Journal of Clinical Psychology in Medical Settings

https://doi.org/10.1007/s10880-017-9516-9

Toward a Unified Integration Approach: Uniting Diverse Primary Care

Strategies Under the Primary Care Behavioral Health (PCBH) Model
Brian E. Sandoval1 · Jennifer Bell2 · Parinda Khatri3 · Patricia J. Robinson4

© Springer Science+Business Media, LLC, part of Springer Nature 2017

Abstract
Primary care continues to be at the center of health care transformation. The Primary Care Behavioral Health (PCBH) model
of service delivery includes patient-centered care delivery strategies that can improve clinical outcomes, cost, and patient and
primary care provider satisfaction with services. This article reviews the link between the PCBH model of service delivery
and health care services quality improvement, and provides guidance for initiating PCBH model clinical pathways for patients
facing depression, chronic pain, alcohol misuse, obesity, insomnia, and social barriers to health.

Keywords  Primary Care Behavioral Health (PCBH) · Behavioral health integration · Behavioral health consultant (BHC) ·
Clinical pathways · Patient-centered medical home (PCMH) · Quality improvement

Primary Health: Unique Challenges emphasis for practices across the United States (Gerrity,
and Opportunities 2016; Jolly et al., 2016).
This article reviews the Primary Care Behavioral Health
The provision of primary health care is unlike many other (PCBH) model of integration, a platform for providing effec-
medical specialties. It requires practices to manage a large tive, holistic care to a large proportion of the population.
segment of the population for preventative, routine, and The PCBH model includes delivery of brief interventions to
chronic health needs (Shi, 2012). Often times, individuals patients of any age for any biopsychosocially related prob-
in primary care have a complex array of physical, emotional, lem at the time of need by a behavioral health consultant
and social concerns that may or may not be explicitly stated (BHC). Additionally, the BHC partners with team members
in the presenting problem (Haas, Leiser, Magill, & Sanyer, to create routine clinical pathways of care for patients with
2005). Thus, delivering effective primary care can be a high-frequency biopsychosocial problems. PCBH model
daunting task; health care providers must attend to myriad clinical pathways typically intersect closely with a clinic’s
concerns both in a brief context and at a high volume. Given efforts to more efficiently and effectively deliver evidence-
the influence of health behaviors and mental health condi- based care. In this article, we offer guidance for development
tions on health care costs and outcomes, primary care behav- of six clinical pathways for PCBH model service delivery:
ioral health integration strategies have become an area of depression, persistent pain, alcohol misuse, obesity, insom-
nia, and social determinants of health.

* Brian E. Sandoval
[email protected] The Evolution of Primary Care
1
Yakima Valley Farm Workers Clinic, Salud Medical Center, The culture of primary care has evolved significantly over
1775 Mt. Hood Ave, Woodburn, OR 97071, USA
the last decade with an increased emphasis on activities
2
Defense Centers of Excellence for Psychological Health that occur outside of a routine exam room visit (Rao et al.,
and Traumatic Brain Injury, Silver Spring, MD, USA
2017). Quality incentive metrics, clinical benchmarks, and
3
Cherokee Health Systems, 2018 Western Avenue, Knoxville, chronic disease registries have become part of the nomen-
TN 37921, USA
clature of primary care as the United States moves toward
4
Mountainview Consulting Group, 1327 SE Tacoma, #322, a pay-for-performance approach (Eidus, Pace, & Staton,
Portland, OR 97202, USA

13
Vol.:(0123456789)
 Journal of Clinical Psychology in Medical Settings

2012). The advent of the Patient-Centered Medical Home especially in many large health networks or large group
(PCMH) approach has been a primary driver in this care practices which have experienced about a 14% increase in
transformation. The PCMH joint principles were published patient volume (“Impact of the Affordable Care Act”, 2015).
and endorsed by four primary care professional societies in In addition, the rise of Medicaid enrollment has resulted in
2007 (American Academy of Family Physicians [AAFP], patient panels with higher rates of chronic disease, men-
American Academy of Pediatrics [AAP], American College tal health comorbidities, tobacco use, and substance use
of Physicians [ACP], American Osteopathic Association (Blumenthal, Rasmussen, Collins, & Doty, 2015). It is this
[AOA], 2007). The defining features of the PCMH are that segment of the population that causes strain on the system
care is delivered in a manner that is patient-centered (i.e., and takes significantly more time to manage in a primary
a partnership among practitioners, patients, and families); care visit (Miller, Teevan, Phillips, Petterson, & Bazemore,
comprehensive (i.e., care provided by a multidisciplinary 2011). Unfortunately, there is not enough time in the clinic
team); coordinated (i.e., care that is organized across the day for PCPs alone to effectively address all needs. For
broad health system); accessible (i.e., care is available after example, Yarnall et al., (2009) point out PCPs would need to
hours or via alternative means); and committed to safety spend 21.7 h each day to provide all recommended preven-
and quality (i.e., care that is effective and outcome-focused; tative, acute, and chronic care for a panel of 2500 patients.
AAFP et al., 2007). The PCMH is the method by which Thus, it is no surprise that PCP burnout is currently at an all-
practices have sought to achieve the Triple Aim: improving time high (Peckham, 2015) as medical professionals expe-
health system outcomes through better population health, rience greater dissatisfaction with work–life balance when
reducing costs, and enhancing the individual experience of compared to other working Americans (Shanafelt et al.,
care (Berwick, Nolan, & Wittington, 2008). As part of this 2012). The increasing evidence mounting toward PCP (and
change, many practices are seeking PCMH recognition by staff) burnout has led to the recent adoption of the Quad-
one of the several recognition agencies (e.g., National Com- ruple Aim approach which extends the elements of Triple
mittee for Quality Assurance [NCQA], Accreditation Asso- Aim (i.e., quality, cost, patient experience) to also include
ciation for Ambulatory Health Care [AAAHC], The Joint improving the work environment for those individuals who
Commission [TJC], and Utilization Review Accreditation deliver care (Bodenheimer & Sinsky, 2014). While some
Commission [URAC]) as a way to demonstrate to patients systems have found creative ways to spread administrative
and payers that they meet a given PCMH quality standard tasks across team members, in our experience there are
(National Association Medical Staff Services [NAMSS], many practices that continue to struggle with the division
2017). There is also a growing movement for payers to and delegation of clinical responsibilities, with PCPs becom-
offer financial incentives to practices meeting higher levels ing the default “owner” of several clinically oriented tasks
of PCMH recognition (Edwards, Bitton, Hong, & Landon, that might be better assumed by other team members. As
2014). the PCMH expands and advances, appropriate task delega-
PCMH recognition, while a well-intentioned strategy for tion is paramount to keeping PCPs engaged in their work as
transparent quality standards, has also placed significant well as providing quality health care to a growing insured
demands (both perceived and realized) on primary care prac- population (Altschuler, Margolius, Bodenheimer, & Grum-
tices (Wise, Alexander, Green, Cohen, & Koster, 2011). For bach, 2012).
example, the NCQA’s PCMH standards (2014) often require
a complete overhaul of administrative and clinical practices
that begins with front office staff and extends to various
PCBH Model Service Delivery
health team members, including the primary care provider
(PCP). Many health systems now have reporting require-
The PCBH model of service delivery was developed as a
ments that must be satisfied both locally (through state
clinician-driven effort to fill a need for effective behavio-
Medicaid) and nationally (through the Health Resources
ral health services in primary care (Strosahl, 1996, 1998;
and Services Administration [HRSA]) to receive funding
Strosahl & Robinson, 2008). Reiter, Dobmeyer, and Hunter
(HRSA, 2016). Additional regulatory demands (Webster &
(2017) describe the PCBH model as:
Grabois, 2015) have put added pressure on primary care
practices to reduce opioid prescription and offer alternatives … a team-based primary care approach to managing
for chronic pain management. The complexity and scope of behavioral health problems and biopsychosocially-
these changes in primary care pose significant organizational influenced health conditions. The model’s main goal
and practice level challenges. is to enhance the primary care team’s ability to man-
This changing climate of health care is having an impact age and treat such problems/conditions, with result-
on PCPs’ service delivery. Their panels are expanding in an ing improvements in primary care services for the
attempt to meet the demands of the Affordable Care Act, entire clinic population. The model incorporates into

13
Journal of Clinical Psychology in Medical Settings

the primary care team a behavioral health consultant including an estimated 83% of US adults who are in a state
(BHC), sometimes referred to as a behavioral health of less-than-optimal mental health (Centers for Disease
clinician, to extend and support the primary care pro- Control and Prevention [CDC], 2013] and the majority of
vider (PCP) and team. The BHC works as a generalist adults who have one or more modifiable causes of disease,
and an educator who provides high volume services death, and loss of functioning (CDC, 2013, 2014b; Ogden,
that are accessible, team-based, and a routine part of Carroll, Kit, & Flegal, 2014). Given the high prevalence of
primary care. Specifically, the BHC assists in the care psychosocial issues that regularly present in primary care (in
of patients of any age and with any health condition one study, for example, patients reported an average of five
(generalist); strives to intervene with all patients on psychosocial problems; Bikson, McGuire, Blue-Howells, &
the day they are referred (accessible); shares clinic Seldin-Sommer, 2009), implementing the PCBH model can
space and resources and assists the team in various assist primary care practices in meeting their overarching
ways (team-based); engages with a large percentage health care services quality goals.
of the clinic population (high volume); helps improve As noted above, the scope, demands, and expectations
the team’s biopsychosocial assessment and interven- of PCPs and health care delivery systems have increased
tion skills and processes (educator); and is a routine considerably. As such, the impact of BHC services can
part of biopsychosocial care (routine). To accomplish and should be greater than the provision of direct patient
these goals, BHCs use focused (15–30 min) visits to care. Improving health at the population level will require a
assist with specific symptoms or functional improve- calculated synergy between clinical practice and organiza-
ment. Follow-up is based in a consultant approach tional administration. The framework of the PCBH model is
in which patients are followed by the BHC and PCP designed to enhance primary care by optimizing its efficacy
until functioning or symptoms begin improving; at that in multiple operational, clinical, and financial domains. For
point, the PCP resumes sole oversight of care but re- example, many states have quality incentive metrics tied to
engages the BHC at any time, as needed. Patients not payment that are directly related to a behavioral health con-
improving are referred to a higher intensity of care, cern (e.g., depression screening and documented follow-up
though if that is not possible the BHC may continue plan; Screening, Brief Intervention, and Referral to Treat-
to assist until improvements are noted. This consultant ment [SBIRT] for substance use, follow-up after mental
approach also aims to improve the PCP’s biopsychoso- health-related hospitalization) or indirectly tied to manage-
cial management of health conditions in general (this ment of conditions that have significant health behavior
issue). components (e.g., tobacco cessation, diabetes control). In
our experience BHCs can play a vital role in helping the
The PCBH model allows behavioral health care to be a
team better meet these types of metrics as well as effectively
normal and expected part of service delivery, intentionally
assist with ongoing health service quality goals. Thus, hav-
structured to provide patients with access to appropriate
ing a BHC with competencies in leadership, teaching, work-
care the moment they need it. When PCBH model services
flow management, and program development and evaluation
are well organized and routine in primary care delivery, the
can provide significant value beyond direct patient care.
model’s unique facets of immediate access and “curbside”
consultation allow patient care to be shared seamlessly
among PCPs and health care team members. Thus, the
BHCs as Clinicians and Integrated Team
PCBH model aligns with NCQA’s intentions of creating a
Members
care delivery structure with individuals working at the top
of their license.
An organization’s health service quality goals are typically
organized around patient groups identified for enhanced
interventions. While these quality goals may arise in an
The Needs of Primary Care and the Value organic fashion within a clinic, funders have increasingly
of PCBH Model Services provided incentives for clinics to adopt and pursue specific
health service quality targets (e.g., increase the percentage
A primary care system that blends usual care with a BHC’s of patients with blood pressure readings less than 140/90
focused biopsychosocial intervention is able to better man- to 85%). Clinics implementing the PCBH model are at a
age the needs of its population with more comprehensive definite advantage in pursuing quality-based initiatives, as
preventive care, early intervention, and treatment (Balasu- change in psychological functioning can facilitate improve-
bramanian et al., 2017; Burt, Garbacz, Kupzyk, Frerichs, ments in physical health outcomes and reduce further risks
& Gathje, 2012). The proportion of primary care patients (Rozanski & Kubzanski, 2005). Having a BHC available
who could benefit from PCBH model services is enormous, to support PCPs and the health team can enhance a clinic’s

13
 Journal of Clinical Psychology in Medical Settings

ability to provide care that is holistic, accessible, and afford- Set (HEDIS), a tool used by more than 90% of America’s
able (World Health Organization [WHO] & World Organiza- health plans to measure performance, is increasingly deter-
tion of Family Doctors [WONCA], 2008). Although improv- mining payment contracts, negotiated fee schedules, and
ing a PCMH’s health service quality metrics without a BHC incentive pay to providers and organizations (Damberg
on the team is possible, it is our experience that services et al., 2014). HEDIS metrics can be either objective out-
may not be as diverse or as effective. Organizational priori- come or process measures of clinical quality, and often
ties that can be supported by BHC activities include several are influenced by an amalgam of physical, behavioral, and
examples below. social factors. Examples of HEDIS measure areas include
prenatal and postpartum care, blood pressure control, dia-
Increased Access and Optimization of Behavioral betes control, obesity assessment, asthma management,
Health psychiatric hospitalization follow-up, breast cancer screen-
ing, depression and attention deficit hyperactivity disorder
Screening for depression is a common criterion for NCQA’s (ADHD) management, tobacco use, and adolescent well
PCMH recognition as well as a core measure for the Uni- visits. BHCs can support protocols and implementation of
form Data System that is required for all Federally Quali- evidence-based practice guidelines to help meet these clin-
fied Health Centers (FQHCs). The United States Preven- ical quality goals. Further, in our experience, the shared
tive Services Task Force (USPSTF) recommends screening care coordination offered by PCBH model service delivery
be implemented with adequate systems in place to ensure allows for robust attention to gaps in care. For example, at
an accurate diagnosis, effective treatment, and appropri- Cherokee Health Systems, a BHC may get a daily list of
ate follow-up (Siu et al., 2016; USPSTF, 2016). The lack patients with scheduled appointments whose quality out-
of timely access to quality behavioral health services has comes are below standards. One such daily Gap in Care
been highlighted as a major public health concern nation- report prompted a BHC to address a patient’s fears about
ally and has prompted the inclusion of access to behavio- getting a mammogram, conduct collaborative dietary goal
ral health services as an important requirement by HRSA, setting to reduce blood pressure in another patient, provide
Veteran’s Health Administration, NCQA, regulatory, and a rapid aftercare follow-up for a patient with a recent psy-
licensing entities at the state level, as well as many payers chiatric hospitalization, and implement a behavioral plan
such as Anthem, Beacon Health Options, and Blue Cross for appropriate inhaler use for a child with asthma.
Blue Shield (America’s Health Insurance Plans Center for
Policy and Research [AHIP], 2016). While a BHC can pro-
vide access to behavioral health through direct clinical ser- PCMH Initiatives
vice, a broader impact can be made by increasing the depth
and breadth of the primary care team’s ability to manage As an anchoring framework for comprehensive and coor-
biopsychosocial concerns. For example, a BHC could help dinated care, PCMH recognition by a quality assurance
PCPs build skills and knowledge in management of depres- entity (e.g., NCQA, TJC) has become an expectation
sive disorders thorough shared care management, formal for most primary care practices (Rittenhouse & Short-
didactics, and patient consultation. Based on our experi- ell, 2009; Rittenhouse, Shortell, & Fisher, 2009). The
ence, enhancing PCPs’ skills can improve their ability to integration of behavioral health care has become highly
effectively address behavioral health issues through a team important to attaining PCMH recognition; for example,
approach (not just the BHC), and may reduce the frequency behavioral health is key to five of the six “must pass” ele-
of unnecessary specialty mental health referrals or situations ments set forth by NCQA (2014). Our experience has been
where these problems are ignored completely (Kinman, Gil- that PCBH model services operating within the PCMH
christ, Payne-Murphy, & Miller, 2015). structure and workflow can play a central role in meeting
the elements within each of the six standards: (1) Enhance
Clinical Quality Improvement and Assurance access and continuity, (2) team-based care, (3) popula-
tion health management, (4) plan and manage care, (5)
Measuring health services quality in a meaningful way, a track and coordinate care, and (6) measure and improve
primary goal of the Triple Aim, has emerged as a priority performance. For example, at Cherokee Health Systems,
for attention by almost every stakeholder in the health- the BHC completes the required self-management goal
care system (Stelfox et al., 2015). “Quality over quantity” setting at the patient level, supports management of high
and “pay for performance” are common mantras guiding complexity at the primary care panel population level, and
efforts to reform the financing and regulation of healthcare provides training on motivational interviewing, shared
delivery (Burwell, 2015). Performance on quality metrics decision-making, and patient activation and engagement
such as the Healthcare Effectiveness Data and Information at the practice team level.

13
Journal of Clinical Psychology in Medical Settings

Program Development and Evaluation While detailing clinical pathways is outside of the scope of
this article, below are just a few examples in which BHCs
Improving population-based health in the resource-lim- can augment the care provided in a PCMH.
ited, (often) chaotic, and dynamic world of primary care
involves systematic and strategic needs assessment, plan- Depression
ning, program implementation, and evaluation (Institute of
Medicine [IOM], 2012). PCBH model services can provide Almost 7% of Americans had at least one major depres-
structure to this process. With PCBH model clinical path- sive episode in the last year (National Alliance for Men-
ways in place, PCMHs can more efficiently and effectively tal Illness, 2015). The USPSTF recommends screening for
target high risk and/or complex conditions that might typi- depression and specifies that “screening should be imple-
cally overwhelm a primary care system. For example, Katon mented with adequate systems in place to ensure accurate
et al.’s (1996) study evaluated BHC services working in a diagnosis, effective treatment, and appropriate follow-up”
team-based vertical strategy designed to improve outcomes (Siu et al., 2016, p. 380). Despite these recommendations,
for depressed primary care patients. In less than three total only 35.3% of people with severe depressive symptoms, 20%
hours of contact with a BHC (a menu of four to six, 30-min with moderate depressive symptoms, and 13% with mild
visits drawing from behavioral activation, values, problem symptoms reported having seen a mental health provider in
solving, cognitive strategies, and relapse prevention), the the previous year (Pratt & Brody, 2014). While appropriate
team achieved improved clinical, cost, and satisfaction out- follow-up for some patients means a referral to specialty
comes relative to usual primary care. Ninety-one percent of mental health, many patients with depression may have their
the patients attending the first visit completed at least four needs met solely in primary care. Use of BHC’s services
visits (considered treatment completion). Thus, it appeared to provide additional assessment, particularly concerning
that this vertical organization strategy for delivery of behav- behaviors that trigger and maintain symptoms of depression,
ioral interventions yielded strong engagement from patients may result in the design of individually tailored behavioral
and greater PCP satisfaction, two important outcomes for plans that promote vitality and health. These interventions
program development. may include behavioral activation, cognitive therapy strat-
egies, mindfulness, and values-based behavior change. In
fact, patients may prefer behavioral or cognitive approaches
PCBH Model Pathways (Gum et al., 2006; van Schaik et al., 2004) and may demon-
strate improvement without use of medications (DeRubeis,
PCBH pathways are defined by Robinson and Reiter (2016) Siegle, & Hollon, 2008). When medications are used, aug-
as “a multidisciplinary management tool developed to menting antidepressant treatment with targeted skill train-
improve outcomes for a target group of patients, using evi- ing in brief BHC visits can increase the likelihood of treat-
dence-based practice and resources available” (p. 236). A ment success; specifically, improvement and safety may be
PCMH ready to develop a PCBH model clinical pathway has enhanced by the BHC’s coaching for medication adherence,
a wide variety of options in health behaviors or conditions risk assessment (Bryan et al., 2012), and delivery of psycho-
from which to choose. One PCMH may develop pathways social interventions such as Acceptance and Commitment
for parenting/pediatric behaviors or ADHD; another may Therapy (ACT; Bauman, 2014; Beachy, 2014), behavioral
focus on tobacco cessation, medication adherence, or head- activation (Kanter, Baruch, & Gaynor, 2006), and brief cog-
aches. In 2014, for example, clinical pathways were devel- nitive behavioral therapy (Cape, Whittington, Buszewicz,
oped for use in the Department of Defense (DoD) for depres- Wallace, & Underwood, 2010). BHCs can also assist with
sion, anxiety, alcohol misuse, tobacco cessation, obesity, referrals to specialty mental health for patients with more
diabetes, insomnia, and chronic pain. Each of these clinical severe symptoms as well as provide a bridge in care while
pathways include direction for PCMH staff on identification patients await their first specialty appointment.
of patients (e.g., screening, data pulls), workflows for con-
necting patients with BHCs, evidence-based interventions The Opioid Epidemic and Management of Persistent
for the BHCs, and methods of monitoring outcomes. Three Pain
of these clinical pathways (depression, alcohol misuse, and
obesity) could help PCPs better follow USPSTF guidelines. Two hundred fifty-nine million prescriptions were written
These recommendations can be difficult for PCPs to address for opioids in 2012, an amount more than enough to give
on their own in an efficient and effective manner; however, every American adult their own bottle of pills (CDC, 2014a).
they are more likely executable by incorporating BHC ser- As many as one in four primary care patients receives opioid
vices. All pathways aim to best meet the needs of the popu- prescriptions long-term for non-cancer pain battle addiction
lation that PCMHs serve by enriching usual primary care. (Boscarino, Rukstalis, & Hoffman, 2010), and over 1000

13
 Journal of Clinical Psychology in Medical Settings

people go to emergency departments each day for opioid persons engaged in risky or hazardous drinking be provided
misuse treatment (Substance Abuse and Mental Health Ser- brief behavioral counseling interventions to reduce alcohol
vices Administration [SAMHSA], 2014). Four of five new misuse. Utilizing an alcohol misuse clinical pathway such
heroin users started with misuse of prescription pain kill- as SBIRT includes a routine method of assessing for risky
ers, and 94% of participants surveyed in an opioid treatment alcohol use and providing early intervention and treatment
group reported choosing heroin because prescription opioids for those who have at-risk drinking behaviors (CDC, 2014b).
were “far more expensive and harder to obtain” (Cicero, Brief (10–15 min), multi-contact counseling interventions,
Ellis, Surratt, & Kurtz, 2014). Opioids (including prescrip- ideally suited for the PCBH model of care, have been shown
tion opioids and heroin) killed more than 33,000 people in to be effective at reducing weekly alcohol consumption and
2015, more than any previous year, and nearly half of opioid improving long-term adherence to recommended drinking
overdose deaths involve a prescription opioid (CDC, 2017). limits (Jonas et al., 2012). BHCs may provide interventions
The PCBH model and use of a clinical pathway can such as cognitive behavioral strategies, action plans, drink-
make a meaningful difference in the problem of persistent ing diaries, stress management, and problem solving. BHCs
pain and opioid use. While PCPs seem to avoid long-term may also facilitate timely referrals to more intensive sub-
opioid therapy and emphasize functional treatment goals stance use treatment when indicated.
for their patients, there are still many individuals that con-
tinue the pursuit of reducing pain intensity (Henry, Bell, Obesity
Fenton, & Kravitz, 2017). Initial goals of a persistent pain,
opioid use pathway might include (1) identifying feasible One-third of the US population is obese (Ogden et al., 2014).
strategies for evaluating patient functioning on an ongoing The USPSTF recommends that all adults be screened for
basis, (2) assisting patients with greater acceptance of pain obesity, and patients with a body mass index (BMI) of 30 kg/
and improved engagement in meaningful life activities, (3) m2 or higher should receive intensive, multi-component
assisting patients with tapering from higher opioid dosages, behavioral interventions (USPSTF, 2014). Behaviorally
and (4) increasing patient participation in treatments such based treatments are known to be safe and effective for
as acupuncture and physical therapy. BHC services might weight loss and maintenance with more treatment sessions
optimally be provided through a group medical visit given (12–26 sessions in a year) associated with greater loss (LeB-
the large number of patients with persistent pain and opi- lanc, O’Connor, Whitlock, Patnode, & Kapka, 2011). Most
oid use, as well as the intensity of behavioral interventions of the higher-intensity behavioral interventions included
needed to benefit patients with persistent pain. Guidance for multiple behavioral management activities, such as setting
implementing PCBH model clinical pathways for persistent weight-loss goals, improving diet or nutrition, increasing
pain is available and includes measurement and implementa- physical activity, addressing barriers to change, actively
tion materials (see Robinson & Bauman, 2017; Robinson, using self-monitoring strategies, and planning to maintain
Bauman, & Beachy, 2016). Focused Acceptance and Com- lifestyle changes. A challenging task for a PCP alone, BHCs
mitment Therapy [FACT]; (Robinson, Gould, & Strosahl, are ideally positioned to team with the PCP, nutritionist, and
2010; Strosahl, Robinson, & Gustavsson, 2012) is one recent other PCMH staff to ensure that a wide array of services are
approach that has emerged as a viable treatment pathway for available and coordinated to best assist patients in meeting
chronic pain by facilitating patients’ achievement of value- health goals. In our experience, having BHCs readily avail-
consistent health goals. The first randomized controlled trial able to address obesity concerns allows practices to dedicate
to evaluate FACT for persistent pain delivered by a BHC in the necessary time and resources to behavior change strate-
a group format is currently in process (Kanzler et al., 2017). gies. Thus, PCBH model services play an important role to
For this trial, efforts were made to create a manualized inter- ensure that behavioral treatment continues to be a first-line
vention that would support rapid dissemination if results are intervention for obesity in primary care.
positive. The problem of persistent pain will not go away
quickly and sustained efforts to reduce harm in this group Insomnia
are imperative.
The National Ambulatory Medical Care Survey found that
Alcohol Misuse 5.5 million outpatient visits in 2010 were for insomnia, with
20.8 million for sleep medication prescriptions (a 293%
According to a 2012 national survey, one in four Ameri- increase from 1999) written in an attempt to address these
can adults aged 18 or older engaged in binge drinking in problems (Ford et al. 2014). Cognitive behavioral therapy for
the past month and 7.1% engaged in heavy drinking in the insomnia (CBT-I) has long demonstrated effectiveness and
past month (SAMHSA, 2012). The USPSTF (2013) recom- even superiority over hypnotics as a treatment for insomnia
mends screening adults for alcohol misuse and specifies that (Trauer, Qian, Doyle, Rajaratnam, & Cunnington, 2015),

13
Journal of Clinical Psychology in Medical Settings

although a shortage of trained providers and the number of of organizational protocols for vulnerable patient popula-
treatment sessions limits its wide-spread use. More recently, tions. We have found that trauma informed care is commonly
University of Pittsburgh developed a protocol for brief championed by BHCs, particularly in areas of sensitivity
behavioral treatment for insomnia (BBTI), a four appoint- training, treatment considerations, and policy revision, to
ment (two of which may be phone) treatment using the core better serve patients with emotional trauma. BHCs’ “expert”
components of stimulus control and sleep restriction. BBTI, knowledge at both the administrative and clinical level
delivered by a master’s level mental health nurse practitioner makes them valuable assets for trauma informed practice
without sleep medicine or behavioral intervention experi- transformation that is both meaningful and sustainable.
ence, has demonstrated efficacy in treating older adults with BHCs can assume a role in addressing the social deter-
insomnia (Buysse et al., 2011). Given these promising find- minants of health by initiating and revising workflows for
ings, this protocol has been adapted to even more closely screening, identification, and treatment based on patients’
align with the PCBH model and is in use by BHCs within unique needs. Often, patients present with myriad psychiat-
the United States Army. ric, social, and behavioral concerns. So it is helpful for the
BHC to assess the patient’s “hierarchy of needs,” implement
Social Determinants of Health appropriate treatment, and determine next steps in care.

While not part of a diagnosis-specific pathway, we have

found that screening and addressing a patient’s health- Developing a Clinical Pathway
related social factors is becoming more commonplace
in primary care practices, especially those recognized as PCBH model clinical pathways define the roles and respon-
PCMHs. This evolution is partly due to the emergence of sibilities of BHCs and, in some instances, the behavior
new data which de-emphasizes physical health interven- of other team members. Pathways may be thought of as
tions and instead focuses on social and emotional health care delivery plans that support close working relation-
interventions. Recent public health findings suggest that ships between a BHC and other team members in efforts to
physical health care delivery only affects about 20% of a improve care to patients in a target population (Robinson &
population’s health (McGovern, Miller, &Cromwick, 2014). Reiter, 2016). Principles guiding the idea of PCBH model
McGovern et al. (2014) posit that socio-economic factors clinical pathways derive from ideas about quality manage-
(e.g., education, employment, income, family/social sup- ment generated in the 1980s. Key goals were to make the
port) and health behaviors (e.g., tobacco use, diet, exercise, most of limited health care resources and improve the effi-
alcohol use, unsafe sex) together impact roughly 70% of ciency of care, and these goals are more important than ever
population health. NCQA and HRSA, among others, have in today’s healthcare environment.
recognized the need to address non-medical factors influ- To identify a pathway target population, BHCs can per-
encing health and now require organizations to collect and form needs assessment and PCBH model clinical pathway
report these data. NCQA’s (2014) standards take it a step surveys to inform priorities for development of population-
further in that social and behavioral determinants of health specific programs that use the BHC to better implement
must be considered for risk stratification, care management, evidence-based interventions. Cross-functional members
and treatment approaches. Closely associated with social of the team design pathways, evaluate them over time, and
and behavioral factors, the identification and treatment of change them as indicated. Pathways define what evidence-
psychological trauma has become an integral component of based services the BHC and other members of the team will
effective, “whole person” care delivery. Findings from the deliver; when and how services will be delivered; and how
Adverse Childhood Experiences (ACEs) study indicate that results will be assessed. PCBH model services may include
the presence of psychological or emotional trauma in one’s phone contacts, individual visits, and class offerings. Path-
childhood has been linked to poorer health outcomes, risky ways often involve group services, as this format allows the
health behaviors, and early death (Felitti & Anda, 1997). BHC to deliver more intensive skill training to patients and
Logically, it makes sense for organizations to prioritize the an opportunity to teach these interventions to health team
aforementioned risk factors given how these concerns can members who also may be involved in delivery of care to
influence one’s current and future health status. these patients. Utilizing a process improvement strategy is
In our experience, BHCs are viewed as integral team helpful in evaluating adaptations of evidence-based interven-
members when patients are impacted by psychological tions, and adaptations are usually necessary in order to meet
trauma and social determinants of health present in pri- the demands of the brief, at-the-moment-of-need context of
mary care. While same day “warm handoffs” tend to ease primary care.
the burden for PCPs in the midst of their busy days, BHCs Robinson and Reiter (2016) recommend nine implemen-
also have become increasingly valued in their development tation steps that may be helpful in successfully initiating

13
 Journal of Clinical Psychology in Medical Settings

a PCBH model clinical pathway. Attention to these steps a variety of health domains. Health systems across the
may support the work of quality improvement committees, country are now embracing the value of integrated care,
help prevent slowed and problematic implementation, and and using the PCBH model of service delivery can be an
enhance rapid attainment of optimal outcomes. important avenue to successfully provide the comprehensive
Step 1 involves identification of a target population for the care that is desired. Optimizing the value of PCBH model
pathway. This target population could be organized by indi- services begins with understanding that the PCBH model
viduals with a general condition (e.g., diabetes, chronic pain) is not just about improving behavioral health outcomes in
or could consist of a narrowed subpopulation based on cer- primary care. Its mission is broader than that: it is designed
tain characteristics (e.g., pregnant mothers who use tobacco, to strengthen the system of health care service delivery by
chronic pain patients who are on opioid medications). making interventions toward healthy behaviors a routine part
Step 2 consists of the development of a pathway-specific of health care. BHC services can be of fundamental impor-
team. Membership needs to include representation from all tance in practice transformation and aid in the attainment of
staff groups that will be involved in the pathway work. clinical quality initiatives. A BHC at the table can help with
Step 3 involves an attempt to describe current practices development and implementation of clinical pathway ser-
and identify available data for evaluating the impact of cur- vices that change and improve population health outcomes.
rent practices.
Step 4 includes a review of evidence for improving care Compliance with Ethical Standards 
to the target population. Evidence specific to primary care
is highly valuable; however, such evidence may not always Conflict of interest  Brian E. Sandoval, Jennifer Bell, Parinda Khatri,
and Patricia J. Robinson declare that they have no conflict of interest.
be available, and the team will need to consider strategies
for adapting evidence obtained from a specialty care setting. Human and Animal Rights and Informed Consent  No animal or human
Step 5 encourages implementers to look at the cost of studies were carried out by the authors for this article.
implementing a variety of possible changes and determining
the best value.
Step 6 consists of forming the pathway statement of “who
does what.” References
Step 7 concerns defining pathway goals and management/
evaluation strategies. Altschuler, J., Margolius, D., Bodenheimer, T., & Grumbach, K.
Step 8 conducting a pilot study, while not always neces- (2012). Estimating a reasonable patient panel size for primary
sary, is often helpful. A pilot allows the team to identify care physicians with team-based task delegation. Annals of Family
Medicine, 10(5), 396–400.
problems and address them prior to wider dissemination. America’s Health Insurance Plans Center for Policy and Research.
Step 9 is dissemination. Pilot results often help to gener- (2016). Ensuring access to quality behavioral health care: Health
ate interest and enthusiasm for dissemination. plan examples.
American Academy of Family Physicians, American Academy of Pedi-
atrics, American College of Physicians, & American Osteopathic
Association. (2007). Joint principles of the patient-centered medi-
Summary cal home.
Balasubramanian, B. A., Cohen, D. J., Jetelina, K. K., Dickinson, M.,
Primary care continues to be in the epicenter of health care Davis, M., Gunn, R., … Green, L. (2017). Outcomes of integrated
behavioral health with primary care. Journal of the American
transformation, and the development of innovative, effective Board of Family Medicine, 30(2), 130–139.
ways to manage large panels of patients is of fundamental Bauman, D. (2014). A brief acceptance and commitment therapy inter-
importance to achieving the Quadruple Aim. Behavioral vention in a primary care, underserved setting: ACTing your way
health leaders and team members with expertise in behav- with anxiety (Unpublished doctoral dissertation). The School of
Professional Psychological at Forest Institute, Springfield, MO.
ioral science support the realization of this opportunity in Beachy, B. (2014). Utilizing ACT principles to address weight manage-
a variety of ways. Fully integrated BHCs can enhance the ment through brief sessions in the primary care setting (Unpub-
resiliency of the team, facilitate patient access to evidence- lished doctoral dissertation). The School of Professional Psycho-
based behavioral interventions, help minimize over-empha- logical at Forest Institute, Springfield, MO.
Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim:
sis on use of medications to address human suffering, and care, health, and cost. Health Affairs, 27(3), 759–769.
deepen the potential for primary care to attain its mission of Bikson, K., McGuire, J., Blue-Howells, J., & Seldin-Sommer, L.
improving the health of a community. BHCs who are fully (2009). Psychosocial problems in primary care: Patient and pro-
integrated in the primary care setting are positioned to sup- vider perceptions. Social Work in Health Care, 48(8), 736–749.
Blumenthal, D., Rasmussen, P. W., Collins, S. R., & Doty, M. (2015).
port healthcare redesign. Does Medicaid make a difference? Findings from the Common-
The PCBH model provides an excellent platform to pro- wealth Fund biennial health insurance survey, 2014. Common-
mote “whole person” care in a meaningful way and among wealth Fund Publication, 1825(19), 1–9.

13
Journal of Clinical Psychology in Medical Settings

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: among US adults: Findings from the national ambulatory medical
Care of the patient requires care of the provider. Annals of Family care survey 1999–2010. Sleep, 37(8), 1283–1293.
Medicine, 12, 573–576. Gerrity, M. (2016). Evolving models of behavioral health integration:
Boscarino, J. A., Rukstalis, M., & Hoffman, S. N. (2010). Risk factors Evidence update 2010–2015. Millbank Memorial Fund. Retrieved
for drug dependence among out-patients on opioid therapy in a from https://www.milbank.org/wp-content/uploads/2016/05/
large U.S. health-care system. Addiction (Abingdon, England), Evolving-Models-of-BHI.pdf.
105, 1776–1782. doi:10.1111/j.1360-0443.2010.03052.x. Gum, A. M., Areán, P. A., Hunkeler, E., Tang, L., Katon, W., Hitch-
Bryan, C. J., Corso, K. A., Corso, M. L., Kanzler, K. E., Ray-Sannerud, cock, P., … Unützer, J. (2006). Depression treatment preferences
B., & Morrow, C. E. (2012). Therapeutic alliance and change in in older primary care patients. The Gerontologist, 46(1), 14–22.
suicidal ideation during treatment in integrated primary care set- Haas, L. J., Leiser, J. P., Magill, M. K., & Sanyer, O. N. (2005). Man-
tings. Archives of Suicide Research, 16, 316–323. agement of the difficult patient. American Family Physician,
Burt, J. D., Garbacz, S. A., Kupzyk, K. A., Frerichs, L., & Gathje, R. 72(10), 2063–2068.
(2012). Examining the utility of behavioral health integration in Health Resources and Services Administration. (2016). Uniform data
well-child visits: Implications for rural settings. Families, Systems, system: Reporting instructions for 2016 health center data.
& Health, 32(1), 20–30. Henry, S. G., Bell, R. A., Fenton, J. J., & Kravitz, R. L. (2017). Goals
Burwell, S. M. (2015). Setting value-based payment goals: HHS efforts of chronic pain management: Do patients and primary care
to improve U.S. health care. New England Journal of Medicine, physicians agree and does it matter? Clinical Journal of Pain.
372, 897–899. doi:10.1097/AJP.0000000000000488.
Buysse, D. J., Germain, A., Moul, D. E., Franzen, P. L., Brar, L. K., Impact of the Affordable Care Act on physician practices and the
Fletcher, M. E., … Monk (2011). Efficacy of brief behavioral quality of care (Part I). (2015). MedPanel. Retrieved from http://
treatment for chronic insomnia in older adults. Archives of Inter- medpanel.com/Expert-Insight/Insights/Impact-of-the-Affordable-
nal Medicine, 171(10), 887–895. Care-Act-on-Physician-Pra.aspx.
Cape, J., Whittington, C., Buszewicz, M., Wallace, P., & Underwood, Institute of Medicine. (2012). Primary care and public health: Explor-
L. (2010). Brief psychological therapies for anxiety and depres- ing integration to improve population health. Washington, DC:
sion in primary care: Meta-analysis and meta-regression. BMC The National Academies Press.
Medicine, 8(1), 38. Jolly, J. B., Fluet, N. R., Reis, M. D., Stern, C. H., Thompson, A. W., &
Centers for Disease Control and Prevention. (2013). Mental health Jolly, G. A. (2016). Review of behavioral health care integration
basics. Retrieved from http://www.cdc.gov/mentalhealth/basics. in primary care at Baylor Scott and White Healthcare, Central
htm. Region. Baylor University Medical Center Proceedings, 29(2),
Centers for Disease Control and Prevention. (2014a). Opioid pain- 131–136.
killer prescribing: Where you live makes a difference. Atlanta, Jonas, D. E., Garbutt, J. C., Amick, H. R., Brown, J. M., Brownley, K.
GA: Centers for Disease Control and Prevention. Retrieved from A., Council, C. L., … Harris, R. P. (2012). Behavioral counseling
http://www.cdc.gov/vitalsigns/opioid-prescribing/. after screening for alcohol misuse in primary care: A systematic
Centers for Disease Control and Prevention. (2014b). Planning and review and meta-analysis for the U.S. Preventive Services Task
implementing screening and brief intervention for risky alcohol Force. Annals of Internal Medicine, 157, 645–654.
use: A step-by-step guide for primary care practices. In Centers Kanter, J. W., Baruch, D. E., & Gaynor, S. T. (2006). Acceptance and
for Disease Control and Prevention, National Center on Birth commitment therapy and behavioral activation for the treatment
Defects and Developmental Disabilities. Atlanta, GA. of depression: Description and comparison. The Behavior Analyst,
Center for Disease Control and Prevention. (2017). Retrieved from 29(2), 161–185.
https://www.cdc.gov/drugoverdose. Kanzler, K. E., Robinson, P. J., Munante, M., McGeary, D., Potter,
Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The J., & MacIntyre, B., … Velligan, D. (2017). A novel treatment
changing face of heroin use in the United States: A retrospective delivery of acceptance and commitment therapy for chronic pain
analysis of the past 50 years. Journal of the American Medical in an integrated primary care setting. Texas: Presentation at Col-
Association, Psychiatry, 71(7), 821–826. laborative Family Health Association annual conference, Houston.
Damberg, C. L., Sorbero, M. E., Lovejoy, S. L., Martsolf, G. R., Raaen, Katon, W., Robinson, P., Von Korff, M., Lin, E., Bush, T., Ludman,
L., & Mandel, D. (2014). Measuring success in health care value- E., … Walker, E. (1996). A multifaceted intervention to improve
based purchasing programs: Findings from an environmental scan, treatment of depression in primary care. Archives of General Psy-
literature review, and expert panel discussions. Rand Health chiatry, 53, 924–932.
Quarterly, 4(3), 9. Kinman, C. R., Gilchrist, E. C., Payne-Murphy, J. C., & Miller, B. F.
DeRubeis, R. J., Siegle, G. J., & Hollon, S. D. (2008). Cognitive ther- (2015). Provider-and practice-level competencies for integrated
apy vs. medications for depression: Treatment outcomes and neu- behavioral health in primary care: A literature review. Report
ral mechanisms. Nature Reviews. Neuroscience, 9(10), 788–796. prepared by the Agency for Healthcare Research and Quality.
Edwards, S. T., Bitton, A., Hong, J., & Landon, B. E. (2014). Patient- Retrieved from https://integrationacademy.ahrq.gov/sites/default/
centered medical home initiatives expanded in 2009–13: Provid- files/AHRQ_AcadLitReview.pdf.
ers, patients and payment incentives increased. Health Affairs, LeBlanc, E. S., O’Connor, E. O., Whitlock, E. P., Patnode, C. D., &
33, 1823–1831. Kapka, T. (2011). Effectiveness of primary care–relevant treat-
Eidus, R., Pace, W. D., & Staton, E. W. (2012). Managing patient ments for obesity in adults: A systematic evidence review for the
populations in primary care: Points of leverage. Journal of the US Preventive Services Task Force. Annals of Internal Medicine,
American Board of Family Medicine, 25, 238–244. 155,(7), 434–447.
Felitti, V. J., & Anda, R. F. (1997). The adverse childhood experi- McGovern, L., Miller, G., & Cromwick, P. H. (2014). Health pol-
ences (ACE) study. Centers for disease control and prevention. icy brief: The relative contribution of multiple determinants
Retrieved from http://www.cdc.gov/ace/index.htm. to health outcomes. Health Affairs. https://doi.org/10.1377/
Ford, E. S., Wheaton, A. G., Cunningham, T. J., Giles, W. H., Chap- hpb20140821.404487
man, D. P., & Croft, J. B. (2014). Trends in outpatient visits for
insomnia, sleep apnea, and prescriptions for sleep medications

13
 Journal of Clinical Psychology in Medical Settings

Miller, B. F., Teevan, B., Phillips, R. L. Jr., Petterson, S. M., & Bazemore, Stelfox, H. T., Niven, D. J., Clement, F. M., Bagshaw, S. M., Cook, D. J.,
A. W. (2011). The importance of time in treating mental health in McKenzie, E., … Services, A. H. (2015). Stakeholder engagement
primary care. Families, Systems & Health, 29(2), 144–145. to identify priorities for improving the quality and value of critical
National Alliance on Mental Illness. (2015). Depression. Retrieved from care. PLoS ONE, 10(10), 1–13. doi:10.1371/journal.pone.0140141.
https://www.nami.org/Learn-More/Mental-Health-Conditions/ Strosahl, K. (1996). Confessions of a behavior therapist in primary care:
Depression. The Odyssey and the ecstasy. Cognitive and Behavioral Practice,
National Association Medical Staff Services. (2017). NAMSS comparison 3, 1–28.
of accreditation standards 2017. Retrieved from http://www.namss. Strosahl, K. (1998). Integration of primary care and behavioral health
org/Portals/0/Education/CertPrepResources/namss_comparison_of_ services: The primary mental health care model. In A. Blount (Ed.),
accreditation_standards.pdf. Integrative primary care: The future of medical and mental health
National Committee for Quality Assurance. (2014). Patient-centered collaboration (pp. 43–66). New York: Norton Inc.
medical home standards and guidelines. Strosahl, K. D., Robinson, P. J., & Gustavsson, T. (2012). Brief inter-
Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Preva- ventions for radical change: Principles and practice of focused
lence of childhood and adult obesity in the United States. Journal of acceptance and commitment therapy. Oakland, CA: New Harbinger
the American Medical Association, 311(8), 806–814. Publications.
Peckham, C. (2015). Physician burnout: It just keeps getting Substance Abuse and Mental Health Services Administration. (2012).
worse. Medscape. Retrieved from http://www.medscape.com/ National Survey on Drug Use and Health. Table 2.46B—Alcohol
viewarticle/838437. use, binge alcohol use, and heavy alcohol use in the past month
Pratt, L., & Brody, D. (2014). Depression in the U.S. household popula- among persons aged 18 or older, by demographic characteristics:
tion, 2009–2012. National Center for Health Statistics, 172, 1–8. Percentages, 2011 and 2012. Retrieved from http://www.samhsa.
Rao, S. K., Kimball, A. B., Lehrhoff, S. R., Hidrue, M. K., Colton, D. gov/data/sites/default/files/NSDUH-DetTabs2012/NSDUH-Det-
G., Ferris, T. G., & Torchiana, D. F. (2017). The impact of admin- Tabs2012/HTML/NSDUH-DetTabsSect2peTabs43to84-2012.
istrative burden on academic physicians: Results of a hospital-wide htm#Tab2.46B.
physician survey. Academic Medicine: Journal of the Association Substance Abuse and Mental Health Services Administration. (2014).
of American Medical Colleges, 92(2), 237–243. Highlights of the 2011 Drug Abuse Warning Network (DAWN)
Reiter, J. T., Dobmeyer, A. C., & Hunter, C. L. (2017). The primary findings on drug-related emergency department visits. The DAWN
care behavioral health (PCBH) model: An overview and opera- Report. Rockville, MD: US Department of Health and Human Ser-
tional definition. Journal of Clinical Psychology in Medical Set- vices; Substance Abuse and Mental Health Services Administra-
tings (submitted). tion. Retrieved from http://www.samhsa.gov/data/2k13/DAWN127/
Rittenhouse, D. R., & Shortell, S. M. (2009). The patient-centered medi- sr127-DAWN-highlights.htm.
cal home: Will it stand the test of health reform? Journal of the Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M., & Cunnington,
American Medical Association, 301(19), 2038–2040. D. (2015). Cognitive behavioral therapy for chronic insomnia: A
Rittenhouse, D. R., Shortell, S. M., & Fisher, E. S. (2009). Primary care systematic review and meta-analysis. Annals of Internal Medicine,
and accountable care: Two essential elements of delivery-system 163(3), 191–204.
reform. New England Journal of Medicine, 3612, 2301–2303. United States Preventive Services Task Force. (2013). Final recom-
Robinson, P., & Reiter, J. (2016). Behavioral consultation and primary mendation statement: Alcohol misuse—screening and behavioral
care: A guide to integrating services (2nd ed.). New York: Springer. counseling interventions in primary care. Retrieved from https://
Strosahl, K. D., & Robinson, P. (2008). The mindfulness and accept- www.uspreventiveservicestaskforce.org/Page/Document/Recom-
ance workbook for depression: Using acceptance and commitment mendationStatementFinal/alcohol-misuse-screening-and-behavio-
therapy to move through depression and create a life worth living. ral-counseling-interventions-in-primary-care.
Oakland, CA: New Harbinger. United States Preventive Services Task Force. (2014). Final recom-
Robinson, P. J., & Bauman, D. (2017). Improving care for a primary care mendation statement: Obesity in adults—screening and man-
population: Persistent pain as an example. In M. E. Maruish (Ed.), agement. Retrieved from https://www.uspreventiveservicestask-
Handbook of psychological assessments in primary care settings force.org/Page/Document/RecommendationStatementFinal/
(2nd ed.). New York: Routledge. obesity-in-adults-screening-and-management.
Robinson, P. J., Bauman, D., & Beachy, B. (2016). Promoting healthy United States Preventive Services Task Force. (2016). Final update
lifestyle behaviors in patients with persistent pain, Chap. 26. In J. and summary: Depression in adults—screening. Retrieved from
Mechanick & R. F. Kushner (Eds.), Lifestyle medicine—manual for https://www.uspreventiveservicestaskforce.org/Page/Document/
clinical practice. New York: Springer. RecommendationStatementFinal/depression-in-adults-screening1.
Robinson, P. J., Gould, D. A., & Strosahl, K. D. (2010). Real behavior van Schaik, D. J., Klijn, A. F., van Hou, H. P., van Marwijk, H. W., Beek-
change in primary care: Improving patient outcomes and increasing man, A. T., de Haan, M., & van Dyck, R. (2004). Patients’ prefer-
job satisfaction. Oakland, CA: New Harbinger Publications. ences in the treatment of depressive disorder in primary care. Gen-
Rozanski, A., & Kubzanski, L. D. (2005). Psychologic functioning and eral Hospital Psychiatry, 26(3), 184–189.
physical health: A paradigm of flexibility. Psychosomatic Medicine, Webster, L. R. & Grabois, M. (2015). Current regulations related to opi-
67(Supplement), S47–S53. oid prescribing. PM&R, 7(11), S236–S247.
Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., Wise, C. G., Alexander, J. A., Green, L. A., Cohen, G. R., & Koster, C.
… Oreskovich, M. R. (2012). Burnout and satisfaction with work- R. (2011). Journey toward a patient-centered medical home: Readi-
life balance among US physicians relative to the general US popula- ness for change in primary care practices. The Millbank Quarterly,
tion. Archives of Internal Medicine, 172(18), 1377–1385. 89(3), 399–424.
Shi, L. (2012). The impact of primary care: A focused review. Scientifica. World Health Organization & World Organization of Family Doc-
doi:10.6064/2012/432892. tors. (2008). Integrating mental health into primary care: A
Siu, A. L., Bibbins-Domingo, K., Grossman, D. C., Baumann, L. C., global perspective. Retrieved from http://apps.who.int/iris/bitstr
Davidson, K. W., Ebell, M., … Krist, A. H. (2016). Screening for eam/10665/43935/1/9789241563680_eng.pdf.
depression in adults: US Preventive Services Task Force recom- Yarnall, K. S. H., Østbye, T., Krause, K. M., Pollak, K. I., Gradison,
mendation statement. Journal of the American Medical Association, M., & Michener, J. L. (2009). Family physicians as team leaders:
315(4), 380–387. “Time” to share the care. Preventing Chronic Disease, 6(2), A59.

13