Table of Contents
Form and Function
Current Initiatives in Primary Care
Triple Aim
Patient Centered Medial Home Model
Primary Care Behavioral Health Model
Challenges to Evolving Primary Care
Lack of Preparation
Low Job Control
High Complexity Patients
Workforce Shortage
Recommended Strategies for Improving Behavioral Health Services in Primary Care
Summary
Review of Strategies
References
List of Abbreviations
The Team and Their Work
The Organization of Primary Care
Internal Primary Care Staff
Primary Care Clinician
PCP Training
Non-physician Primary Care Clinicians
Naturopathic Physicians
ND Training
Registered Nurses
RN Training
Licensed Practical Nurses, Nursing Assistants and Medical Assistants
Support Staff in Primary Care
Front Desk Staff Members
Ward Clerks
Appointment Line
Billing Specialists
Interpreters
Administrators
Medical Directors
Nursing Director
Clinic Manager or Director
Other Leaders
Primary Care Behavioral Health Staff
Behavioral Health Clinician
Behavioral Health Clinician Assistant
Health Coach
Community Health Worker
A Note About Teamwork in Urban, Suburban, and Rural Clinics
Prosocial Teams
Acceptance and Commitment Therapy
A Word About Resilience
The Maslach Burnout Inventory
Compassion: An Antidote for Stress
Morning Huddle Compassion
End of Day Gratitude Circle
Recommended Strategies for Promoting Healthy PC Teams
Summary
Review of Strategies
References
List of Abbreviations
What Do Patients Want?
Measurement of Flourishing
Barriers to Flourishing
Psychological Flexibility and Inflexibility
Psychological Flexibility and Avoidance
A Clinical Definition of Psychological Flexibility
Basic Methods for Targeting Behavior Change in Primary Care
Recommended Strategies for Promoting A New View of Behavior Change in PC
Review of Strategies
References
List of Abbreviations
Starting a Conversation About Behavior Change
Standardized Assessments
Rating Scale Questions
The Contextual Interview Questions
Workability and Values Clarification
The Four-Square Tool
Contextual Assessment Checklist
Case Examples
Amy: Trauma and Health Risk Behavior
Bob: Life Stress and Difficulties with Self-Management of Chronic Disease
Mary: Grief and Demoralization
Pillars of Psychological Flexibility
Putting It All Together
Amy
Bob
Mary
A Note About Suicide and Risk Assessment
Recommended Strategies for Providing Assessments That Engage Patients in Behavior Change
Summary
Review of Strategies
References
List of Abbreviations
A Syringe and Powerful Medicine
Primary Care Behavioral Health
Powerful Medicines
Focused Acceptance and Commitment Therapy
Generating Information to Inform Interventions for Primary Care
Promoting Psychological Flexibility in Clinical Contacts
The Pillars Intervention Guide
Open
Aware
Values
Targeting Open and Aware
Targeting Values
The “Relate the Problem to Values” Worksheet
Behavioral Experiments
Behavioral Variability
Confidence
Values
A Note About Time and Behavioral Experiments
Amy’s Behavioral Experiment
Bob’s Behavioral Experiment
Metaphors
Bull’s-Eye
Life Path
Working Smart in Primary Care
Use Assistants
Think Beyond Clinic Visits
Think Beyond the One-To-One
Strategies for Delivering Powerful Behavior Change Interventions
Summary
Review of Strategies
References
List of Abbreviations
Appendix A:
A.1.1 Contextual Behavioral Scientist Check-In
Appendix B:
B.3.1 The Flourishing Project Measure
B.3.2 The Acceptance and Action Questionnaire- II
B.3.5 The Approach-Avoidance Tool
Appendix C:
C.4.7 Rating Scale Questions
C.4.8 Contextual Assessment Checklist
C.4.9 Pillars Assessment Tool (PAT)
C.4.12 Contextual Interview Questions
C.4.13 Four-Square Tool
Appendix D:
Table D.5.1 The “Relate the Problem to Values” Worksheet
Table D.5.2 The “SMART Behavioral Experiment” Worksheet
Table D.5.3 Bull’s-Eye Plan Worksheet
Table D.5.4 The “Life Path Plan” Worksheet
Table D.5.7 FACT Pillar Intervention Guide (PIG)
Figure D.5.1 The Life Path Plan
Figure D.5.3 Bull’s-Eye Plan
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 health care 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 re-locating 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 inter-professional team member, capable of delivering interventions for patients of all ages for all behaviorally influenced problem 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 health care workers, and health coaches all over the world. We 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 our 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, we suggest a conceptualization for assisting patients of any age with on-going development of skills that promote flourishing and healthy aging. Chapters 4 introduces Contextual Interview Questions, a tool that helps clinicians complete a functional assessment of the problem that most concerns the patient. In Chapter 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 in skill practice exercises, the other appendices offer copies of the scales and tools introduced in Chapters 3-5 (Appendix B: Chapter 3 scales and tools; Appendix C: Chapter 4 tools; Appendix D: Chapter 5 tools). 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 (HC’s) and Community Health Workers (CHW’s). 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, we 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, we offer on-line coaching services to readers seeking assistance in applying and refining what they learned from reading this book (see www.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 inter-disciplinary courses to graduate and under-graduate 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 inter-professional team.
I want to express our 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 co-write 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 super-heroes, 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, Wayne Blackburn, David Bauman and Bridget Beachy. 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.