Get the Right People on the Bus – Integrating Behavioral Health Into the Medical Home

An excerpt from "Integrating Behavioral Health into The Medical Home: A Rapid Implementation Guide".

In the U.S. military, a common phrase heard around leadership planning tables is, “If you get the right people on the bus, everything else falls into place.” Once those people are on the bus, you also have to ensure they are placed in the “right” seats. A few straightforward business actions described in this chapter and the next, such as personnel selection, training, and management, will help you accomplish this. Unfortunately we are aware of no reliable empirical information that details how to select the best personnel for behavioral health service delivery in primary care. However, experts have made several recommendations over the past two decades that align with our experiences of delivering and training others to deliver evidence-based behavioral health services in primary care.

Who Are the “Right” People?

Scout for employees who are hard-working, responsible, flexible, and forward-thinking.

Find people who clearly work well in teams—who are confident and likable.

Hire employees who genuinely care about what they do. These professionals and paraprofessionals already operate with these positive work habits because these habits are consistent with their personal values.

Keep in mind that conscientiousness is the personality trait most closely and consistently associated with high job performance.

You want people in your medical home who have an internal compass consistent with medical home concepts.

Hire BHPs who have sufficient training and the right personality characteristics for this work. If some of the skills are lacking, that’s fine, you can tap into available training resources.

The most successful mental health professionals to recruit for medical homes are:

• Flexible;• Adaptive;• Genuine;• Empathic;• Non-judgmental;• Extroverted; and• Not intimidated by working with other specialties.• Interested in learning and teaching;• Sociable;• Personable;• Adept at thinking quickly, particularly without preparation;• Conscientious;• Able to multitask;• Able to handle stress, chaos, and unpredictability calmly and effectively;• Confident, but balanced with some humility;

Seek potential mental health providers who have sufficient prerequisite skills:

• Builds and maintains positive relationships, particularly in ambiguous or uncertain situations;• Ability to accurately communicate complex concepts in very few words;• Learns quickly;• Strong diagnostic skills;• Strong assessment skills;• Strong knowledge and skill in implementing behavioral and cognitive interventions;• Strong motivational interviewing skills;• Solid understanding of the medical model (e.g., assess, treat, monitor, repeat);• Adroit at teaching patients and medical team members; and• Consultation experience (added bonus);

If possible, avoid hiring staff with these personality red flags:

• Rigidity;• Overconfidence;• Insistence on being right;• Self-aggrandizing;• Needing excessive preparation or time to perform optimally;• Non-adaptive; and• Easily or often defensive.

Select mental health professionals who possess sufficient training prerequisites. Avoid people who:

• Shy away from being observed and co-treating with PCPs;• Love delivering psychotherapy;• Convey the need to “own” their own caseload of patients;• Are sensitive to power and authority;• Assume too much responsibility for their patients;• Foster excessive patient dependency on himself/herself;• Does not take feedback well;• Lack experience and desire to work in teams;• Lack experience in behavioral medicine; and• Are unable to analyze and conceptualize patients’ biopsychosocial factors.

By hiring people who already demonstrate these positive characteristics, you ensure your organization’s training teams and programs have time and resources to address higher-level problems instead of spending time on basic or remedial issues. Hiring the “right” people means resources can be devoted to the initiatives the company values, and less time is wasted grappling with personnel issues.

Shifting to a medical home model of primary care and introducing IBH triggers a shift in healthcare culture on multiple levels. Culture clash between primary care and mental health has been identified as a common barrier to successful integration. To minimize this, hire people with prior experience in IBH. If you cannot find someone with prior experience, a second strategy may be to search for someone who has worked in multidisciplinary care settings. This may be behavioral health or other medical personnel who have experience working in the Emergency Department, in crisis units, in hospitals, or in other places that have team-based care. Often this is not possible, so consider hiring someone who meets the aforementioned personality characteristics criteria and a stated desire to work in a team-based primary care or medical setting. Regardless, we suggest providing subsequent training after hiring the BHP. We will discuss this more in the next chapter.

As a part of the hiring process, arrange for the potential BHP to shadow and observe someone working in the model you intend to launch. If you are starting a new program and have no other BHP for the prospective hire to observe, consider reviewing online videos of the respective model of care with your prospective hire. Several resources depict role-plays that are useful for hiring and training purposes. For the primary care behavioral health (PCBH) model of service delivery, consider viewing the following YouTube channels: NCR Behavioral Health and Primary Care Shrink. For other models, you may be able to find demonstrations on YouTube or through Internet search engines such as Google. View the demos with applicants and ask them to discuss how the video reflects or does not reflect their prior experience and practice skills, and if they believe they can learn and appreciate this modality.

For the Care Management Model, have the prospective hires review a few research reports with you (e.g., “The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes ” or Respect-Mil: Primary Care Clinician’s Manual ), then ask them how they would fit if hired to implement these protocols and serve in this role.

A few final words about interviewing. The more behavioral your interview is with the BHP candidate, the more accurate a conclusion you will make about the goodness-of-fit between this person and a high-functioning IBH program. We suggest as a part of the interview you ask fund-of-knowledge questions about medical problems (e.g., What is hemoglobin A1C and why is it important in diabetes care? What are the common side effects of selective serotonin re-uptake inhibitors? Describe the underlying etiology that explains why patients experience difficulties with sleep onset and sleep maintenance in insomnia). This knowledge can often be taught (unlike the personal and professional characteristics we listed earlier), but it is helpful if your applicant already possesses this knowledge.

It is also vital to use behavioral interview tasks such as providing the applicant case vignettes and asking candidates to assign a diagnosis and brief treatment goals on the spot, verbalize a biopsychosocial case conceptualization for the vignette, demonstrate how to give the PCP feedback about the case described in the vignette, demonstrate how he or she would educate the patient about a particular mental health or general health condition. It may be helpful to include someone with behavioral medicine knowledge (a PCP and another BHP experienced in IBH) while conducting the interview. It also may require the use of role play exercises to ascertain the information about the applicant that you need for making solid hiring decisions. Your selectiveness will pay off, trust us. If the applicant cannot do these tasks in the interview there is little chance he/she will be able to do them in “real-time.”

Excerpted from: Corso, et. al. Integrating Behavioral Health into The Medical Home: A Rapid Implementation Guide