As mentioned in earlier posts (here, here, and here—which I would encourage you to read first, if you haven’t yet), one of the key frameworks of PCBH is the GATHER acronym which captures the essential characteristics of primary care .

Generalist

Primary care, by definition, is generalist care —PCPs see patients of any age and with any condition. To be successful in primary care settings, a BHC must be both willing and able to see any patient and any condition that the PCP in the clinic will see.

Often, new BHCs struggle with how to navigate presenting concerns or patient populations with which they don’t have much (or any!) experience. To be a successful generalist, BHCs benefit from access to point-of-care resources such as UptoDate and EthnoMed. I encourage new BHCs and trainees to ask the PCP making the referral what they are hoping the BHC can provide to the patient. Very often, what the PCP needs from us, is help reinforcing the care plan that they’ve already discussed with the patient.

Sometimes clinics or providers are less familiar with the model of care that we provide and think of BHCs as colocated therapists or counselors. It can be tempting to give a list of what we do and don’t see—but the reality is, as generalists in a primary care setting, we see everything the PCP sees. If the patient came in to see the PCP, then we can see them too.

Accessible

BHCs are accessible to both patients and the care team. For patients, this means that when they need services, they can be seen in the moment via a warm handoff (WHO). The warm handoff is often the aspect of PCBH with which people are most familiar and occurs when a PCP identifies a patient need that can be addressed by a BHC and reaches out in the moment for a visit.

When I was in graduate training, an early supervisor frequently repeated the cliched tautology. “strike while the iron is hot” to emphasize the importance of listening for change talk and leaning into that “teachable moment” —we know that motivation can change, and once the patient has been sent to the front desk to schedule with a BHC, we’ve already lost them .

Functionally, being accessible means building a schedule in a way that BHCs are available anytime that a patient needs to be seen (Drs. Beachy and Bauman have a great PCBH Corner Episode on this very topic!). It means normalizing interrupting visits, knocking on exam room doors, and responding in the moment to PCP requests via instant message, phone call, or in-person, and it means sitting in team-centric provider pods, not in an office.

Being accessible includes language and cultural accessibility. BHCs make use of interpreters and point-of-care resources to tailor services to the language and cultural needs of the patient in front of the BHC.

Team-based

Integrated BHCs are members of a care team, not siloed providers. This means that BHCs do not carry their own caseload—PCPs have a panel of patients, and we see their patients. It can be helpful to remind ourselves that PCBH is a consultant model. BHCs are there to provide direct patient care and consultation to the PCP as part of the primary care team. This means, among other things, that when working with a patient, you have other people to rely on when you get stuck, and it also means that you don’t make clinic decisions in a silo.

When working with interns, for example, my first question after they present a clinical case in supervision is, “what does their PCP think?” Some BHCs struggle with this model and feel like it creates a hierarchy that privileges medical providers over mental health providers. While it is certainly possible to have a PCP that feels that way, part of successful teams is mutual respect between various team members. Whether it is the PCP, the patient, the RN, the medical assistant, the nutritionist, the receptionist, the clinical pharmacist, or the BHC—each team member brings important expertise to the care of the patient—and the patient will have better health outcomes when all members of the team are working together.

Charting should be clear and compatible with the needs of primary care. I strongly encourage an APSO format for notes so that the assessment and plan are easily visible when the note is opened without any scrolling.

Mentioned in the discussion about access, but team-based care works best when the team is working in close physical proximity—preferably on the same floor and within 26 feet of each other .

Highly productive

The high productivity expectation of this model is perhaps the most controversial part of PCBH. For example, when Drs. Robinson and Reiter published the second edition of their influential book, Behavioral Consultation and Primary Care: A Guide to Integrating Services, an early one-star review on Amazon foresaw, “the behavioral health consultant burning out less than a year on the job”—despite many of us working in this model, providing highly productive care for many years, in some cases even decades.

The reality is that providers in primary care settings see many more patients than providers in most specialty settings. In some cases, PCPs may be seeing in excess of 20 patients in a day. If a BHC doesn’t adapt their own workflow to also see more patients than they would in a specialty setting, they are creating inequitable workloads that can breed resentment—which will, over time, reduce the BHC’s effectiveness.

Ultimately, primary care is a population health approach to care and to work well in this setting, a BHC must learn to work from a population health perspective.

Educator

When I do presentations on the PCBH model I have a slide where I say that I care just as much about the patients I don’t see, as those I do—I’m pretty sure at some point in the past, I stole the idea from Dr. Reiter. There are a number of ways that PCBH allows me to do that, but one of those ways is in my role as an educator to the care team. Consistent with consultation models, BHCs provider direct patient care, but also, both directly and indirectly, provide education and modeling to PCPs, medical assistants, front office personnel, etc., how to help patients make changes in their health behaviors or to create teachable moments , for example, teaching a 90-second Motivational Interviewing technique to discuss smoking cessation .

For example, one of my colleagues took a handoff from an Urgent Care provider for a patient experiencing a panic attack in the exam room. After spending a few minutes teaching the patient how to do a relaxation exercise, the BHC came out to update the urgent care provider. The provider asked the BHC to teach them how to teach the exercise to patients so that in the future, they could do it without needing to use the BHC.

The role of educator is not only to those on the care team but also to patients. Psychoeducation is a valid intervention for use with patients, by being an educator means more than teaching patients about managing their diabetes using diet, exercise, and medication adherence, it’s also teaching patients how to navigate the US healthcare system, how to discuss an interpersonal conflict with their PCP, or how to advocate for themself when they are trying to schedule an appointment with that endocrinologist their PCP referred them to.

Routine

Finally, behavioral health care should be a routine, normal part of care. The BHC is just another member of the care team, not someone who is just when there when there are serious mental health issues. Just as patients don’t think it is weird to have a medical assistant or nurse join a visit, it shouldn’t feel weird to have a BHC join a visit regardless of the reason for visit.

Making the BHC a routine part of care helps to reduce stigma of working with behavioral health providers—but it also normalizes that health behaviors play an important role in managing health. Think about ways that a BHC can be incorporated into well-person exam, diabetes follow-up visits, dental cleanings, hypertension care plans, etc. in ways that do NOT focus on mental health, stress, or anxiety.

As an example, I enjoy participating in diabetes half-days. During these events, a PCP’s schedule is blocked for 4 hours of back-to-back patients with diabetes. Those with A1c greater than 9.0 follow up monthly, those above 7.0 every three months, and those who are controlled every 6 months. During their visit, the patient is roomed by the MA, and seen by the RN, the nutritionist, the BHC, the clinical pharmacist, and the PCP. During the visits, the BHC’s role is to help the patient take in all the information provided, discuss their existing SMART goal, and set a new behaviorally grounded SMART goal to work on until their next follow-up. AND, if the patient has achieved control of their A1c, then the BHC (and all the rest of the care team members) goes in and reinforces the patient for achieving their goal and provides positive feedback about the changes made.

Conclusion

GATHER provides an important and easy to remember framework for BHCs working in primary care to help center our expertise in the setting in which we are working. As you think about how to implement PCBH into your clinic, or how to make adjustments to your workflows, make sure to review each of these domains to help ensure you are acting consistently with the goals of primary care.

Let me know your thoughts in the comments.

References