A Process Evaluation of Primary Care Behavioral Health Integration in the Military Health System

Behavioral health (BH) problems are common in the military and can adversely affect force readiness. Research suggests that primary care–behavioral health (PCBH) integration can improve BH outcomes by making high-quality BH care available in more accessible settings. However, sustaining high-quality implementation of PCBH is challenging. We conducted a process evaluation of the PCBH program in the military health system to understand why the program is working as it is. We conducted semistructured interviews, rigorously coded the qualitative data to identify causal links, and created and validated causal loop diagrams that provide a visualization of how the system is working.

We provide findings in four key areas: staffing and capabilities, valued tasks, program stewardship, and fostering program awareness and support. Adequate staffing—meaning the right level and with the right capabilities—is crucial to the success of PCBH. This adequate staffing can be achieved by retaining existing staff and hiring when needed. Retention, in turn, is driven by staff and supervisor satisfaction, reflected in adherence to the model (which local leaders interpret as productivity and number of visits per patient, among other factors). When leadership works actively to improve staff satisfaction and adherence to the model, it is supporting PCBH staff retention. When staff are hired, those with more PCBH-relevant capabilities are more likely to succeed in the role, thus improving retention. While some sites regarded General Schedule (GS) staffing as the potential solution to staffing issues because of flexibility in managing and incentivizing staff, it also can create administrative burdens.

Patient care consists of providing direct patient care, bridging care with other providers, providing consultations to other staff members, and group classes. However, there are other valued tasks in addition to patient care, such as conducting screenings, fostering awareness of the PCBH program, and charting or other documentation. All of these together make up the PCBH staff workload, and when the workload becomes too high, staff responds by either limiting associated valued tasks or encouraging fewer referrals. If these compensation mechanisms do not work, staff members get burned out, which places a higher burden on staff that work closely with them, and if they leave the position, the workload of those remaining will be further increased.

Local leadership acts as stewards of the program by maintaining staffing and capability levels. This is accomplished by hiring new staff when needed, working to improve scope of work and benefits packages, being a good and supportive manager, and working with staff to understand the model of care. These activities are conducted depending on leadership perceptions of adherence to the model and retention. The success of the PCBH program also relies on having supportive stakeholders. Primary care managers (PCMs) buy into the program when they are fully aware of it and can see that it works. Teamwork, understanding the model, and routine day-to-day promotion bolster PCM support, while behavioral health consultant (BHC) turnover makes it more challenging to maintain support.

We identified recommendations to improve program implementation, and we present them according to the four key results areas.

PCBH Staffing and Capabilities

• Improve job descriptions. This will ensure that applicants have a comprehensive understanding of the positions and can better self-assess whether they are a good match for the job. We suggest ensuring that job descriptions convey the high volume of clinical work (i.e., large number of brief appointments) and clearly lay out nonclinical duties. We further suggest putting pressure on local installation contracting offices to, in turn, pressure contracting organizations to accurately convey what the positions entail.
• Improve contracting process and/or transition key PCBH staff positions to GS. It may be possible to work with installation contracting offices to put pressure on contractors to reduce turnover and to incorporate management tools into contracts. If it is not possible to improve the contracting process, we recommend transitioning key PCBH positions to GS.
• Prioritize rapid rehiring. This will minimize gaps in service as well as ensure that the staff role continues to be valued.

Valued Tasks

• Identify, count, and reinforce valued tasks. We recommend identifying all valued tasks and giving them increased visibility, protecting and dedicating time for them, and targeting them in routine, ongoing training.
• Continue to work toward awareness of tasks and roles—beyond BHC. We recommend increasing efforts to promote understanding of the behavioral health care facilitator (BHCF) role and local (clinic and installation) leadership roles.

PCBH Stewardship

• Increase support for local leadership. We recommend increasing orientation and ongoing communication with local leaders regarding their role and assisting local leadership in helping BHCs and BHCFs in fostering awareness of the PCBH program.
• Implement routine measurement and monitoring of comprehensive metrics.We recommend that central program leadership and local installation leadership routinely use a comprehensive set of implementation metrics and performance objectives in assessing how things are going and providing sites with more training on how to use these metrics. We further suggest setting trip wires that flag need for action (e.g., for BHC workload, decreased PCM referrals).
• Cultivate local champions.We recommend that the PCBH managers increase their efforts to identify and cultivate installation-level champions.
• Increase central support for local PCBH staff. We recommend efforts to continuously build BHC skills so that staff members are comfortable treating the full range of conditions—and PCMs are comfortable referring for a full breadth of conditions—as well as regular and ongoing support for BHCs and BHCFs and orientation for PCMs.

Fostering PCBH Awareness and Support

• Provide more central assistance in fostering awareness of the PCBH program. We recommend increasing support for local leadership in routinely promoting close teamwork and awareness of PCBH. We further recommend that central program leaders do more to promote program awareness, such as regularly updating and disseminating centrally developed promotional materials for both BHC and BHCF services.