Table 2.

Summary of Observed Skills Clinicians Need to Deliver Integrated Care¹²

PCC	BHC	Consulting Psychiatrist
Open to sharing care with others: recognizes that other professionals bring specialized expertise	May proactively review patients to identify potential needs/opportunities for BHC services to PCC	Views role as adjunct to PCC and BHC, not as the replacement
	Participates in briefing by listening and asking for clarification when needed
Reviews screenings, uses clinical discretion, or considers suggestions to identify patients needing BHC services	Introduces self as a member of the care team: normalizes behavioral health care delivery as part of “routine” practice	Introduces self as a member of the care team
Provides brief assessment of patient’s behavioral health needs and establishes foundation for BHC handoff: describing expertise, importance of whole person care, expectations (“selling” resource to patient)	Conducts rapid, targeted assessments of patient needs; identifies “feasible” targets for brief intervention	Provides psychiatric consultation to the primary care team as needed
Briefs BHC on perceived patient condition/needs: assessment of situation, depression intervention	Sets agenda balancing patient/PCC priorities, or negotiates focus of these two stakeholders	Assists PCC: diagnosis, treatment planning, and recommendations
Available to debrief with BHC during encounter or post-encounter to develop care plan	Apply brief interventions using abbreviated evidence-based treatment strategies: solution-focused therapy, behavioral activation, cognitive behavioral therapy, motivational interview	Willing to treat/consult on some patients without seeing them
Reinforces care plan and/or BHC intervention during next encounter	Clinical capacity to address full spectrum of behavioral health needs: common mental health conditions (depression, anxiety), lifestyle behaviors (self-care, social engagement, relaxation, sleep hygiene, diet, exercise)	Makes a treatment plan in a short amount of time with limited information
	May develop specialization areas: substance use counseling, biofeedback	Focuses on complex patients who cannot be managed alone by PCP and BHC
	Links efforts to overall patient care: reinforce care plan with PCC and summarize goals/next steps with patient
	Leads group sessions for patients: pain groups, diabetes management	Engages other professionals in patient care plan: BHC, social worker, pharmacist
	Determines care level needed: additional followup with BHC, transition to specialty mental health care	Coaches PCCs to manage complex patients; transitions patients back to primary care
	Assists with specialty mental health/other treatment resource transitions (case management)
	Concisely communicates information to the primary care team: verbally, EHR notes	Concisely communicates information to the primary care team verbally, EHR notes

BHC, behavioral health clinician; EHR, electronic health record; PCC, primary care clinician.