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

Despite the prevalence of depression and anxiety in the United States and the effectiveness of psychotherapy as a first-line treatment, a majority of U.S. adults with such conditions do not receive treatment (1), often because of the lack of available or appropriately trained clinicians (2). Left untreated, these conditions yield devastating personal and public health consequences (3). In this Open Forum, we propose the development of the role of a nonspecialist 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. With this model, low-intensity behavioral health services are delivered by nonspecialist providers (NSPs) under appropriate supervision, thereby expanding access and freeing up limited expert resources (4). The need for such services is great in low- to middle-income countries (5), and such strategies are readily translatable to high-income countries. Notably, in England, task sharing is the linchpin of the National Health Service’s Improving Access to Psychological Therapies (IAPT) program, in which psychological well-being practitioners deliver structured, low-intensity behavioral interventions for depression and anxiety disorders within a stepped care model (6). These practitioners have the U.S. equivalent of college coursework and no prior specialized training in mental health.

Task sharing has great potential for deployment in the United States, given that one in five Americans live in a rural area (7) and that 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. Although these roles are also intended to expand access to care, the scope of such NSPs’ work typically centers on care coordination and navigation (8). NSPs do not routinely 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 for generalized anxiety disorder and found comparable patient outcomes for treatment provided by these lay counselors and by doctoral-level psychologists. Raue and colleagues (10) effectively embedded behavioral activation services for depression in senior centers, delivered by trained volunteers. Choi and colleagues (11) trained bachelor’s-level case managers at a social services agency to deliver tele–behavioral activation 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

Our group has been working with various educational, clinical, policy, and philanthropic partners across Washington State 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 of a licensed clinician. Our preliminary work has focused on primary care as a particularly relevant setting to improve behavioral health service provision, given that a majority of mental health conditions are recognized and treated in such settings (3). We modeled the BHSS in large part on the nonspecialist, low-intensity workforce from IAPT, who often work in integrated primary care.

In developing such a role, we sought input from a variety of behavioral health educators, clinicians, administrators, and policy makers who have potential interest in or concerns about such a position and the power to influence services. With this multilevel stakeholder approach, we aimed to solicit views from stakeholders with diverse expertise and backgrounds to develop solutions that are more relevant to and sustainable in 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 State. Of the 40 stakeholders who completed the survey, a majority worked in primary care (N=21, 53%) or community mental health (N=11, 28%) and were primarily clinicians, administrators, and educators (further details on methods and a table with participant characteristics are available in the online supplement). We first presented a sample job description of 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 to adult patients with mild-to-moderate symptoms of common mental health conditions, such as anxiety or depression. Interventions including brief behavioral activation are currently under development. The BHSS would also maintain and track an active registry of patients, use measurement-based care strategies to refer patients in need of high-intensity psychotherapy, engage in case management, and facilitate community referrals. BHSS training, which we are currently developing, was conceived of as specialized coursework and supervised practicum training alongside a relevant bachelor’s degree program. Respondents were asked to rate the feasibility of the BHSS role, acceptability to their team, and acceptability to patients by using a scale ranging from 1, not at all, to 5, completely. 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” (mean±SD=3.33±1.40) and between “somewhat” and “mostly acceptable” to the team (3.80±1.31) and to patients (3.83±1.15). Two-way between-group analysis of variance was used to compare 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 statistically significant interaction effects. However, regardless of provider occupation (behavioral health or primary care clinician), we found a main effect of setting, such that respondents in primary care rated the BHSS as less acceptable to patients (F=7.34, df=1 and 36, p=0.01). This is an intriguing finding that warrants further exploration; our primary care respondents may have been unfamiliar or inexperienced 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

Open-ended responses were coded for content by the first and second authors by 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 concern with the BHSS’s scope of practice was the ability of a bachelor’s-level worker to properly assess and treat mental health conditions 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. Last, stakeholders posed concerns about the adequacy of BHSS training to prepare these professionals 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 in the online supplement.)

Challenges and Implications

Our findings suggest that task-sharing approaches may be promising, but development and implementation of roles such as the BHSS will need to explicitly engage various stakeholders to ensure success. Compared with respondents in other settings, respondents in primary care settings, a target stakeholder group, perceived this position as less acceptable to patients regardless of profession. Importantly, we did not survey patients or individuals with lived experience, whose perceptions represent a crucial question for future research. The next steps in developing this role must rigorously delineate the BHSS’s scope of practice, competencies, and training requirements in order 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, on which our BHSS role is based. The success of IAPT has been driven largely by three components to support the nonspecialist, low-intensity workforce: training in and delivery of evidence-based psychological therapies, routine outcome monitoring, and regular supervision focused on patient outcomes (6). Many of these components are present in existing U.S. integrated primary care models (e.g., collaborative care [3]) and may provide a foundation for integrating such a role. Future development must attend to best practices for supervision, for triaging cases most appropriate for BHSS service, and for referral processes to higher steps of care.

Conclusions from our preliminary assessment were limited by voluntary survey response, recruitment specific to Washington State, and a small sample relative to our wide range of recruitment efforts. Our survey, representing an initial litmus test, used brief measures to obtain perspectives of potential stakeholders. Only one item inquired about feasibility, although respondents had the opportunity to elaborate in open-ended comments. Indeed, multiple respondents commented on billing and reimbursement, which are crucial in developing such a role. Feasibility and acceptability will likely vary by setting on the basis of 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.

Conclusions

Training lay counselors, such as our proposed bachelor’s-level BHSS, to deliver low-intensity psychological treatments for common mental health conditions 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 must include patients as a critical stakeholder group.