Q&A: Behavioral Health Care Managers in Rural Primary Care Practices
George Nasra, M.D., M.B.A., is professor of clinical psychiatry at the University of Rochester Medical Center, where he serves as chief of the Division of Collaborative Care and Wellness.
Q: Dr. Nasra, what needs were you trying to address and what were your goals when developing this approach for rural primary care practices?
Dr. Nasra: There are several areas we are trying to address with this practice: We know there is tremendous unmet need for behavioral health care. The center is focused on substance use disorder (SUD)—especially reducing the harmful effects of the opioid crisis—in rural communities. In rural areas, unmet need and access challenges can be even more significant for several reasons, such as the shortage of psychiatrists and behavioral health clinicians, a lack of resources to support programs, transportation issues, and stigma and confidentiality concerns.
There is an opportunity to help people with mental health and SUD when they seek health care for reasons other than behavioral health in general health care settings, such as their doctor’s office. Primary care practices can take that opportunity to increase access to patients with opioid use disorder (OUD) and other behavioral health concerns. Our goal is to provide rural primary care providers (PCPs) with a practical, financially viable approach to incorporate behavioral health into their practices so they can more effectively identify patients who have those needs and address them.
Q. What strategy do you suggest?
Dr. Nasra: In my experience, the Collaborative Care Model (CoCM) is an important, well researched, evidence-based approach to behavioral health integration (BHI). At the same time, given resource constraints and other challenges that rural PCPs typically face, implementing the CoCM with all the traditional requirements as described by the AIMS Center would be difficult as a first step. So we focused on adapting the model to make it more feasible to implement in rural practices by simplifying the requirements for and the role of the Behavioral Health Care Manager (BHCM) to help rural practices integrate behavioral health in a less resource-intensive way.
Q. Why did you need to pivot from the established CoCM for rural communities?
Dr. Nasra: We made this adaptation because the requirements of the traditional CoCM for recruitment, training, and billing are likely to be a major barrier to implementation in rural practices. The traditional CoCM requires the BHCM to have formal education or specialized training in behavioral health. This specification alone is a barrier for rural communities that struggle to recruit and retain behavioral health specialists.
Our adapted model encourages practices to identify an RN within the practice who has prior experience or interest in behavioral health. An existing member of the team may be in a position to receive some additional training on the CoCM and on the assessment and management of common psychiatric conditions—enough to provide care management and basic self-management for depression, anxiety, and SUD; introduce basic interventions such as behavioral activation, problem-solving therapy, and suicide risk assessment; and transfer the patient to more specialized services, such as an SUD treatment program as necessary. This approach capitalizes on the essential functions of a care manager while minimizing some of the heavy requirements of training and, in some cases, licensure.
Q: Using this approach, what skills and training would the BHCM need?
Dr. Nasra: I’m glad you asked this question. While specialized training in behavioral health is not required under this adapted BHCM model, it is important that the clinician assuming the BHCM role is able to provide assessment and care management interventions to patients. Typically, an RN degree would be required for that purpose. The RN would need to have some experience and/or special interest in behavioral health because they will play the integral role of managing care for all patients with behavioral health concerns in the practice.
Online programs are available at relatively low or no cost that provide training in screening, care management, basic intervention, and other skills to equip the BHCM to manage behavioral health care under the direction of the PCP. Also, some state Medicaid programs provide technical assistance, including BHCM training, for practices interested in implementing the CoCM. Most RNs are already familiar with providing basic care-management interventions, such as chronic disease management, symptoms monitoring, and transitions of care. Implementing those basic interventions for depression, anxiety, and SUD management is what is asked of the BHCM when they start in this role.
Additional training in specific behavioral health interventions, such as problem-solving therapy, behavioral activation, suicide risk assessment, as well as the assessment and management of individuals with substance use disorders, including the support of individuals on medications for opioid use disorder (MOUD) treatment would allow the BHCM to gain more skills and provide further interventions to patients in the practice. To give the nurse assuming this role more time for BHCM responsibilities, the practice may need to consider reassigning some of their duties to other staff or hiring another RN.
Q. Are you concerned about losing some of the quality of care with this adaptation of the CoCM?
Dr. Nasra: One thing to remember is that people in rural communities currently have limited access to behavioral health interventions, which means their mental health or substance use disorders are often under recognized and untreated. This adaptation to the CoCM is not meant to replace the more traditional CoCM. It is a more flexible option to help rural practices introduce screening and monitoring together with providing some basic interventions and referral for common psychiatric conditions such as depression, anxiety, and substance use. This is a level of care provided by an RN who receives basic training and could potentially develop their skills over time to grow toward a more traditional CoCM.
Q. What happens if the patient’s needs go beyond the BHCM’s training or comfort level?
Dr. Nasra: Another important component of this model is that the practice has a relationship with a psychiatric provider with whom the BHCM can regularly consult via telehealth to review cases and discuss the care plan, including medication management, to ensure the BHCM has robust clinical support and guidance.
It’s a relatively small number of patients in collaborative care programs who request or require referral to more specialized psychiatric care. Usually these are patients who have an acute crisis or who require or prefer more traditional psychotherapies such as Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy (IPT), Dialectical Behavioral Therapy (DBT), or other. Unfortunately, in rural communities, connecting with behavioral health specialists, even via telehealth, may be very challenging due to long wait times and the provider shortage. This model allows the BHCM and other members of the PCP care team to continue providing basic monitoring and manage the patient’s behavioral health care more effectively until a transfer to specialty care can be made.
Q. Can you describe how the BHCM would manage a visit with a patient with behavioral health concerns?
Dr. Nasra: Under this adapted model, when patients present at the PCP’s office, the BHCM identifies those with probable SUD or other behavioral health concerns through screening. If confirmed through additional assessment, the BHCM would communicate with the patient about their condition and provide patient education. If the patient is interested, the BHCM may provide some basic self-management skills and assess the level of engagement as well as the level of risk of the patient. If the patient is interested, other evidence-based interventions can include problem-solving therapy, motivational interviewing, or health coaching, if appropriate.
The BHCM would consult with a psychiatric provider via telehealth to review the care plan, obtain further guidance on patients who require additional help, and provide feedback to the PCP regarding any medication recommendations made by the psychiatric provider.
The care provided by the BHCM may occur via traditional scheduled visits (in-person or via telehealth) as well as through outreach and contacts between visits to maintain engagement, reinforce the plan of care, track patient progress, and coordinate with other providers as indicated.
Q. What about for patients with OUD needing MOUD and additional treatment?
Dr. Nasra: Under this model, the BHCM coordinates the care of patients requiring MOUD as well as other SUD treatments. Through screening, patients who require additional support or treatment are identified. After further evaluation, the BHCM will determine the level of readiness to engage in treatment. For those who may not be ready, the BHCM will attempt to maintain some level of outreach and provide further education and motivational techniques. For those who are ready to engage in treatment, the BHCM will coordinate either a warm transfer to an SUD provider or, if the PCP is an MOUD provider, work with the PCP to initiate MOUD if appropriate. The BHCM will also support the transition of patients from SUD specialty care sites back to the PCP for MOUD treatment as described in the Vermont Hub and Spoke model of care. The BHCM establishes relationships with SUD treatment organizations to facilitate warm handoffs.
This brings up a critical point. It is essential for the BHCM to be familiar with the local community and to have strong cultural competency skills to help patients with SUD feel welcome in the practice and to effectively help them manage their treatable chronic condition for the long term.
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