Primary Care Behavioral Health

DoD Instruction 6490.15

The Primary Care Behavioral Health (PCBH) approach used by DoD is outlined in the DoD Instruction 6490.15 published August 8, 2013, Integration of Behavioral Health Personnel (BHP) Services Into Patient-Centered Medical Home (PCMH) Primary Care and Other Primary Care Service Settings.

The Patient-Centered Medical Home (PCMH) is a team-based care delivery model built on the premise that the best health care begins with a strong primary care foundation. According to the Agency for Healthcare Research and Quality’s Patient-Centered Medical Home Resource Center, the medical home encompasses five functions and attributes:

  • Comprehensive care
  • Patient-centered care
  • Coordinated care
  • Accessible services
  • Quality and safety

In support of these functions, the Department of Defense (DoD) has implemented programs to integrate behavioral health services and personnel into PCMHs to better address the mental and physical health of military members, family members and retirees by: 1) increasing availability of behavioral health services to adult beneficiaries, 2) early identification of mental health problems, 3) reducing stigma associated with seeking mental health treatment, and 4) reducing costs for both patients and military medical facilities.

DoDI 6490.15 established policy, assigned responsibilities and prescribed procedures for attainment of inter-service standards for developing, initiating and maintaining adult behavioral health services in primary care. Service-specific program names using the DoD model include Behavioral Health in Patient-Centered Medical Home (BH-PCMH), National Capital Region Medical Directorate; Behavioral Health Integration Program (BHIP), U.S. Navy; Behavioral Health Optimization Program (BHOP), U.S. Air Force; and Primary Care Behavioral Health (PCBH), U.S. Army.

PCBH Personnel

The personnel responsible for delivering the PCBH services in military treatment facilities (MTFs) across DoD include internal behavioral health consultants (IBHCs), behavioral health care facilitators (BHCFs), and external behavioral health consultants (EBHCs).

IBHCs are psychologists and social workers who provide focused interventions for adult enrollees across a broad spectrum of behavioral health (e.g., depression) and health behavior (e.g., tobacco cessation) problems.

BHCFs are registered nurses who provide regular telephone follow-up for patients with depression, anxiety and PTSD in order to monitor symptom severity, treatment adherence and clinical risk; to assist patients with problem solving, goal setting and active coping; and to strengthen and enhance specialist-patient-primary care contact, communication and treatment planning.

Finally, while not co-located in the primary care clinic, EBHCs are psychiatrists, prescribing psychologists, or psychiatric nurse practitioners who are available for consultation to the primary care team.

Appropriate Patients for Primary Care Behavioral Health

It's appropriate to consider almost every PCMH patient for referral to an IBHC. The IBHC is well positioned to provide interventions to:

  • The 83 percent of U.S. adults who are in a state of less than optimal mental health
  • The vast majority of U.S. adults with one or more of the "Big 4" modifiable causes of disease, death and loss of functioning (sedentary lifestyle, obesity, tobacco use and/or excess alcohol use)[1]
  • Patients with chronic medical conditions with related adverse health behaviors and/or sub-clinical psychological factors

Primary care managers (PCMs) are encouraged to consider referral to an IBHC for an integrated treatment approach for any of the following conditions:

Pain Management Psychological Health Health Promotion/Disease Prevention Other General Medical Issues
  • Chronic pain
  • Headache
  • Fibromyalgia
  • Low back pain
  • Generalized anxiety disorder
  • Depression
  • Panic and other anxieties
  • Relationship problems
  • Grief/bereavement
  • Stress
  • Anger
  • Diet (weight loss, diet adherence, etc.)
  • Exercise
  • Alcohol misuse
  • Tobacco use
  • Insomnia/hypersomnia
  • Asthma
  • Diabetes
  • Hypertension
  • Cardiovascular disease
  • Gastrointestinal problems
  • Chronic obstructive pulmonary disease
  • Women’s health issues
  • Chronic illness
  • Sexual dysfunction

Referral to an IBHC may also be helpful in caring for complex patients such as those with multi-system illnesses, patients who are frequent utilizers of the medical system, and patients who have difficulties with treatment or medication adherence.  The chart below illustrates just how common hurdles with medical adherence can be.

Medication Adherence

For every 100 prescriptions written

  • 50 to 70 go to a pharmacy
  • 48 to 66 come out of the pharmacy
  • 25 to 30 are taken properly
  • 15 to 20 are refilled as prescribed

Source: National Association of Chain Drug Stores, Pharmacies: Improving Health, Reducing Costs, July 2010. Based on IMS Health data] [18] | Figure 2.

It should be noted that PCBH is not a barrier to referral to specialty mental health care.  For patients who may benefit from a referral to specialty mental health care, PCMs are encouraged to speak with the IBHC both to discuss options for treatment and, when needed, to provide a bridge in care while waiting for the specialty care appointment.

In addition to referral to the IBHC, PCMs are encouraged to refer patients with depression, anxiety and/or PTSD for care facilitation with a BHCF. For these conditions, it is appropriate to refer the patient to both the IBHC and the BHCF so that the patient may benefit by working with both of these PCMH team members.