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Primary Care and Specialty Mental Health

Primary care-based behavioral services operate at a different clip and level than traditional mental health care. The fast-paced, cognitively-oriented, short-term aspects of integrated behavioral counseling often contrast with the more in-depth, longer-term treatment offered by many mental health clinics. The contrast in operational and professional cultures sometimes makes adjustment difficult for traditional mental health professionals.

The following charts, delineating the differences between primary behavioral health and specialty mental health treatment in concepts and approach, were taken from the “Primary Behavioral Health Care Services Practice Manual 2.0, U.S. Air Force Medical Operations Agency, 2002.

Conceptual Differences Between Primary Behavioral Health Care and Specialty Mental Health Models


Primary Care Behavioral Health Care
Specialty Mental Health Care
Model of care Population based
Client based
Primary customers Medical provider, then client Client, then others
Primary goals
  • Promote Medical provider efficacy
  • Support small client change efforts
  • Prevent morbidity in high risk clients
  • Achieve medical cost savings
Resolve client’s mental health issues
Service delivery structure Part of primary care services A specialized service, either in or out of primary care clinic
Who is “in charge” of patient care Medical provider Medical provider and therapist
Primary modality Consultation model Modified specialty treatment model
Team structure Part of primary care team and behavioral health team Part of specialty mental health team
Access standard Determined by medical provider preference Determined by medical provider and client preference
Cost per episode of care Potentially decreased Highly variable, related to client condition

Defining Characteristics of the Primary Care Behavioral Care vs. Specialty Mental Health Treatment Models

Dimension Primary Behavioral Health Care Mental Health Specialty Care
Primary Goals
  • perform appropriate clinical assessments
  • support medical provider decision making
  • build on medical provider interventions
  • teach medical provider “core” mental health skills
  • educate patient in self management skills through exposure
  • improve medical provider-patient working relationship
  • monitor, with medical provider, “at risk” patients
  • manage chronic patients with medical provider in primary provider role
  • assist in team building
  • deliver primary treatment to resolve condition
  • reauthorization with Medical Provider
  • teach patient core self management skills
  • manage more serious mental disorders over time as primary provider
Session Structure
  • one to three visits in typical case
  • 15-30 minute visits
  • session number variable, related to client condition
  • 50 minute visits
Intervention Structure
  • informal, revolves around primary care (medical) provider assessment and goals
  • less intensity, between session interval longer
  • relationship generally not primary focus
  • visits timed around medical provider visits
  • long term follow up rare, reserved for high risk cases
  • formal, requires intake assessment, treatment planning
  • higher intensity, involving more concentrated care
  • relationship built to last over time
  • visit structure not related to medical visits
  • long term follow-up encouraged for most clients
Intervention Methods
  • limited face to face contact
  • uses patient education model as primary model
  • consultation is a technical resource to patient
  • emphasis on home-based practice to promote change
  • may involve medical provider in visits with patient
  • face to face contact is primary treatment vehicle
  • education model ancillary
  • home practice linked back to treatment
  • medical provider rarely involved in visits with client
Termination/ Follow Up
  • responsibility returned to medical provider in toto
  • medical provider provides relapse prevention or maintenance treatment
  • therapist remains person to contact if in need
  • therapist provides any relapse prevention or maintenance treatment
Referral Structure
  • client referred by medical provider only
  • client self-refers or is referred by others
Primary Information Products
  • consultation report to medical provider
  • consultation report to medical provider
  • part of the medical record
  • specialty treatment notes (i.e., intake or progress notes)
  • part of a separate mental health record with minimal notation to medical record