Innovative Formats to Deliver Behavioral Interventions in Primary Care

Benjamin P. Van Dyke, PhD, Julie C. Gass, PhD, Tziporah Rosenberg, PhD, Christina B. Shook, PsyD & Jennifer S. Funderburk, PhD; Integrated Primary Care SIG

A number of evidence-based behavioral interventions for a variety of concerns that significantly impact health, such as insomnia, are suitable for primary care. However, implementation of these interventions lags behind. Due to primary care embracing the medical home model of care, it has become a place for diverse interprofessional teams to work together to help improve patient care. Embedded behavioral health providers or care managers are becoming more common, providing new opportunities for behavioral interventions. Several new formats for team delivery of interventions in primary care exist, which maximize efficiency by sharing responsibility and taking advantage of team members’ strengths. We review several formats that provide opportunities for clinicians as well as researchers for translation of behavioral treatments.

Interprofessional group medical visits (a.k.a. shared medical appointments) represent an opportunity for interprofessional healthcare team members to treat patients who share a common concern (e.g.., chronic pain) by combining group didactic sessions with brief 1:1 medical visits. Patients engage in regularly scheduled group visits in which they benefit from improved access to their healthcare providers, the benefit of behavioral interventions with additional members of a health care team (e.g., health educator), and an opportunity to share experiences. These group visits capitalize on the skills of the multidisciplinary team while enhancing focus on patient self-management, social support, enhanced access to care, and more time with their care team.

A conjoint appointment happens when two providers with different areas of expertise meet simultaneously with the patient to deliver an intervention, which can occur on an as-needed basis (ex. clinical pharmacist and health psychologist). This type of encounter can be especially useful for patients with behaviorally driven medical issues (e.g., diabetes, untreated sleep apnea) because it allows for a medical expert (e.g., physician) and other members of the team, such as an embedded behavioral health expert, to work together with the patient to tackle a complex problem. For instance, a patient who has not responded to advice to reduce their alcohol use may benefit from both providers conjointly, where the primary care provider can share the medical implications of continued alcohol use and the embedded behavioral health provider can use motivational interviewing to increase readiness to change.

An interdisciplinary evaluation and consult clinic allows patients to be seen by a team of multidisciplinary providers (e.g., primary care, psychology, pharmacy, physical therapy, etc.) during one appointment, where patients are typically evaluated in a group shared medical visit, provided relevant education, and obtain a private physical exam which results in a personalized interdisciplinary treatment plan. This approach can reduce wait times, streamline referral pathways, and enhance “buy-in” for follow-up care. For example, patients with chronic pain receive education on medications and the gate-control/neuromatrix model of pain, are evaluated in a group by psychology and clinical pharmacy, and receive conjoint physical exams from a pain physician or physician assistant as well as a physical therapist before participating in the formulation of an individualized multidisciplinary treatment plan. It is similar to an interdisciplinary geriatric primary care evaluation clinic.

 

References

1. Bloor LE, Fisher C, Grix B, Zaleon CR, Wice S. Conjoint sessions with clinical pharmacy and health psychology for chronic pain: enhancing participation in behavioral management. Federal Practitioner. 2017 Apr;34(4):35. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370402/
2. Burns R, Nichols L, Martindale-Adams J, & Graney MJ. Interdisciplinary geriatric primary care evaluation and management: two-year outcomes. Journal of the American Geriatric Society. 2000 Jan; 48(1): 8-13. Link: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1532-5415.2000.tb03021.x
3. Kirsh, S. R., Aron, D. C., Johnson, K. D., Santurri, L. E., Stevenson, L. D., Jones, K. R., & Jagosh, J. (2017). A realist review of shared medical appointments: How, for whom, and under what circumstances do they work?. BMC health services research, 17(1), 113. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5291948/

An additional resource regarding these team-delivered interventions is SBM’s Integrated Primary Care Special Interest group. Feel free to contact us for further assistance or look at our website for additional information: https://www.sbm.org/membership/special-interest-groups/integrated-primary-care