Basics of Behavior Change in Primary Care

By Patricia J. Robinson

Emerging policy changes are encouraging adoption of a team-based approach to healthcare, yet most healthcare professionals receive little training in how to practice integrated care. Basics of Behavioral Health in Primary Care is a playbook for mental health and medical professionals to share in addressing behavioral health concerns in primary care. Concise and practical, this clinically-focused book addresses the needs of a diverse group of healthcare providers, as well as students preparing for careers in the rapidly changing landscape of healthcare. 

• Language: English
• Publisher: Springer
• Release date: Jun 2, 2020
• ISBN: 9783030320508

Book preview

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Patricia J. Robinson

Basics of Behavior Change in Primary Care

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Patricia J. Robinson

Mountainview Consulting Group, Inc., Portland, OR, USA

ISSN 2192-8363e-ISSN 2192-8371

SpringerBriefs in Psychology

ISBN 978-3-030-32049-2e-ISBN 978-3-030-32050-8

https://doi.org/10.1007/978-3-030-32050-8

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To all people on our big blue marble, may you learn to flourish.

Patti Robinson, Wheeler, Oregon, June, 2019

The Purpose of This Book

I am writing this book to help people who want to help others be effective agents of change in the powerful setting of primary care. Primary care is the place where most people can access the services of a healthcare clinician, and this book aims to empower those clinicians to promote changes in behavior that help people to flourish (Fledderus, Bohlmeijer, Smit, & Westerhof, 2010). Whether you are a trained professional and relocating to the primary care setting or a student preparing for a career in primary care, my hope is that this book will help you become an effective member of an interprofessional team, capable of delivering interventions for patients of all ages for all behaviorally influenced problems when the patient asks for help.

I have met and worked with physicians, nurse practitioners, physician assistants, team nurses and nursing assistants, pharmacists, physical therapists, social workers, psychologists, counselors, community healthcare workers, and health coaches all over the world. I have worked in rural, urban, and suburban settings in the United States and provided training and technical assistance in Sweden, Norway, Denmark, France, Spain, Italy, Great Britain, Germany, Ireland, Mexico, Argentina, Canada, Japan, Korea, Australia, Peru, and New Zealand. Everywhere, there are difficulties with healthcare and opportunities for improvement. The ability to effectively support behavior change among patients presenting with medical and psychological problems is central to realizing the Quadruple Aim outcomes of improved population health, patient experience, value, and primary care staff wellness (Bodenheimer & Sinsky, 2014).

More and more countries are waking up to this idea and are initiating efforts to make delivery of behavior change services a routine part of primary care. Strategies recommended by the Primary Care Behavioral Health (PCBH) model (Reiter, Dobmeyer, & Hunter, 2017; Robinson & Reiter, 2016, 2007) offer guidance for these pilots and large-scale deployment following successful pilots. Dozens of studies on the PCBH model document its promise as an effective population health approach to delivery of behavioral health services and its association with positive clinical and system-level outcomes (Hunter et al., 2017). Strategies in this book are consistent with the PCBH approach, where many more people access behavioral health services than was possible in traditional soloed approaches to healthcare. PCBH services are also associated with the achievement of health equity, such that people who need healthcare the most can access it as easily as those with better health (www.tetumuwaiori.com).

The most significant barrier to PCBH deployment is the lack of a trained workforce, capable of delivering empirically supported behavior change interventions. This book is an attempt to promote rapid uptake of assessment and intervention strategies by all members of the interprofessional teams that are developing in primary care clinics around the world. This is a small book, with five chapters that can be read in any order by any member of the primary care team. The first chapter introduces readers to primary care—its mission and methods and its current challenges. The second chapter concerns the development and maintenance of strong teams. In the third chapter, I suggest a conceptualization for assisting patients of any age with ongoing development of skills that promote flourishing and healthy aging. Chapter 3 introduces Contextual Interview Questions, a tool that helps clinicians complete a functional assessment of the problem that most concerns the patient. In Chap. 5, readers learn to intervene to promote more psychologically flexible behavior in patients and to develop engaging behavioral experiments with patients. Several metaphors commonly used by PC teams using Focused Acceptance and Commitment Therapy (FACT) are introduced, including the Bull’s-Eye and the Life Path. Both of these interventions can be used in individual and group visits with patients.

The Appendices offer readers a Contextual Behavioral Scientist Checklist (Appendix A) to track their progress in developing skills in using the toolkit offered by this book. For convenience in duplicating and use of tools and skill practice worksheets, other appendices provide copies of forms introduced in Chaps. 2–5 (including outcome measures in Appendix B, assessment methods in Appendix C, and worksheets in Appendix D). Readers will find these scales and tools on the book website as well (basicsofbehaviorchangeinprimarycare.com).

This book is for all healthcare professionals working to improve health in their communities, including Primary Care Clinicians (PCCs), nursing staff and nursing assistants, Pharmacists (Ph), Physical Therapists (PTs) and their assistants, Behavioral Health Clinicians (BHCs) and their assistants, Dieticians, Emergency Department and Hospital Staff, Specialty Service Providers, Health Coaches (HCs), and Community Health Workers (CHWs). This book is also written for clinic and healthcare system leaders. A fully informed leadership supports rapid, efficient change toward delivery of better primary behavioral healthcare services. To encourage the use of this book by leaders, I include a section for leaders at the end of each chapter (Tips for Leaders) as a part of the chapter summary. Knowledge gained from reading this book is a first step toward developing an evolved primary care service; mastery develops as a part of a flexible application of methods and strategies introduced in the book. To encourage our readers to attain mastery, I offer online coaching services to readers seeking assistance in applying and refining what they learned from reading this book (see book website: basicsofbehaviorchangeinprimarycare.com).

Whether you are a healthcare leader or provider or a student preparing for a career in primary care, this book is for you. I hope that students of nursing, psychology, social work, counseling, marriage and family therapy, pharmacy, physical therapy, nutrition, exercise science, epidemiology, public health, and medicine will read this book early in their studies. This book is also for the faculty members that teach them. Increasingly, faculty members will team-teach interdisciplinary courses to graduate and undergraduate students embarking on careers in healthcare. In this way, we develop a group of healthcare providers for the future, one that knows how to deliver high-impact behavior change services as a part of an interprofessional team.

I want to express my gratitude for the many people that assisted with and inspired this book. First, I want to thank Jeff Reiter for mulling over ideas for the book with me and for providing helpful feedback on several chapters. I wish his life circumstances had allowed him to cowrite with me, as he is an excellent writer and a deep thinker. Second, I want to thank Justin Kerr for his proof-reading and editorial assistance; this book would not have been possible without his resolute assistance in the final days of writing. Sharon Penulla, an editor at Springer, has shared a vision of better behavioral health services in primary care with me for almost 15 years. Thank you, Sharon. I also must name a few of my healthcare superheroes, including Kirk Strosahl, Sue Hallwright, Jo Chiplin, Johnny O’Connell, Aaron O’Connell, Marcia Sasano, Julie Geiler, Ann Dobmeyer, Chris Hunter, Neftali Serano, Lt Col Matthew Nelson, Jodi Polaha, Jennifer Funderburk, Katie Kanzler, Kent and Megan Corso, Stacy Ogbeide, Nicola Silberleitner, Anneli Voncederwald, Margaret Lemp, Lisa Braverman, Emily Parker, Julie Oyemaja, Mary Peterson, Robyn Godye, Alysha Simonsen, Emma Usmar, Wayne Blackburn, David Bauman, Bridget Beachy, and Mark Sauerwein. Finally, I am grateful for all the patients that have helped me learn about how to help people make small changes that improve the quality of their lives.

References

Bodenheimer, T., Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the patients requires care of the provider. Annals of Family Medicine, 12(6), 573–576. https://doi.org/10.1370/afm.1713

Fledderus, M., Bohlmeijer, E. T., Smit, F., & Westerhof, G. J. (2010). Mental health promotion as a new goal in public mental healthcare: a randomized controlled trial of an intervention enhancing psychological flexibility, American Journal of Public Health, 100, 2372–2378. https://doi.org/10.2105/AJPH.2010.196196

Hunter, C. L., Funderburk, J. S., Polaha, J., Bauman, D., Goodie, J. L., & Hunter, C. M. (2017). Primary Care Behavioral Health (PCBH) model research: Current state of the science and a call to action. Journal of Clinical Psychology in Medical Settings. https://doi.org/10.1007/s10880-017-9512-0

Reiter, J. T., Dobmeyer, A. C., & Hunter, C. L. (2017). The primary care behavioral health (PCBH) model: An overview and operational definition. Journal of Clinical Psychology in Medical Settings, 24(4).

Robinson, P. J., & Reiter, J. D. (2007). Behavioral consultation and primary care: A guide to integrating services. New York, NY: Springer.

Robinson, P. J., & Reiter, J. D. (2016). Behavioral consultation and primary care: A guide to integrating services (2nd ed.). New York, NY: Springer.

The Alphabet Soup of the Evolving Primary Care Team

This is a list of the most commonly used abbreviations in this book. They include abbreviations for titles of team members and models for delivery of primary care services.

Additionally, each chapter includes a list of the abbreviations used in that chapter.

List of Abbreviations

BHC

Behavioral Health Clinician

CHW

Community Health Worker

FACT

Focused Acceptance and Commitment Therapy

HC

Health Coach

MA

Medical Assistant

PC

Primary Care

PCBH

Primary Care Behavioral Health

PCC

Primary Care Clinician

PT

Physical Therapist

PT-A

Physical Therapist Assistant

PCBH

Primary Care Behavioral Health

Contents

1 Primary Care 1

Form and Function 2

Current Initiatives in Primary Care 3

Triple Aim 3

Quadruple Aim 3

Patient Centered Medical Home Model 4

Primary Care Behavioral Health Model 5

Challenges to Evolving Primary Care 7

Lack of Preparation 7

Low Job Control 8

High Complexity Patients 8

Workforce Shortage 9

Recommended Strategies for Improving Behavioral Health Services in Primary Care 9

Summary 13

Review of Strategies 13

References 14

2 Team Work in Primary Care 17

The Team and Their Work 18

The Organization of Primary Care 19

Internal Primary Care Staff 19

Primary Care Clinician 20

PCP Training 20

Non-physician Primary Care Clinicians 21

ARNP and PA Training 21

Naturopathic Physicians 22

ND Training 22

Registered Nurses 22

RN Training 22

Licensed Practical Nurses, Nursing Assistants and Medical Assistants 23

LPNs, NAs, and MAs 23

Support Staff in Primary Care 23

Front Desk Staff Members 23

Ward Clerks 24

Appointment Line 24

Billing Specialists 24

Interpreters 24

Administrators 25

Medical Directors 25

Nursing Director 25

Clinic Manager or Director 25

Other Leaders 25

Primary Care Behavioral Health Team Members 26

Behavioral Health Clinician 26

Behavioral Health Clinician Assistant 28

Health Coach 28

Community Health Worker 29

Other Possible Primary Care Behavioral Health Team Members 29

A Note about Teamwork in Urban, Suburban, and Rural Clinics 30

Prosocial Teams 31

Acceptance and Commitment Therapy 34

A Word About Resilience 35

The Maslach Burnout Inventory 36

Compassion-An Antidote for Stress 36

Morning Huddle Compassion 37

End of Day Gratitude Circle 37

Self-Compassion 37

Recommended Strategies for Promoting Healthy PC Teams 38

Summary 41

Review of Strategies 41

References 42

3 Behavior Change in Primary Care:​ The Basics 45

What Do Patients Want?​ 46

Measurement of Flourishing 47

Barriers to Flourishing 48

Psychological Flexibility and Inflexibility 49

Psychological Flexibility and Avoidance 50

A Clinical Definition of Psychological Flexibility 52

Basic Methods for Targeting Behavior Change in Primary Care 53

Strategies for Promoting A New View of Behavior Change in PC 54

Summary 57

Review of Strategies 58

References 59

4 Behavior Change in Primary Care:​ Assessment 61

Starting a Conversation about Behavior Change 64

Standardized Assessments 65

Rating Scale Questions 66

Contextual Interview Questions 68

Workability and Values Clarification 69

The Four-Square Tool 70

Contextual Assessment Checklist.​ 71

Case Examples 72

Amy:​ Trauma and Health Risk Behavior 74

Bob:​ Life Stress and Difficulties with Self-Management of Chronic Disease 74

Mary:​ Grief and Demoralization 75

Pillars of Psychological Flexibility 76

Putting It All Together 77

Amy 77

Bob 81

Mary 85

A Note About Suicide and Risk Assessment 89

Recommended Strategies for Providing Assessments that Engage Patients in Behavior Change 89

Summary 90

Review 90

References 91

5 Behavior Change in Primary Care:​ Interventions 93

A Syringe and Powerful Medicines 94

Primary Care Behavioral Health 94

Powerful Medicines 95

Focused Acceptance and Commitment Therapy 95

Generating Information to Inform Interventions for Primary Care 96

Promoting Psychological Flexibility in Clinical Contacts 96

The FACT Pillars Intervention Guide 97

Open 98

Aware 98

Values 99

Targeting Open and Aware 99

Targeting Values 101

The Relate the Problem to Values Worksheet 102

Behavioral Experiments 104

Behavioral Variability 104

Confidence 106

Values 107

A Note about Time and Behavioral Experiments 107

Amy’s Behavioral Experiment 110

Bob’s Behavioral Experiment 111

Metaphors 112

Bull’s-Eye 113

Life Path 118

Working Smart in Primary Care 122

Use Assistants 123

Think Beyond Clinic Visits 123

Think Beyond the One-to-One 123

Making Progress Over Time 124

Strategies for Delivering Powerful Behavior Change Interventions 124

Summary 126

Review 126

References 127

Appendix A 129

Appendix B (Chapter 3 Measures, Tools, Worksheets) 131

Appendix C (Chapter 4 Measures, Tools, Worksheets) 135

Appendix D (Chapter 5 Measures, Tools, Worksheets) 141

References 149

Index 155

List of Figures

Fig. 4.1 FACT pillars of flexibility 73

Fig. 5.1 The bull’s-eye plan115

Fig. 5.2 Mary’s bull’s-eye plan (Example)116

Fig. 5.3 The life path plan119

Fig. 5.4 Bob’s life path plan (Example)122

List of Tables

Table 1.1 Checklist: Recommended strategies for improving delivery of behavioral health services in primary care13

Table 1.2 Tips for leaders 14

Table 2.1 Checklist: Recommended strategies for developing healthy teams capable of helping patients with behavior change40

Table 2.2 Tips for leaders 42

Table 3.1 The flourishing project measure48

Table 3.2 The Acceptance and Action Questionnaire-II50

Table 3.3 The approach-avoidance tool 51

Table 3.4 Checklist: Recommended strategies for promoting a new perspective on behavioral health services in primary care57

Table 3.5 Tips for leaders 58

Table 4.1 Contextual interview questions 62

Table 4.2 Four-square tool 63

Table 4.3 FACT Pillars Assessment Tool (PAT) 64

Table 4.4 Rating scale questions 66

Table 4.5 Contextual assessment checklist 71

Table 4.6 Amy’s four-square (Example)80

Table 4.7 Amy’s PAT (Example)81

Table 4.8 Bob’s four-square (Example)83

Table 4.9 Bob’s PAT (Example)84

Table 4.10 Mary’s four-square (Example)87

Table 4.11 Mary’s PAT (Example)88

Table 4.12 Checklist: Recommended strategies for using behavior change assessments that engage patients90

Table 4.13 Tips for leaders 91

Table 5.1 FACT Pillar Intervention Guide (PIG) 97

Table 5.2 The Relate the Problem to Values worksheet 102

Table 5.3 The SMART Behavioral Experiment worksheet 105

Table 5.4 Bull’s-eye plan Worksheet114

Table 5.5 The life path plan worksheet120

Table 5.6 Checklist: Recommended strategies for providing powerful behavior change interventions125

Table 5.7 Tips for leaders 126

List of Appendices

Appendix A Table A.1.1 Contextual behavioral scientist check-in129

Appendix B (Chapter 3 Measures, Tools, Worksheets)Table B.3.1 The flourishing project measure131

Table B.3.2 The Acceptance and Action Questionnaire-II (AAQ-II)132

Table B.3.3 The approach-avoidance tool133

Appendix C (Chapter 4 Measures, Tools, Worksheets)Table C.4.1 Contextual interview questions135

Table C.4.2 Four-square tool136

Table C.4.3 FACT Pillars Assessment Tool (PAT)137

Table C.4.4 Rating scale questions137

Table C.4.5 Contextual assessment checklist138

Fig. C.4.1 FACT pillars of flexibility138

Appendix D (Chapter 5 Measures, Tools, Worksheets)Table D.5.1 FACT Pillar Intervention Guide (PIG)139

Table D.5.2 The Relate the Problem to Values worksheet140

Table D.5.3 The SMART Behavioral Experiment worksheet141

Table D.5.4 Bull’s-eye plan worksheet142

Table D.5.5 Life path plan worksheet143

Fig. D.5.1 Bull’s-eye plan144

Fig. D.5.3 Life path plan145

About the Author

Patricia J. Robinson

Patti Robinson, PhD,