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Research Question

  1. Why does the PCBH program in the military health system work the way it does?

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. The authors conducted a process evaluation of the PCBH program in the military health system to understand why the program is working as it is and provide recommendations for quality improvement. They 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.

Findings fall into four key areas: staffing and capabilities, valued tasks, program stewardship, and fostering program awareness and support. Overall, the authors found that the PCBH program is highly valued by primary care staff. However, the PCBH care model is inconsistently adhered to, owing to a combination of staff preferences, local pressures, and lack of knowledge of PCBH staff roles. Recommendations are offered to improve program implementation.

Key Findings

Adequate staffing, meaning the right level and the right capabilities, is crucial to the success of PCBH

  • Leadership work to promote staff satisfaction and adherence to the model supports retention.
  • New hires with more PCBH-relevant capabilities are more likely to succeed in the role, which also improves retention.

Valued tasks are patient care, conducting screenings, fostering awareness of the PCBH program, and charting or other documentation

  • All of these together make up the PCBH staff workload; when the workload becomes too high, staff may work less on valued tasks or encourage fewer referrals.
  • If these compensation mechanisms do not work, staff members get burned out, increasing the workload of colleagues.

Local leadership act as program stewards by maintaining staffing and capability levels

  • Good stewardship involves hiring new staff when needed, working to improve scope of work and benefits, being a good and supportive manager, and working with staff to understand the model of care.

The success of the PCBH program also relies on fostering program awareness and support among 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.


  • In the area of PCBH staffing and capabilities, PCBH staff job descriptions should be improved to ensure that applicants have a comprehensive understanding of the positions and can better assess whether they are a good match for the job; the contracting process should be improved, and/or key staff positions should be transitioned to General Schedule; and rapid rehiring should be prioritized to minimize gaps in service and ensure that the staff role remains valued.
  • In the area of valued tasks, such tasks should be identified, counted, and reinforced—giving them greater visibility and protected and dedicated time—and targeted in ongoing training; work should also continue toward awareness of tasks and roles, beyond the BHC role, with increased efforts to promote understanding of the behavioral health care facilitator (BHCF) role and local leadership roles.
  • In the area of PCBH stewardship, support for local leadership should be increased, including improved orientation and ongoing communication; measurement and monitoring of a comprehensive set of implementation metrics and performance objectives should be routine, with trip wires that flag the need for action; local champions should be cultivated; and central support for local PCBH staff should be increased, with continuous building of BHC skills so that consultants are comfortable treating the full range of conditions, regular and ongoing support for BHCs and BHCFs, and orientation for PCMs.
  • In the area of fostering PCBH awareness and support, more central assistance should be provided to promote understanding of the PCBH program.

This research was sponsored by the Psychological Health Center of Excellence and conducted within the Forces and Resources Policy Center of the RAND National Security Research Division.

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