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PCBH Clinical Pathways

The Department of Defense (DOD) has developed Clinical Pathways for use by Primary Care Medical Homes (PCMHs) to support increased use of Behavioral Health Consultants (BHCs). Clinicians should consider including a BHC in the care of any primary care patient who is not at optimal mental health, has one or more modifiable adverse health behaviors, or has challenges related to a chronic medical illness.

PCBH Clinical Pathways are designed to assist DoD PCMHs in providing improved collaborative care for a number of specific mental health and chronic medical conditions frequently seen in PCMH settings. Each pathway contains guidelines for the provision of coordinated, collaborative care between the primary care manager (PCM) and the BHC, while making use of PCMH staff and data management tools available through the electronic medical record (EMR).

Each pathway contains detailed guidance on strategies for:

PCBH Clinical Pathways 1. Identifying patients for pathway inclusion (screening, provider visit, PCMH Data Pulls)  2. Connecting the patient with the BHC  3. Intervening with evidence based approaches from the BHC (medication BHC intervention, care facilitation)  4. Monitoring outcomes of care (e.g. standard assessment tools, symptoms, labs)

PCBH Clinical Pathways address the following mental health and chronic medical conditions:













Connecting the patient to the BHC

  • When a patient is identified during the PCM visit, the PCM nurse or technician may arrange for a same-day appointment with the BHC, and/or schedule the patient for a future BHC appointment
  • Alternatively, patients may be identified through an AHLTA and/or Care Point data pull; a team member may contact the patient via telephone or secure messaging to offer a visit with the BHC
  • If a patient declines to see the BHC, a team member (PCM, nurse, technician) may ask the BHC to offer (and document in the medical record) recommendations for care based on available medical record data

Alcohol Use

Last Updated: July 11, 2023
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