasing awareness, allowing self-exploration, and promoting self-referrals for treatment. Most medical offices have handouts/brochures available for patients, and providers may encourage patients to review one related to their specific condition. These materials can be purchased but are sometimes made internally so that they can be customized. Additionally, many integrated BHPs will create simple one-sided prescription-like sheets that serve both as a review of content discussed in-person and a behavioral action plan that has been agreed upon with the patient. Patients are referring to the internet for health information with increasing regularity. A recent study by Schwartz, Roe, Northrup, Meza, Seifeldin, & Neale (2006) found that 74% of family medicine patients who have internet access had looked for health related information online. Though the reliability of these resources can vary greatly, it is obvious that patients are interested in increasing their understanding about their own health. Patient education materials are a common component in primary care patient interactions. BHPs can help the providers in the practice locate appropriate behavioral health patient education materials for patients. Patient education materials can be expensive to purchase in quantity; in some cases, creating materials from available resources can be more cost effective and allow for customization. Education materials should be written at the 6th to 8th grade reading level to ensure the information is usable by most adults, and purchased materials should be screened for readability. Studies show that people with higher literacy levels will gain more information from those resources written at this level when compared to those written at higher reading levels (Freda, 2004). Patient information should be checked for readability.

    Resources:
    Newsletters for PCP staff and patients
    BHPs can advertise their behavioral health programming by providing newsletters to the clinic’s patients and PCPs. Patient newsletters can focus on psychoeducation for common conditions, information about the clinic’s behavioral health services, and other items that expand awareness to target areas. The content should be easily readable and highlight behavioral health education-related information and the BH services in the clinic (See section, “Patient Handouts, Education Materials, and Brochures”, for more detail)
    Advertising your program inside and out
    Brochures and posters aimed at advertising and destigmatizing behavioral health services will keep the behavioral health program visible, may increase patient self-referrals, and can help initiate conversation about behavioral health concerns between PCPs and their patients.

    Resource:
    The Mountain Area Health Education Center’s Integrated Care web page has examples of behavioral health exam room/waiting room posters and a patient brochure explaining how behavioral health services can be helpful.
    Handouts for PCP’s
    PCPs can use evidence-based behavioral health information in helping their patients. BHPs can provide handouts that target common behavioral health issues or address a particular condition that has relevance to a BHP/PCP patient interaction or informs them about the ways in which to use the BH service (Robinson and Reiter, 2007)

    Resources:
 
Recommended Models
Motivational Interviewing

Although Motivational Interviewing (MI) skills have gained significant attention in the last couple of years, they have actually been used for some time to help patients in substance abuse treatment arenas to make behavioral changes to their lifestyle for the promotion of their health (Robinson and Reiter, 2007). MI focuses on working through a patient’s ambivalence, establishing a plan for change, and commitment to change through a brief counseling experience. These skills are now recognized as being effective for use beyond working with patients who have substance abuse issues (Levensky, Forcehimes, O’Donohue, & Beitz, 2007).

The following link is the presentation Making Shift Happen: A Motivational Interviewing Primer for Healthcare Professionals developed by Paul Nagy, MS, LPC, LCAS, CCS.

Resources:

Substance Abuse Models

The rates of alcohol misuse in adult primary care patients collected in 2004 by the US Preventative Health Services ranges from 4 to 29 percent (Robinson & Reiter, 2007). A study targeted the alcohol consumption habits of those 50 years and older. It was determined that in participants who were 65 and older, 13% of men and 8% of women reported using alcohol in the at-risk level, while 14% and 3% respectively reported to meet the level for binge drinking. Those between ages 50 and 64 had higher rates of use. (Blazer & Wu, 2009). Primary care and integrated primary care practices should be aware of the current rates of use so that they may screen, educate, provide brief interventions, and refer when needed for specialty services.

Resources:

Stress Management

Stress management techniques are a common BHP skill in primary care settings.

Resources:

Caregiver Stress

Parents of children, adult children taking care of their chronically ill parents, and spouses who are caring for their partners, may be experiencing significant stress that can manifest in a number of ways: loss of sleep, feelings of being overwhelmed, anger and resentment, a loss of interest, or self-neglect. BHPs can help to assess and educate caregivers in coping skills.

Resources:

Positive Psychology
Cognitive Behavioral Approaches
Stepped Care

Stepped Care approaches allow clinicians and administrators to plan for cost effective ways to address their entire patient population while providing patient care that is proportional to the needs of the patient and the treatment of their condition. The five steps in care are as follows: 1. Informal Interventions; 2. Information and Minimal Decision support and Social support; 3. Information and Packaged Group Counseling; 4. Disease Focus “Vertical” Integrated Care; 5. Full Clinical Focus (O’Donohue and Cucciare, 2005). BHPs need to consider these steps and provide appropriate levels of treatment and collaboration for patients in each category, which will maximize available resources and time for the entire patient population. If most patients with any degree of behavioral health issues received level 5, Full Clinical Focus, the BHP would have a full caseload that would serve a small portion of the clinic’s population. When there is an overflow of patients with high needs, the BHP will need to refer some patients to services in the community.

Resources:

  • William O’Donohue and Michael A. Cucciare’s (2005) article in the Journal of Clinical Psychology in Medical Settings, Pathways to Medical Utilization.
  • Annotated bibliography: Gatchel and Oordt, 2003, Clinical Health Psychology and Primary Care, Practical Advice and Clinical Guidance for Successful Collaboration, Chapter 1, “Clinical Health Psychology in the Primary Care Setting”
  • Annotated bibliography: James and O’Donohue (Eds.), 2009, The Primary Care Toolkit: Practical Resources for the Integrated Behavioral Care Provider, “Part II: Toolbox for Integrated Consultation-Liaison Services: Guidelines and Handouts”