Practice transformation facilitators are employed in primary care sites around the country helping practices make the changes needed to be recognized as Patient Centered Medical Homes (PCMH). Other practices are working on integrated behavioral health into primary care. Because current requirements of the national committee for quality assurance (NCQA) to become a level 3 PCMH include a substantial element of behavioral health services, if the transformation to PCMH and to integrated primary care are done at once the outcomes can be better and disruption minimized (walk-across between NCQA requirements and BH integration). The following modules comprise a training program that can be used to give practice facilitators a background in behavioral health integration to support their work in PCMH practice facilitation. 

 

Each of the 5 modules (about ½ hour each) is followed by a suggested interactive exercise that the facilitator could offer to the members of the practice to illustrate the concepts put forward in the module.

Creating a Mandate for Integration

For a practice to be successful, they need to know why they are committing to the shift towards BHI. When a practice begins the BHI process, there can often be fear of change, of failure, and difficulty coming up with the positive reasons to support BHI.

Accompanying Exercise:

This exercise is designed to better understand the fears related to BHI and to turn those fears into positive “elevator pitches” for BHI. What we find is that people’s fears are often things that are, or could be, solved by integration. It is also helpful to know and acknowledge people’s fears up front so they do not feel silenced through the process. Lastly, knowing people’s fears and helping them reframe will help guide a work plan.

A pitch based on these lists could sound like:

“I want to work in a joyful practice where we efficiently manage the patient to the best of their needs. We will build on our successes with improving the workflow for newly pregnant patients. Our documentation will support the needs of the clinic and the patient, and we’ll only collect additional information about the patient that we need/ can ask on. All staff will be trained so we can all better support the patient!”

This pitch:

  • Reframes the concerns into desires

  • Speaks directly to the practice’s concerns, thus outlining some priorities

  • Acknowledges the practice’s strengths and successes

  • Is spoken in the practice’s own voice
     

The pitch should be documented and revisited at different stages in the integration process!

For example, a list of fears/ barriers might include:

  • Space issues

  • All staff knowing how to interact with the patient appropriately

  • Confidentiality issues

  • Clash of clinical culture

  • Fear of additional screening, documentation

  • Won’t meet the patient’s needs

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What is Special about Primary Care Behavioral Health?

This didactic module will be paired with a group exercise that focuses on understanding different models of integration and creating options for BHI in the primary care setting. The goal of this exercise is to support teams in coming up with creative solutions for BHI, open their thinking to different options, and support the creation of workflows.

Accompanying Exercise:

Team members will discuss examples of what different models of integration look like and what each can contribute in pragmatic terms. This will both paint a clearer picture of integration for the facilitators and provide them with a tool for helping teams envision integration in their clinics. For each topic, team members should brainstorm all possible options, even ones that seem unlikely. The lists will be used to build workflows in the future. Often, many brainstorm options can be used.

Areas for brainstorm include (but aren’t limited to):

  1. Shared workstation/ workspace: What are different options for how desks can be situated/ have office space to support integration?

  2. Hand-offs: How will the team manage patient hand-offs when they realize a patient needs to speak with a BHC? Who can handle the hand-offs?

  3. Documentation: What are options for integrated documentation?

  4. Use of Behavioral Health Clinician: under what circumstances should the BHC be involved?

Brainstorming should be specific. For example, under hand-offs the list could include: EMR flagging, paging, using markers on the patient room, texting, phone calls, etc. They should also cover every option available to the practice, including ones that seem aspirational or impossible.

To begin, the group should introduce themselves and identify their communication style(s) when they are calm and when they are stressed/ burnt out. Examples of communication styles include:

  • Direct or roundabout

  • Expressive (vocal/facial expressions, hand gestures) or quiet

  • Talk first, think later or think first, talk later

  • Wait until others have spoken or initiate conversation

  • Big picture or details

Accompanying Exercise:

Option A: Feedback and Communication

The associated dynamic module will be focused on communication and feedback and will provide an exercise that can be replicated in the practices. A team that works on their communication and feedback will have the skills that result in greater success with their integration (and any other transformation) efforts.

For a practice to be successful, they need to know why they are committing to the shift towards BHI. When a practice begins the BHI process, there can often be fear of change, of failure, and difficulty coming up with the positive reasons to support BHI.

Building the Team

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Once the group has discussed communication styles, they should move into feedback. Start by brainstorming feedback styles. The list can include (but is not limited to):

  • Formal or informal

  • Focusing on one instance vs. overall performance (formative vs. summative)

  • Positive or negative/constructive

  • Verbal or non-verbal

Then the group should brainstorm effective and ineffective methods of giving and receiving feedback. For example:

  • Effective feedback = Feedback given well + Feedback
    received well

  • Check in with yourself before giving feedback: what are your emotions, your thoughts, your physical sensations?
    (triangle of awareness)

  • Check in with yourself as you are getting feedback: what are your emotions, your thoughts, your physical sensations?

  • Ineffective feedback =

  • Feedback not given well + Feedback not received well

  • Feedback given well + Feedback not received well

  • Feedback not given well + Feedback received well

Practice

Now the group will practice giving and receiving feedback. In pairs, pick a situation in which you might give feedback (feedback should not be specific to the person with whom you are practicing, but should be a general example). Taking turns, each member should practice giving and receiving feedback. Debrief the experience in pairs, and then as a whole group.

Option B: Creating team huddles

Huddles are a key component of high functioning teams. Huddles should be scheduled regularly (at least daily), include the integrated team members, and should focus on achieving highest quality team based care. Well executed huddles allow teams to appropriately communicate about, and plan for, the session. When planning your huddle, consider the following components:

  1. Define who will participate in huddles. At a minimum, huddles should include: medical assistants, nurses, Providers, Behavioral Health clinicians, and anyone else on an integrated team. They could also include front desk staff, call center staff, and other people who interact with the team and the patients.

  2. Define your goals for the huddle, and create a standard agenda. What information do you need to get through the day most effectively? How can patients maximize their time at the health center? How can each member of the team contribute to the patient’s care?

  3. Define the time(s) of days for huddles and length. Effective huddles can be as short as 5 minutes, and probably won’t be longer than 15 minutes. Huddles could be at the beginning of the day, before each session begins, at the end of the day (to plan for the next day), or at other natural meeting points during the day.

  4. Define your huddle leader. Your huddle leader can be anyone on the team. They are responsible for creating and keeping the agenda, and ensuring appropriate data is available. This may be a great chance for someone like a medical assistant to shine in their leadership.

  5. Define your data for the huddle. Often people huddle using the Provider’s schedule for the session. They will discuss the patients who are coming in, identifying folks who are due for certain care, are high risk, or are known in advance as needing an integrated service.

  6. Identify barriers to achieving your huddle goals and come up with a plan for overcoming those barriers.

  7. Bonus: Identify a time and space to discuss patients who aren’t coming in for care but need more attention!

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Getting Started

This didactic training will be paired with an interactive module that focuses on potentially difficult conversations about BHI. Building off the first exercise, one member of the group will be assigned to make a pitch on BHI, with other members playing clinical leaders who will point out misgivings they have for their team. People can choose specific roles (ex: the anxious physician, the resistant medical assistant, etc), and can build off real-life experiences.

Accompanying Exercise:

The person making the pitch should:

  • Focus on positive language that engages as many people in the room as possible

  • Use neutral and welcoming body language

  • Build on the practice’s previous experiences, especially successes

  • Appropriately engage folks who are resistant to change

  • Identify (or have already identified) allies & champions in the meeting to assist in moving the conversation forward

  • Keeping calm under pressure, paying special attention to their communication style!

 

One person should observe to support and give feedback to the person making the pitch. What did the facilitator do well? What are areas of improvement? The group will then talk about how to support and facilitate the practice members in addressing the problems that were identified.

Accompanying Exercise:

Groups should identify:

  1. The aim of their project

  2. Who and how to engage on developing the project

  3. The intervention

  4. The training/ implementation plan

  5. The measures for assessment and data collection plan

  6. The cycle time for the project

  7. Method for collecting and reviewing feedback

The interactive portion of this training will build on the facilitators’ knowledge of quality improvement. The facilitators will break into teams and be asked to create one quality improvement project related to BHI (groups should use an example from the didactic lecture). The team should identify the workflow, data needed, and associated PDSA (Plan, Do, Study, Act) cycle that will be used.

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