Table 1 Summary of categories derived from qualitative analysis of Behavioral Health Provider narratives

System

Working in the VA context: Specific characteristics of the VA system and Veterans that impacted the practice and professional behaviors of BHPs

· VA's EMR and Clinical Reminders system facilitated mental health screening but could be time consuming, thereby impacting ability to provide brief treatment

· BHPs at geographically distant and diverse CBOCs experienced logistical and travel-related barriers when referring Veterans for specialty mental health services at VAMCs

· Patient complexity impacted BHPs ability to provide focused, brief treatment

System and Clinic

Managing access to care on the front line: BHPs perceived role in increasing Veterans’ access to behavioral health care by providing brief assessment and intervention in primary care

· Attending to Veterans in crisis impacted BHPs ability to maintain an open access schedule to provide population level care

· BHPs exerted considerable effort in developing local workarounds to address wait times for specialty mental health services

Assessing a care trajectory : In lieu of established clinical practice guidelines, BHPs engaged in a process of predicting the appropriate course of behavioral health care a Veteran would receive during, or in conjunction with, CCC

· BHPs typically immediately referred to specialty mental health care those Veterans with clear patient safety risks, significant functional limitations, or patients with stated strong preferences for specialty mental health care

· Among patients without clear indicators of need for specialty care referral, BHPs relied on clinical judgment and indicators that patient-specific goals were achieved to suggest the end of treatment

Developing a local integrated model: The combination of local resource limitations and BHP’s knowledge and skills regarding population-based care models directed how CCC was enacted at each clinic

· The Hybrid Clinic combined elements of a traditional specialty mental health and minimally implemented population based model due to both limited local resources and limited BHP knowledge and skills regarding CCC

· The Brief Treatment Clinic provided brief treatment limited to common mental health issues and was a product of moderate local resources and low to moderate BHP knowledge and skills regarding CCC

· The aspirational Truly Integrated Primary Care Clinic provided brief treatment for both mental health and health psychology issues among clinics with high local resources and high levels of BHP knowledge and skills regarding CCC

Clinic and Provider

Working in collaborative teams: BHPs felt most satisfied with their jobs when they believed that they were contributing to a high functioning collaborative team to improve outcomes for Veterans in primary care

· Communication with primary care staff was the single most important factor in developing working collaborations, with BHPs adopting a highly flexible stance in finding ways to communicate with medical providers

· PCPs openness and understanding of CCC facilitated collaboration, especially when willing to co-manage patients

Being a behavioral health generalist: BHPs described a "generalist" role because although they treated Veterans with mental health diagnoses, they addressed a wide variety of presenting concerns with an emphasis on improving functional outcomes

· BHP's generalist role was comprised largely of providing brief assessment, treatment, and outcome monitoring directed by a patient-centered stance

· Initial and on-going assessment of Veterans emphasized functional domains through clinical interview and patient report over assessment of psychiatric symptoms with formal assessment tools

· BHPs reported using a wide range of interventions, but forms of cognitive and behavioral therapies were most commonly cited

· BHPs believed that having significant clinical experience prior to entering the CCC environment was critical in developing accurate case conceptualization and diagnostic skills