It is easy to recommend a prominent role for behavioral healthcare within the primary care setting. It is more challenging to provide a blueprint for how to do it. No such design is offered here, but instead a contribution is made to a new literature: the imaginary job description. The “primary care psychologist” springs from a newly conceived framework in which a psychologist and a PCP are business partners.
I am picturing myself as a psychologist in this role, but this proposal applies equally to other behavioral healthcare clinicians. The focus for this job description and its reimagined setting will include the structure and goals for each clinical session, the information analyzed, supplemental services offered beyond each office visit, and the coordination among professionals within the primary care setting.
While this depiction of a primary care psychologist (PC-Psy) is not currently in existence, there are no major impediments to this role becoming real. It necessitates finding PCP partners who understand the primacy of behavioral health and the gnawing reality that over half of PCP visits today are driven by psychosocial issues. The collaborative care model outlined here is unique.
This delivery model involves more than inserting a behavioral clinician in the primary care setting. The parameters of the clinical work must change to fit the setting. Remote and digital solutions must be incorporated. The collaboration must be data-driven, including clinical data from both behavioral health and PCP assessments. Collaboration is organized with a team leader selected for high-risk patients.
Primary care sessions
The end of the 50-minute psychotherapy hour will be crowned in the primary care setting. Primary care work is intended to occur intermittently, and the focus is improved health and wellbeing. Coordination with the PCP is paramount. The initial session establishes a therapeutic relationship, set goals based on a consolidated behavioral health (CBH) assessment, and provides digital resources for ongoing work.
A therapeutic relationship is distinct from others, and it is a critical focus for the first session. The nature of the ongoing work together is explained. Results are reviewed from the online comprehensive clinical assessment completed prior to the visit. Collaboration with the PCP is discussed, including the terms of confidentiality. The digital resource platform is introduced, and appropriate sections are highlighted.
The typical session includes 20 minutes of interaction with 10 minutes for chart review and notes. Each session incorporates an assessment and referral component. People with more severe behavioral health disorders are referred for the level of care needed, including psychiatric evaluation. Progress with digital resources is routinely reviewed, along with clinical change on embedded measures.
The issues discussed are identified as either confidential for their discussions only (e.g., history of trauma), or to be included within the healthcare context and shared with the PCP (e.g., evidence of alcohol abuse). Sessions are scheduled to coincide with PCP visits, if possible, and are held every six months unless greater frequency is indicated. The CBH assessment is completed annually.
Coordination of a comprehensive range of services
The PC-Psy is a coordinator for all behavioral health resources. This includes digital self-directed resources with diverse content, such as interactive content on stress, life transitions such as divorce and grieving, lifestyle choices impacting health, early signs of psychological distress, and comprehensive modules for addressing common behavioral health disorders such as depression, anxiety and SUD.
Some patients need referral for more intensive therapy, and this must be addressed in a timely manner, using multi-modal connections. Modalities would include text/email, telephone, video and in-person interactions with licensed clinicians. Patients with lower levels of distress might benefit from more frequent support, and so referral to a non-licensed coaching network is appropriate for them.
Medication management is under the purview of the primary care physician, but the PC-Psy manages a small network of consulting psychiatrists for emergency evaluations and for medication consultations. Patients with severe mental or substance use disorders need the right level of care and the best support system with wraparound services. The PC-Psy functions like a care manager toward that end.
PCPs have historically been limited in their health promotion and disease prevention efforts, and these constitute one of the cornerstones of CBH. The work is based on a psychotherapy model. For example, diet and exercise are not addressed with simple goals and encouragement. They may instead be the clinical focus for sessions, exploring underlying conflicts along with any mental health and SUD issues.
The PCP is not the leader for clinical collaboration in all cases. The “quarterback” is established for each case that warrants more active collaboration due to risk factors or current illness. Collaboration decisions are mutually agreed upon based on clinical evidence and a determination of the most significant physical and behavioral health issues. The health home concept is utilized.
Clinical coordination is best accomplished with data integration. The ideal electronic medical record combines both sets of data and provides a whole patient view. Comorbidities drive a large percentage of total healthcare costs, and so a registry of complex comorbid cases needing closer monitoring and more contact is essential. Hiring a dedicated care manager for these cases is ideal, if resources permit.
A new language
Some may fault the term “Primary Care Psychologist,” or PC-Psy, as a sign of either hubris or dullness. In either case, the defense is a desperate need for new language. Integration is a term applied to so many disparate systems today as to be nearly meaningless. While many examples exist of behavioral healthcare supporting a primary care system, there are few collaborations of equality like PC-Psy.
Primary care psychologist is the language of primacy, rather than secondary support. Principles matter more than the organizational details at this point. The principle is that behavioral healthcare should expand into the primary care setting, and in so doing it should share the lead alongside PCPs in health promotion and disease prevention. Behavior change is the critical element in these domains.
How is behavioral healthcare modified based on this transition? Our field would be able to help more people. We would be on the front lines of healthcare. Our purview would expand from diagnosable psychiatric conditions to the maladaptive behaviors that promote illness and disease. Psychotherapy, a well-validated intervention, is a strong foundation for building this new role and new system of care.
Any campaign for change in our healthcare system requires support by experts and the public alike. Political campaigns are launched with two- or three-word slogans. Primary care psychologist fits the description. We need a phrase that focuses the mind on a clear goal. You may want to revise this job description in many ways, but can you get behind the goal for our field becoming part of primary care?
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.