Scaling out a Digital-First Behavioral Health Care Model to Primary Care

There is an established supply/demand problem in addressing behavioral health needs. A proposed solution is to have primary care providers respond to patients' behavioral health challenges directly. The current study describes the adaptation and evaluation process of Precision Behavioral Health (PBH), a digital-first behavioral health care model with provider-referral to an ecosystem of digital interventions. User-centered design strategies used to adapt the PBH program included applying process to system-level behaviors, defining target users and their needs, defining workflows, rapid prototyping cycles, and a complimentary mixed-methods iterative development phase with a pilot trial. Twenty-one primary care providers, 164 medical assistants and check out staff, and 45 nursing staff were trained as part of the pilot. The RE-AIM implementation framework was used for evaluation. Fourteen primary care providers participated in a semi-structured interview to provide feedback on their experience. The adapted PBH program reached 39.54% of primary care patients seen by the pilot providers during the timeframe. Providers offered PBH to 76.63% of the patients reached, and 26.10% accepted the PBH referral. Out of the accepted patients, 78.15% registered, 73.95% activated their digital intervention, and 59.09% showed clinical improvement in outcomes. Nineteen (90.48%) pilot providers adopted PBH and referred a median of 2 patients each week. Medical assistants/check out staff scheduled 5% of digital care navigator appointments and 84.03% of provider follow up appointments. Primary care providers used the program's clinical decision support tool to aid their discussion and referral process with 95.33% of patients that accepted PBH and selected one of the top 3 recommended tools 95% of the time. Qualitative results identified six broad content categories: Overall PBH referral experience, PBH training, PBH eligibility flag, PBH follow-up appointment workflow, impacts of PBH program on providers, and future modifications. Providers described a positive experience with PBH elements, low burden, positive impact on their jobs, and PBH enhancing treatment options for their patients. Primary care providers identified several adaptations, such as expanding PBH to other types of visits (e.g., sick visits), and optimizing workflow for check-out staff when booking follow-up appointments. Primary care providers are willing and able to successfully refer patients to behavioral health digital interventions with minimal training time for onboarding. Patients referred through primary care demonstrate high acceptance rates, and comparable rates of improvement to those that are referred by licensed behavioral health providers. The results have the potential to impact public health, by increasing behavioral health access for patients without adding burden to providers, and providing healthcare organizations an alternative pathway to address increasing needs without having to increase personnel or introduce major organizational changes.