Task Sharing to Expand Access to Care: Development of a Behavioral Health Support Specialist

Abstract

Task sharing improves access to mental health care in global contexts, but little formative research has examined uptake in the United States. This Open Forum proposes the development of non-specialist professionals to deliver low-intensity behavioral interventions for common mental health conditions in U.S. settings such as primary care. Using data from a multilevel stakeholder assessment, we discuss findings and challenges associated with such a role. Key themes concern scope of practice, competencies, pragmatic concerns, and training needs. Although stakeholders generally found this role to be acceptable and feasible, the themes raised will be critical to developing and implementing such a role.

Despite the prevalence of depression and anxiety and the effectiveness of psychotherapy as a first-line treatment, the majority of U.S. adults with such conditions do not receive treatment (1), often because of lack of available or appropriately trained clinicians (2). Left untreated, these conditions impart devastating personal and public health consequences (3). In this Open Forum, we propose the development of a non-specialist lay counselor trained to deliver structured low-intensity behavioral interventions for common mental health conditions under supervision in a stepped care model in the United States.

Existing Models to Expand Access to Mental Health Care

Expanding the capacity and reach of the mental health workforce is essential to improving access to care. Global mental health initiatives are bridging this gap with provider task sharing, in which tasks are redistributed in a stepped care model. In this model, low-intensity behavioral health services are delivered by non-specialist providers (NSPs) under appropriate supervision, expanding access and freeing up limited expert resources (4). Although the need for such services is great in low- to middle-income countries (5), such strategies are readily translatable to high-income countries. Notably, task sharing is the linchpin of England’s National Health Service’s Improving Access to Psychological Therapies (IAPT) program, in which Psychological Well-being Practitioners —a cadre of NSPs with the U.S. equivalent of college coursework and no prior specialized training in mental health—deliver structured low-intensity behavioral interventions for depression and anxiety disorders within a stepped care model (6).

Task sharing has great potential for deployment in the United States, given one in five Americans lives in a rural area (7) and even urban areas have varying degrees of provider availability and access barriers. Existing NSP models in the United States include peer counselors and community health workers. While these roles are also intended to expand access to care, the scope of such NSPs typically center on care coordination and navigation (8). NSPs are not routinely used to deliver behavioral health treatment in the United States outside of randomized controlled trials. Stanley and colleagues (9) trained bachelor’s-level research assistants to deliver cognitive behavioral therapy (CBT) for generalized anxiety disorders, and found comparable patient outcomes between these lay counselors and doctoral-level psychologists. Raue and colleagues (10) embedded behavioral activation (BA) services for depression in senior centers, delivered by trained volunteers. Choi and colleagues (11) trained bachelor’s-level case managers at a social service agency to deliver tele-BA and found meaningful improvement in depression outcomes among service recipients. Thus, this model is potentially effective, but little formative research has evaluated relevant barriers and perceived implementation outcomes (i.e., feasibility and acceptability) of NSPs in clinical contexts in the United States.

Behavioral Health Support Specialist (BHSS)

Our group has been working with various educational, clinical, policy, and philanthropic partners across Washington to develop a role that we call a “Behavioral Health Support Specialist” (BHSS). The BHSS role is framed as a trained bachelor’s-level professional delivering structured low-intensity behavioral interventions for common mental health conditions in a stepped care model under supervision by a licensed clinician. Our preliminary work has focused on primary care as a particularly relevant setting to improve behavioral health service provision, given the majority of mental health conditions are recognized and treated in such settings (3). We modeled the BHSS in large part on the non-specialist low-intensity workforce from IAPT, who often work in integrated primary care.

In the course of developing such a role, we sought input from a variety of behavioral health educators, clinicians, administrators, and policymakers who have potential interest or concerns in such a position and the power to influence services. Such a multilevel stakeholder approach solicits views from stakeholders with diverse expertise and backgrounds to develop solutions that are more relevant and sustainable to the community and settings of interest (12). We briefly present a stakeholder assessment conducted as part of the formative development of this role.

Case Example: Multilevel Stakeholder Assessment

A web-based survey was distributed to multilevel stakeholders across Washington. Of the 40 stakeholders who completed the survey, the majority worked in primary care (52.5%) or community mental health (27.5%) and were primarily clinicians, administrators, and educators (table with participant characteristics and further detail on methods available online). We first presented a sample job description describing the BHSS role (see online supplement). We described the BHSS as a member of an integrated primary care team working under the supervision of a licensed provider to deliver low-intensity evidence-based treatment strategies for adult patients with mild-to-moderate symptoms of common mental health conditions, such as anxiety or depression. Interventions are currently under development but include brief behavioral activation. The BHSS would also maintain and track an active registry of patients, use measurement-based care strategies to refer patients needing high-intensity psychotherapy, engage in case management, and facilitate community referrals. BHSS training is under development by this authorship team but was described as specialized coursework and supervised practicum training alongside a relevant bachelor’s degree program. Respondents were asked to rate (1) feasibility of the BHSS role; (2) acceptability to their team; and (3) acceptability to patients on a 1 (not at all) to 5 (completely) scale. They were prompted to provide open-ended comments on the job description, including concerns and competencies that would be important for this type of position.

Feasibility and Acceptability

All items received the full possible range of scores (1–5). The BHSS role was rated as “somewhat feasible” (M = 3.33, SD = 1.40) and between “somewhat” to “mostly acceptable” to the team (M = 3.80, SD = 1.31) and patients (M = 3.83, SD = 1.15). Two-way between-groups analysis of variance (ANOVAs) compared differences in acceptability and feasibility ratings between groups (provider type: behavioral health provider or other; setting: primary care or other). Feasibility and acceptability ratings did not vary by provider type (behavioral health clinician or other) and there were no interaction effects, all ps > .10. However, regardless of occupation (behavioral health or primary care clinician), there was a main effect of setting, such that respondents in primary care rated the BHSS as less acceptable to patients (F(1,36) = 7.34, p = .01). This is an intriguing finding that warrants further exploration; it may be that our primary care respondents were less familiar with integrated behavioral health services. Preliminary qualitative data suggested that primary care respondents were concerned about training needs (e.g., competency in substance use disorders, cultural humility). Qualitative examination with actual patients is a necessary next step to explore barriers and facilitators.

Stakeholder Concerns

Free text responses were coded for content by the first and second author using thematic analysis (13). Four themes emerged from participants’ comments on the job description related to scope of practice, competencies, pragmatic concerns, and educational and training needs. Stakeholders’ main concerns with the BHSS’ scope of practice was the ability of a bachelor’s-level worker to properly assess and treat mental health disorders and determine referrals for more complex diagnoses. Stakeholders valued the ability to work and communicate effectively on an integrated care team as a key competency. A common concern was potential overlap with Master’s-level behavioral health clinicians. Lastly, stakeholders posed concerns about the adequacy of BHSS training to prepare for practice within this scope, although some respondents thought the skills needed for this position could be learned on the job. More details on qualitative themes are available online.

Challenges and Implications

Our findings suggest that such a task sharing approach may be promising, but development and implementation of such a role will need to explicitly engage various stakeholders to ensure success. Respondents in primary care settings—a target stakeholder group—perceived this position as less acceptable to patients compared to respondents in other settings, regardless of profession. Importantly, we did not survey patients or those with lived experience; this is a crucial future direction. Next steps must rigorously delineate scope of practice, competencies, and training requirements to ensure acceptability.

Although there is great support for such a model in low- and middle-income countries (4), little formative research has assessed barriers and facilitators of task sharing of mental health interventions in high-income contexts. The exception is the IAPT model, upon which our BHSS role is based. The success of IAPT is driven in large part by three components to support the non-specialist low-intensity workforce: first, training in and delivery of evidence-based psychological therapies; second, routine outcome monitoring; and third, regular supervision, focused on patient outcomes (6). As many of these components are present in existing U.S. integrated primary care models (e.g., Collaborative Care (3)), these may provide a foundation for integrating such a role. Future development must attend to triaging cases most appropriate for BHSS service, best supervision practices, and referral processes to higher steps of care.

Conclusions from our preliminary assessment are limited by voluntary survey response, recruitment specific to Washington, and a small sample relative to our wide range of recruitment efforts. Our survey used brief measures to obtain an initial litmus test among potential stakeholders. Only one item inquired about feasibility, although respondents had the opportunity to elaborate in free text. Indeed, multiple respondents commented on billing and reimbursement, which are crucial in developing such a role. Feasibility and acceptability will likely vary by setting based on myriad factors, including reimbursement for services, policy changes to credential such a role, and available clinic space. Ongoing development will target multiple stakeholder perspectives across settings with more rigorous qualitative examination to better evaluate implementation issues.

Conclusion

Training lay counselors, such as our proposed bachelor’s-level BHSS, to deliver low-intensity psychological treatments for common mental health disorders may be an acceptable and feasible way to expand care in the United States. Our findings from professional stakeholders can inform the design and implementation of such a role. Future work needs to include patients as a critical stakeholder group.