What’s the Difference between Primary Care Behavioral Health and Specialty Behavioral Health?

photo of a women soldier in fatigues sitting in an office waiting room.
U.S. Air Force photo/Airman 1st Class Curt Beach
By Anne C. Dobmeyer, Ph.D., ABPP
March 2, 2020

“My primary care patient is experiencing depression. Should I recommend the patient be seen by the behavioral health consultant (BHC) in primary care? Or should I refer the patient to the specialty behavioral health clinic? What’s really the difference?”

The Military Health System (MHS) has various levels of care available for patients with behavioral health concerns. Clinicians in the MHS may have questions about which level and location of care is right for a particular patient: primary care behavioral health (PCBH) or specialty behavioral health services.

Integrated within primary care clinics, BHCs are licensed psychologists or social workers who assist primary care teams in the care of patients with a wide range of conditions and concerns. BHCs work with patients who would like to make changes to better manage their health, adjust to life changes, improve adherence to their primary care manager’s (PCM’s) treatment plans, or address behavioral health conditions or symptoms. BHCs provide focused, evidence-based assessment and intervention in appointments that are no more than 30 minutes in length. Many patients see the BHC for one or two visits; others engage in longer courses of care spaced out over time. BHCs typically work with patients until symptoms or functioning begin to improve, at which point care is continued by the primary care manager, who reinforces strategies that have been helpful and monitors the condition over time.

If the patient does not improve with interventions at the primary care level, the BHC can link the patient with a higher level of care in a specialty behavioral health clinic for a comprehensive assessment and full course of psychotherapy. In specialty behavioral health, appointments are typically longer in duration (e.g., 50 to 60 minutes). Assessment may include a comprehensive battery of psychological tests and integration of information from various sources. Evidence-based psychotherapy may include weekly or bi-weekly appointments delivered over longer courses of care (e.g., 10 to 12 appointments). Patients are often seen in specialty behavioral health care until symptoms have remitted. When specialty behavioral health care is no longer needed, patients may still benefit from periodic visits with their primary care clinic’s BHC to assist with maintaining gains and preventing relapse.

In considering level of care decisions, a PCM may wonder: “If I think my patient needs specialty-level care, should I still send them to the BHC?” Sometimes it is clear that a patient would benefit from a higher level of care. For example, a patient with serious mental illness or a need for more complex psychotropic medication management may have needs best addressed in specialty behavioral health. While PCMs can bypass the BHC in these situations, there is often value in discussing the case with the BHC and potentially involving the BHC in care. BHCs can work with patients to increase willingness to accept a referral to specialty care, can address barriers that may interfere with accessing care, and can provide care to bridge gaps until a specialty care appointment is available and attended.

Learn more about primary care behavioral health and the role of BHCs on the Psychological Health Center of Excellence website.

Capt. Dobmeyer is a U.S. Public Health Service psychologist in the Primary Care Behavioral Health branch at the Psychological Health Center of Excellence. She specializes in clinical health psychology and the integration of behavioral health services into primary care clinics within the Department of Defense.

The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


  • My first suggestion to anyone experiencing depression is to take long walks on a daily basis. This probably counters VA policy as it does not allow the big business overlay of typical pharmaceutical prescriptions with their attendant side effects.

  • I've spent 5 decades as a BHC clinician and faculty member. We triage based on degree of risk from urgent, emergent, and non-emergent, and it is based on harm to self and others; we refer to this as degree of risk to self/others within 72 hrs. or less. I've never encountered someone who is "routine".
    In regards to combat vets I've counseled, the vast majority present w/ clinical complexity. I am aware of the high risk of suicide.

    And we titrate levels of care based on the above data.

    Rich (former AF ER medic from 1969~1973)

  • Interesting piece but was wondering given the relatively high level of co-occurrence among behavioral health 'issues', is short, comprehensive screening and assessment conducted at intake at both systems to identify potential sources of the presenting symptoms?

    • You’re absolutely right that behavioral health conditions frequently co-occur. While BHCs conduct a targeted assessment of the identified referral problem, they also use an assessment measure at each appointment to obtain information on a wide range of behavioral health symptoms and life functioning. This information helps the BHC, the patient, and the PCM develop an appropriate plan of care. If the patient is referred for specialty behavioral health care, the behavioral health provider conducts a comprehensive intake evaluation that typically includes one or more standardized assessment measures. This evaluation aids the provider’s understanding of the nature and scope of the problem and helps them shape the treatment plan.

      -- CAPT Anne Dobmeyer 

  • This is a very important concept for users of our healthcare processes to understand. Mental-Behavioral Health Care begins and should be monitored within PRIMARY CARE. Prevention should be our goal, rather than treatment after crises. All medical treatment teams should conduct a targeted assessment of mental health at every opportunity, whether routine, urgent, or emergency care as point of contact. The integrated patient-centered medical home approach emphasis a safety health plan owned and followed by the patient we all serve. This plan, and the safety team generated by it, is made up of people the patient trusts, whether family, friends, or the BHC and PCM. The BHC in the PC Clinic should not only provide screening, but treatment as well, to reduce the need to refer out for specialty behavioral health care. The specialty provider should not require another screening if they act virtually as an extension of the integrated primary care team with the patient. We are still too silo'd into separately funded, isolated entities following processes dictated by insurance companies with delays and dropped communications. When we all acknowledge this fact, and change our intake and referral processes, we will then be able to provide holistic, integrated, preventive, and person-centered mental and physical health care cost-effectively with the highest quality and outcomes. The DoD should be the model for this kind of care given we do NOT have to follow the civilian fee-for-service for-profit sick care system prevalent in the USA.

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