While the primary care team involves many team members and disciplines, the main team members who are responsible for delivering PCBH services in military hospital or clinic primary care clinics throughout the Department of Defense include the Primary Care Manager (PCM), Behavioral Health Consultant (BHC), External Behavioral Health Consultant (EBHC), and the Behavioral Health Care Facilitator (BHCF).

Primary Care Manager

The PCM drives and leads execution of the treatment plan for those patients enrolled in PCBH services. PCMs work together with BHCs, BHCFs, and EBHCs to develop and maintain a comprehensive treatment plan for patients so that patients receive quality care in a timely manner and achieve optimal levels of physical and mental health more quickly.

Options for the PCM include:

• Refer patients to the BHC to address conditions such as anxiety, depression, PTSD, chronic pain, sleep disorders, substance use, relationship problems, diabetes
• Refer patients with diagnoses of depression, anxiety, and/or PTSD to the BHCF for care facilitation services
• Consult with EBHCs to clarify diagnoses, receive relevant advice for treatment, determine best treatment approach
• Refer patients who may benefit from more intensive treatment approaches to specialty behavioral health providers

Behavioral Health Consultant

BHCs are behavioral health providers who provide care for a wide range of behavioral health conditions, chronic medical problems and adverse health behaviors. BHCs are specially trained psychologists and social workers who consult PCMs and perform brief, focused assessment and intervention with patients to assist them in making behavioral changes to optimize their own health. For patients who may require more intensive services (e.g., extensive evaluation, traditional therapy or prolonged care), BHCs will help link these patients to specialty behavioral health services.

BHCs:

• Screen and assess patients who have or are at risk for developing physical or mental health conditions
• Help patients replace maladaptive behaviors with adaptive ones by providing skill training through patient education strategies and developing specific behavior-change plans that fit the fast pace of primary care
• Enhance patients’ resilience and prevent further psychological or physical deterioration
• Immediately meet with and assess patients who show signs or symptoms of putting them at risk of harming others or themselves
• Help prevent reoccurrence of symptoms or conditions
• Help prevent and manage addiction to prescription medications such as pain medicine or tranquilizers
• Guide primary care patients toward self-managing their chronic disease or persistent physical symptoms
• Link patients with specialty mental health care when appropriate
• It's appropriate to consider almost every PCMH patient for referral to a BHC. The BHC is well-positioned to provide interventions to patients with modifiable adverse health behaviors, chronic medical problems, mental health needs, and any patient who struggles with adherence to the treatment plan.

Examples include:

Behavioral Health Care Facilitator

BHCFs are usually registered nurses who have been trained to help patients who are experiencing depression, anxiety and/or posttraumatic stress disorder (PTSD). BHCFs support PCMs by providing frequent contact with patients and address patient questions or concerns, encourage adherence to the treatment plan, and monitor treatment response. BHCFs ensure that the primary care team is well-informed by bridging communication to and from patients, PCMs, BHCs, and EBHC when necessary.

BHCFs:

• Assess and monitor response to treatment, using validated assessment measures, including the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and Posttraumatic Stress Disorder (PTSD) Checklist (PCL)
• Assist patients with problem solving, goal setting and active coping, overcoming barriers to their treatment plan, adhering to PCM or BHC recommendations
• Encourage continuity of care by connecting patients with their PCMs for medication management and/or BHCs for behavioral intervention/skills training
• Patients appropriate for referral to BHCF include those prescribed a medication for depression, anxiety, and PTSD.

External Behavioral Health Consultant

EBHCs are psychiatrists, prescribing psychologists, or psychiatric nurse practitioners who are not usually co-located in the primary care clinic. EBHCs do not meet with or evaluate patients during face-to-face appointments but instead consult with the primary care team.

EBHCs:

• Enhance the PCM’s management of psychoactive medications
• Provide verbal and/or written consultation for initial medication decisions, medication changes, and managing side effects
• Advise the PCM regarding work-ups of neuro-psychiatric symptoms (e.g., need for neuro-imaging, lab testing, EEG, etc.); ongoing management of psychotropic medications (e.g., drug-level monitoring, chemistry/complete blood count (CBC)/urine testing, etc.); and need for referral to specialty mental health care
• Consult with BHCs regarding behavioral health cases