Primary Care Behavioral Health Clinical Pathways

Clinicians should consider a referral to an IBHC for any primary care patient who is not at optimal mental health, has one or more modifiable adverse health behaviors, or has challenges related to a chronic medical illness. To support increased use of IBHCs, DoD has developed Clinical Pathways for use by Primary Care Medical Homes (PCMH).

PCBH Clinical Pathways are designed to assist DoD PCMHs in providing improved collaborative care for a number of specific mental health and chronic medical conditions frequently seen in PCMH settings. Each pathway contains guidelines for the provision of coordinated, collaborative care between the primary care manager (PCM) and the IBHC, while making use of PCMH staff and data management tools available through the electronic medical record (EMR).

Each pathway contains detailed guidance on strategies for:

  1. Identifying patients for pathway inclusion (screening, provider visit, PCMH Data Pulls)
  2. Connecting the patient with the IBH
  3. Intervening with evidence-based approaches from the IBHC (medication, IBHC intervention, care facilitation), and
  4. Monitoring outcomes of care (i.g., standard assessment tools, symptoms, labs)
    • Alcohol use

      Patients for inclusion:

      • Patients with elevated scores on the AUDIT-C
      • Patients scoring positive on the AUDIT-C per the above criteria and not currently seeing an IBHC, in specialty behavioral health care, or in a specialty substance use program
      • Patients previously diagnosed with an Alcohol Use Disorder as defined in the DSM-5 and not currently seeing an IBHC, in specialty behavioral health care, or in a specialty substance use program
      Learn more about how an IBHC can support a patient who would like to decrease alcohol use.

      IBHCs implement evidence-based assessment and intervention with patients whose levels of symptoms and functional impairment can be addressed in primary care. IBHCs often see patients for one to four appointments with follow-up occurring every two to four weeks. However, the time between appointments will vary depending on the IBHC’s assessment of the patient’s readiness to change, ability to successfully make changes with a self-management approach, and the nature of the intervention(s) selected. IBHCs and patients collaboratively select interventions that are most appropriate given the nature of the patient’s difficulties and readiness for change. Interventions include self-monitoring of drinking habits and patterns, patient education on recommended drinking levels, motivational interviewing and problem solving to assist in limiting or abstaining from use, and reviewing ways to pace drinking (when patients are limiting alcohol consumption). IBHCs recommend referrals to other services as appropriate (e.g., specialty behavioral health or specialty substance use program if patient is active duty and meets criteria for a substance use disorder). Changes in a patient’s symptoms/functioning may be assessed by the BHM-20 (Behavioral Health Monitor) and AUDIT-C (Alcohol Use Disorders Identification Test).

    • Anxiety

      Patients for inclusion:

      • Patients with an anxiety disorder diagnosis
      • Patients who screen three or more on GAD-2 during a routine medical visit
      • Active-duty patients who report anxiety/stress-related symptoms on the PHA/PDHRA
      • Patients who are prescribed a psychotropic medication for anxiety
      Learn more about how an IBHC can support a patient who has anxiety.

      Patients with anxiety are appropriate for the PCBH setting when the IBHC can address anxiety symptoms and functional impairment in about one to four appointments. IBHCs implement evidence-based assessment and interventions to address patients’ anxiety via a self-management approach. For example, IBHCs introduce strategies during appointments and collaboratively set goals for patients to incorporate the tools in their daily lives. Brief interventions include reducing the physical response to anxiety (e.g., physical exercise, relaxation strategies), challenging unhelpful thinking, and engaging in enjoying/distracting activity. IBHCs inform the PCM about the nature of the selected intervention(s) and plan, and offer recommendations to the PCMH team after patient appointments. IBHCs recommend referrals to other services as appropriate (e.g., specialty behavioral health). Changes in a patient’s symptoms/functioning may be assessed by the BHM-20 (Behavioral Health Monitor) and GAD-7 (Generalized Anxiety Disorder).

    • Depression

      Patients for inclusion:

      • Patients scoring 10 or more on the PHQ-9
      • Patients with a new depression diagnosis
      • Patients starting an antidepressant medication or a new antidepressant medication because the first medication was not adequately effective
      • Patients not meeting HEDIS metrics for acute or continuation phase antidepressant medication treatment
      • Patients on antidepressant medication who have not seen their PCM in over 12 months
      Learn more about how an IBHC can support a patient who has depression.

      IBHCs implement evidence-based assessment and interventions for patients whose depressive symptoms and functional impairment can be addressed in approximately one to four appointments. After a completing a biopsychosocial functional assessment, a self-management approach to managing depression is implemented. There are numerous evidence-based interventions from which the IBHC and patients can collaboratively select. Interventions include education about depression (e.g., relationship between biological and psychosocial factors of depressive symptoms) and the introduction of a daily mood record to better understand triggers and patterns of symptoms. Patients may also make a behavioral health plan to increase pleasurable and/or mastery activities, use problem solving strategies focusing on one specific area of concern, shift from overly negative thinking to more realistic or balanced thinking, and/or focus on medication adherence to manage depression. IBHCs inform the PCM about the nature of the selected intervention(s) and plan, and offer recommendations to the PCMH team after patient appointments. IBHCs may also recommend referrals to other services as appropriate (e.g., specialty behavioral health). Changes in a patient’s symptoms/functioning may be assessed by the BHM-20 (Behavioral Health Monitor) and PHQ-9 (Patient Health Questionnaire).

    • Diabetes

      Patients for inclusion:

      • Patients newly diagnosed with diabetes
      • Patients with poor glucose control (defined as an HbA1c of 7 or greater)
      • Diabetic patients with comorbid depression
      • Diabetic patients with comorbid tobacco dependence
      • Diabetic patients with comorbid hyperlipidemia, hypertension, or obesity
      Learn more about how an IBHC can support a patient who has diabetes.

      IBHCs implement evidence-based assessment and interventions with patients. This may be short-term consultation (one to four appointments) or continuity consultation (more than four appointments with longer follow-up intervals) to manage diabetes.

      IBHCs and patients collaboratively select intervention(s) with consideration to comorbid mental health problems (e.g., depression, anxiety, and stress) that impact diabetes management. Interventions include education about diabetes self-management, improving relevant health behaviors, and modifying unhelpful beliefs that negatively affect diabetes management. IBHCs provide the PCM with the nature of selected intervention(s) and plan, and offer recommendations to the PCMH team after appointments with the patients. IBHCs will also recommend referrals to other services as appropriate (e.g., weight management programs, comprehensive diabetes programs). Outcomes for patients with diabetes may be monitored by HbA1C blood test, BMI (Body Mass Index), and symptoms/functioning as assessed by the BHM-20 (Behavioral Health Monitor).

    • Obesity

      Patients for inclusion:

      • Patients with a body mass index (BMI) of 30 or greater
      • Patients with a diagnosis of obesity
      Learn more about how an IBHC can support a patient’s weight loss goals.

      IBHCs implement evidenced-based assessment and interventions with patients to improve weight management. Patients are usually seen for one to four appointments. After initial appointments are complete, patients with obesity may benefit from continuity consultation where they are seen for additional appointments, spaced at longer intervals, to maintain the substantial behavior changes needed for weight loss.

      There are numerous interventions that can be helpful for weight loss. IBHCs and patients collaboratively select the intervention(s) that are most appropriate given the nature of the patient’s difficulties and readiness for change. Possible interventions include education on effective weight loss with a focus on eating and physical exercise, motivational interviewing to determine the importance and readiness to change, problem-solving potential barriers to change, goal setting for improved health behaviors, and instructions in use of a food and activity diary. IBHCs may also recommend that patients be linked to other PCMH team members or external resources (e.g., nutrition, Wellness). IBHCs provide the PCM with the nature of the selected intervention(s) and plan, and offers recommendations to the PCMH team after patient appointments. Outcomes for patients with weight loss goals may be monitored by BMI, percentage of total weight lost, and symptoms/functioning as assessed by the BHM-20 (Behavioral Health Monitor).

    • Pain

      Patients for inclusion:

      • Patients with a diagnosis of a chronic pain condition (e.g., ankylosing spondylitis, costochondritis, fibromyalgia, complex regional pain syndrome, headaches, rheumatoid arthritis, osteoarthritis, lupus, chronic low back pain, degenerative disc disease, irritable bowel syndrome)
      • Patients enrolled in the one-provider program (i.e., only one provider is prescribing narcotic medications)
      • Patients who have signed a pain agreement
      • Patients who have taken narcotic medications for a pain condition for three months or more
      Learn more about how an IBHC can support a patient who has chronic pain.

      IBHCs implement non-pharmacological evidence-based assessment and interventions related to chronic pain. This is typically conducted with short-term consultation (one to four appointments), but could extend to a continuity consultation (more than four appointments with longer follow-up intervals) if needed to manage the chronic condition. A self-management approach is used to increase patients’ engagement in daily activities and improve functioning. Interventions include providing education, using a pain diary, engaging in activity pacing, increasing valued activities, providing relaxation training, challenging unhelpful thinking related to chronic pain, and promoting adherence to pain mediation prescriptions as prescribed. IBHCs provide the PCM with the nature of the selected intervention(s) and plan, and offers recommendations (e.g., referral to physical therapy or occupational therapy). Change in patient symptoms/functioning assessed by the BMH-20 (Behavioral Health Monitor) and PEG (Pain, Enjoyment, General Activity) scale.

    • Sleep problems

      Patients for inclusion:

      • Patients requesting sleep medications
      • Patients having difficulty falling asleep (taking longer than 15 minutes)
      • Patients having difficulty staying asleep (waking throughout the night)
      • Patients having difficulty falling back asleep after waking (taking longer than 15 minutes)
      • Patients who do not feel rested in the morning or who feel sleepy throughout the day
      Learn more about how an IBHC can support a patient who has sleep problems.

      IBCHs implement evidenced-based assessment and interventions with patients to improve sleep problems. Patients with sleep problems are appropriate for the PCBH setting when they can achieve improvement with short-term consultation. IBHCs and patients collaboratively select intervention(s) to improve sleep quality/quantity and reduce functional impairment.  IBHCs may use components of Cognitive-Behavioral Therapy for Insomnia or implement Brief Behavioral Treatment for Insomnia. These approaches include providing education on the biopsychosocial factors of sleep; providing education and setting a plan for sleep hygiene, stimulus control behaviors (e.g., bed is only used for sleeping and intimacy), and sleep restriction (e.g., limiting hours in bed to duration actual sleeping); and teaching patients relaxation techniques. IBHCs inform the PCM of the nature of the selected intervention(s) and plan, and offer recommendations to the PCMH team after patient appointments. Changes in a patient’s symptoms/functioning may be assessed by the BHM-20 and Insomnia Severity Index.

    • Tobacco

      Patients for inclusion:

      • Patients with a tobacco dependence diagnosis
      • Patients identified as a current tobacco user
      Learn more about how an IBHC can support a patient who would like to quit tobacco.

      IBHCs implement evidence-based assessment and intervention(s) with patients. Patients who benefit from short-term consultation are appropriate for the primary care behavioral health setting. The IBHC performs a biopsychosocial functional assessment focused on tobacco cessation. The appointments then address tobacco use behaviors, as well as thoughts and emotions that initiate and maintain tobacco use. Appointments help prepare for the quit attempt, provide support on or before the quit date, promote maintenance, and provide relapse prevention. IBHCs inform the PCM about the nature of the selected intervention(s) and plan, and offers recommendations to the PCMH team after patient appointments. Outcomes of patients who desire to quit tobacco use include the patient being a non-tobacco user six weeks after the quit date and changes in a patient’s symptoms/functioning as assessed by the BHM-20.

    Connecting the patient to the IBHC

    • When a patient is identified during the PCM visit, the PCM nurse or technician may arrange for a same-day appointment with the IBHC, and/or schedule the patient for a future IBHC appointment
    • Alternatively, patients may be identified through an AHLTA and/or Care Point data pull; a team member may contact the patient via telephone or secure messaging to offer a visit with the IBHC
    • If a patient declines to see the IBHC, a team member (PCM, nurse, technician) may ask the IBHC to offer (and document in the medical record) recommendations for care based on available medical record data