BEHAVIORAL HEALTH COUNSELOR ROLES AND RESPONSIBILITIES
Behavioral health counselors must be able to function in the face-paced primary care environment. To be effective, they should:
- be flexible enough to deal with noise, frequent interruptions, and constant changes in scheduling;
- be able to offer brief, targeted interventions usually lasting less than 30 minutes;
- be comfortable with short-term counseling, often lasting less than eight visits;
- function well in a team-approach accept the fact that they are not in charge of the clients’ care;
- be behaviorally, rather than personality, focused;
- be able to perform consultations and give provider feedback “on the fly”;
- be able to effectively communicate and interact with primary care providers.
Therapists used to more traditional, long-term, in-depth psychotherapy approaches may experience a “culture shock” in the primary care environment and may need to make significant adjustments in their therapeutic style and way of thinking to be effective in this milieu.
(based in part on Integrated Behavioral Health Care, A Guide to Effective Intervention by William O’Donohue, 2006):
- proficiency in the identification and treatment of mental disorders;
- ability to think in terms of population management, addressing a large clientele in the most efficient ways possible, using Approaches like stepped care and group psychotherapy;
- knowledge of evidence-based behavioral assessments and interventions relevant to medical conditions, e.g., disease management; treatment adherence; and lifestyle change;
- ability to make quick and accurate clinical assessments;
- care-management skills and knowledge of local resources for outside referrals;
- skill in targeted, brief psychotherapy and in running group sessions;
- knowledge of basic physiology, psychopharmacology and medical terminology;
- familiarity with the stepped care model (clients move along different levels of intervention depending on past responses);
- ability to document services in a way that is useful both to the primary care provider and to management for quality-improvement services;
- consultation liaison skills.
MaineHealth has developed a synopsis of Core Competencies for Mental Health Providers in Primary Care which not only describes the skill sets needed, but makes recommendations to the providers about how to establish mental health services in primary care setting.
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(taken from Open Door Community Health Center’s Behavioral Health Program, 2005)
Taken as a whole, the primary behavioral health care model is designed to increase the total proportion of eligible patients that receive appropriate mental and behavioral health services. To do this, the behavioral health counselor may assist primary care providers in:
- Recognition and treatment of mental disorders and psychosocial problems;
- Early detection of “at risk” clients, with the aim of preventing further psychological or physical deterioration;
- Prevention of relapse or morbidity in conditions that tend to recur over time;
- Prevention and management of addiction to pain medicine or tranquilizers;
- Prevention and management of work and/or functional disability;
- Obtaining quality clinical outcomes with high prevalence mental disorders;
- Efficient and effective treatment and management of clients with chronic emotional and/or health problems;
- Management of clients who use medical visits to obtain needed social support;
- Improving the quality of primary care provider interventions without the aid of behavioral health consultation;
- Efficiently moving clients into appropriate mental health specialty care when indicated.
The following is, in part, adapted from the sample job description included in “Providing Behavioral Health Services in a Community Center Setting” promulgated by the Washington Association of Migrant and Community Health Centers, 2002 (some of these functions may overlap):
- assists the primary care provider in recognizing, treating and managing mental health and psychosocial issues and acts as a contributing member to the primary care team;
- conducts client intakes, focusing on diagnostic and functional evaluations, then makes recommendations to the primary care provider concerning the clients’ treatment goals and plan;
- provides consultation and training to the primary care providers to enhance their skill and effectiveness in treating mental health problems;
- provides brief, focused intervention for clients who are in need of mental health services;
- gives primary care providers timely feedback the client’s about care, treatment recommendations and progress via documentation in the client’s record and verbal feedback;
- advises the primary care provider about which clients are better served at the primary care setting and which should be referred to specialty mental health facilities or elsewhere;
- initiates follow-up to ascertain how clients are doing and to determine if any changes in treatment approaches are indicated;
- develops, where indicated, relapse prevention plans and helps clients maintain stable functioning;
- assists in the detection of “at risk” clients and in the development of plans to prevent worsening of their condition;
- monitors and coordinates the delivery of health services for clients as related to behavioral health care, including linking with other treatment providers not only within the primary care setting but, with the clients’ permission, outside it as well;
- assists, to the extent feasible, in the clients’ community functioning by helping with public benefits, vocational rehabilitation, social support, housing, etc;
- documents the clients’ progress and diagnostic informationj in the treatment chart;
- keeps the primary care providers fully informed of the clients’ needs and progress and works with providers to formulate treatment plans;
- works, where indicated, to effect behavioral changes in clients with, or at risk for, physical disorders and helps them make healthier lifestyle choices;
- provides clients with self-management skills and educational information needed so they can be full participants in their own treatment and recovery;
- helps the clients, where indicated, to cope with chronic conditions like pain and diabetes;
- provides consultation to clinic management and other team members about behavioral services and suggested areas of outcome and program evaluation;
- assists the clients in complying with any medical treatment initiated by the primary care provider, such as offering strategies to cope with medication side effects;
- provides treatment for substance use disorders. Workforce Issues Related to Physical and Behavioral Healthcare Integration, Specifically Substance Use Disorders and Primary Care provides a framework for providing this service.
For an example of how a Behavioral Counselor might introduce him/herself to the client, see Sample Introductory Script.
The following was taken from Cherokee Health Systems in Tennessee:
Job Title: Behavioral Health Consultant.
Education/License: Licensed Social Worker (Masters) or a licensed Clinical Psychologist (Doctoral).
- Has excellent working knowledge of behavioral medicine and evidence based treatments for medical and mental health conditions.
- Has ability to work through brief client contacts as well as to make quick and accurate clinical assessments of mental and behavioral conditions.
- Is comfortable with the pace of primary care, working with an interdisciplinary team, and has strong communication skills.
- Has good knowledge of psycho-pharmacology.
- Has the ability to design and implement clinical pathways and protocols for treatment of selected chronic conditions.
To assist in the hiring process, MaineHealth developed a series of interview questions to determine if behavioral health consultant candidates have the needed skill set, perspective and experience to work in a primary care setting.
- Management of psychosocial aspects of chronic and acute diseases.
- Application of behavioral principles to address lifestyle and health risk issues.
- Consultation and co-management in the treatment of mental disorders and psychosocial issues.
The following description of a consultation service model was taken, with slight modifications, from the Primary Behavioral Care Services Practice Manual 2.0, 2002 by Kirk Strosahl:
- Triage/Liaison Services – Initially screening visits usually of 30 minutes or less to determine appropriate level of need for mental health care.
- Behavioral Health Consultation – Intake visits of usually 15 to 30 minutes for clients referred for general evaluation. The focus is typically on diagnostic and functional evaluation, problem-solving, and recommendations for treatment and forming limited behavioral change goals. The visit may involve assessing clients at risk because of some life stress event, educating clients about community and/or clinic resources, or referring them to more appropriate treatment resources. In all cases, the visits will result in consultative feedback given to the clients’ primary care provider.
- Behavioral Health Follow-up – Secondary visits by a client to support a behavioral change plan or treatment started by a primary care provider on the basis of earlier consultation – often occurring in tandem with primary care visits.
- Compliance Enhancement – Visits designed to help the client adhere to an intervention initiated by the primary care provider – often spaced at longer intervals.
- Behavior Medicine – Visits designed to assist clients in managing a chronic medical condition or to tolerate invasive or uncomfortable medical procedures. The focus may be on lifestyle issues or health risk factors among clients at risk (ie, smoking cessation, weight loss) or may involve managing issues related to progressive illness such as end-stage COPD, etc.
- Specialty Consultation - Designed to provide consultative services over time to clients whose situation requires ongoing monitoring and follow-up; applicable to patients with chronic psychosocial issues and/or physical problems requiring longer term management. While the visits are structured like regular behavioral health consultations, they are less frequent and spread out over a longer period of time. The focus should be on restoring adaptive functioning rather than eliminating an acute mental disorder.
- Disability Prevention/Management - Visits designed to assist clients on medical leave from job to return to work quickly. The focus is on coordinating care with primary care provider, job site and client with emphasis on avoiding “disability building” treatments.
- Psycho-educational Classes - Brief group treatment designed to promote education and skill-building that either replaces or supplements individual consultative treatment. Often a psycho-educational group can serve as the primary psychological intervention, as many behavioral health needs are best addressed in this type of group treatment.
- Conjoint Consultation: Visits with primary care provider and client designed to address an issue of concern to both, often involving a conflict between them.
- Telephone Consultation - Planned, scheduled intervention contacts or follow-ups with patients that are conducted by the behavioral health counselor via telephone, rather than in-person.
- On-Demand Behavioral Health Consultation - Usually unscheduled, primary care provider- initiated contact, either by phone or face to face, generally in an emergent situation requiring immediate or short-term response.
- On-Demand Medication Consultation - Usually unscheduled, primary care provider-initiated contact regarding a medical or medication issues, either by phone or face to face, generally in an emergent situation requiring immediate or short-term response.
- Care Management - Designed to coordinate delivery of medical and/or mental health services through multi-disciplinary involvement. Can also involve assisting the client with resources in the community.
- Team Building -Conference with one or more members of the health care team to address peer relationships, job stress issues or process of care concerns.
- Medical Provider Consultation: Face-to face-visits with the primary care provider to discuss client care issues; they often take the form of “curbside” consultation.
- Team Education – Training provided to the primary care providers and other clinic staff about identification and treatment of mental disorders; the relationship of medical and psychological systems; and the services and procedures offered by the behavioral health program, including appropriate candidates for referral.
The Washington Association of Migrant and Community Health Centers, in their “Providing Behavioral Health Services in a Community Health Center Setting” Manual, 2002, framed behavioral functions in the following grid, offered here as an example of how services could be rendered:
|Behavioral Health Service Type||Estimated % of Patient Contacts||Key Service Characteristics|
|General Behavioral Health Consultation Visit||60-70%||
|Behavioral Health Psycho-education Visit||10-20%||
|Behavioral Health Case Conference||10%*||
*These services do not necessarily involve direct client contact.
Staffing Ratios for Behavioral Health Counselors
A common question by those undertaking integrated care concerns how many behavioral health specialists should be employed on staff. While there is no one-size-fits-all answer, and the need/demand varies considerably with the particular model of integration utilized, some experts guestimate that one behavioral health counselor is needed for every four primary care providers. At the highly regarded Cherokee Health Systems in Tennessee, where the behavioral specialists are heavily involved in patient care and treat a high need population, the ratio is more than one mental health worker for every primary care provider.
In their 2013 article, "A needs-based method for estimating the behavioral staff needs of community health centers", authors Bridget Burke et al. found that "More than 2.5 million patients, 12 or older, with mild or moderate mental illness and more than 357,000 with substance abuse disorders, may have gone without needed behavioral services in 2010. This level of need would have required more than 11,6000 full time providers. This translates to approximately 0.9 licensed mental health provider FTE, 0.1 FTE psychiatrist, 0.4 FTE other mental health staff, and 0.3 FTE substance abuse provider per 2,500 patients. These estimates suggest that 90% of current centers could not access mental health services or provide substance abuse services to fully meet patients' needs in 2010. If needs are similar after health center expansion, more than 27,000 full time behavioral health providers will be needed to serve 40 million medical patients, and grantees will need to increase behavioral health staff more than four-fold."
Christopher Hunter PhD has authored an excellent paper, "Operational and clinical Components for Integrated Collaborative Behavioral Healthcare" (which cannot be included here in full because of its American Psychological Association copyright) that discusses integrated models, procedures and staffing. In his words: "The working group recommended that clinics with 7,500 or more empanelled patients use a blended model of care. At least one full-time behavioral health provider (BHP), following the PCBH model, would deliver services within the primary care clinic. At least 32 hours per week would be devoted to patient contact, treatment planning, and consultation with medical providers. Additionally, BHPs would conduct educational presentations, program development, and attend staff meetings. The clinic would also employ one full-time health care professional (e.g., nurse) to fulfill the CM model responsibilities of this blended model. The care manager would spend 32 hours per week delivering depression care management pathway services. These services could be expanded to include clinical pathways for other problems (e.g., anxiety, obesity, diabetes, etc.) as indicated by clinic need and time availability.The BHP would serve as a clinical supervisor for the care manager when
In smaller clinics with 1,500-7,499 empanelled patients, it was recommended that the clinic employ one full-time BHP delivering services consistent with the PCBH model, or one full-time care manager providing CM model services, or a full-time BHP delivering PCBH and CM model services. Providing options for smaller clinics was intended to allow for clinic flexibility based on local needs and funding. It is the authors' opinion that a full-time BHP delivering services using PCBH model and CM model program components is thebest fit to fully meet PCMH goals for these smaller clinics.
At another patient-centered medical home (PCMH) summit (Dorrance,2009), "a breakout team design working group comprised of family medicine physicians, nurses, practice managers and a psychologist developed a set of PCMH staffing recommendations including a BHP staffing ratio. The team design working group recommended a ratio of a 0.25 full-time BHP for every one full-time PCP, who typically manages an enrollment of 1200 patients. Using this ratio, one BHP would be employed for every four PCPs or every 4800 enrollees, which is roughly equivalent to the Department of Defense working group staffing recommendations if patient empanelment had been used instead. These recommendations, geared for military settings, can also serve as a compass to guide staffing in the civilian market. At the same time, regardless of the type of setting (e.g., civilian, Veterans Affairs or military), the level of behavioral health integration desired, and the need of the population being served, are likely to be important factors when determining BHP staffing ratios."