week 2 discussion Psy 699

1. Integrated Primary Care at Salud Family Health Centers

Establishing an Integrated Care Practice in a Community Health Center

Contents

2. Components of Integrated Care

3. Clinical Variables

4. System Variables

5. Putting It All Together: Salud's Integrated Care Model

6. Services Offered

7. Patient Contacts

8. Financing

9. Conclusion

10. References

Integrated Primary Care at Salud Family Health Centers

By: Andrea Auxier Salud Family Health Centers, Fort Lupton, Colorado; University of Colorado, Denver Tillman Farley Salud Family Health Centers, Fort Lupton, Colorado; University of Colorado, Denver Katrin Seifert Salud Family Health Centers, Fort Lupton, Colorado;

Biographical Information for Authors: Andrea Auxier received her PhD in clinical psychology from the University of Massachusetts, Boston. She is Director of Integrated Services and Clinical Training at Salud Family Health Centers and a senior clinical instructor at the University of Colorado, Denver, Department of Family Medicine. Her areas of professional interest include integrated primary care research and practice, especially as they apply to immigrant populations with trauma histories.

Tillman Farley received his MD from the University of Colorado, School of Medicine, and completed his residency at the University of Rochester. He is board certified in Family Medicine. He is the Medical Services Director at Salud Family Health Centers and an associate professor at the University of Colorado, Denver, Department of Family Medicine. His areas of professional interest include integrated primary care and health disparities, particularly as they apply to immigrant populations.

Katrin Seifert received her PsyD in clinical psychology from the University of Denver. She is the Associate Psychology Training Director at Salud Family Health Centers. Her areas of professional interest include practice and clinical training in integrated primary care as well as complex trauma.

Acknowledgement:

The health care system in the United States is facing a paradox of declining outcomes and rapidly increasing costs (Rabin et al., 2009). In 2008, mental health conditions accounted for $72 billion in expenditures, making them the third most costly group of conditions (along with cancer), exceeded only by heart conditions and trauma-related disorders or conditions (Agency for Healthcare Research & Quality, 2008). In an effort to improve the provision of health care, many experts and key organizations are lending support to the movement for integration of behavioral health into primary care settings (Blount, 2003; Institute of Medicine, 2001, 2006; Pincus, 2003; U.S. Department of Health and Human Services, 2006; World Health Organization & World Organization of Family Doctors, 2008). Numerous studies have demonstrated that integrated services can improve access to mental health care, enhance quality of care, decrease health care costs, improve overall health, decrease the burden on primary care providers (PCPs), and improve PCPs' ability to address patients' mental health needs (Butler et al., 2008; Chiles, Lambert, & Hatch, 1999; O'Donohue, Cummings, & Ferguson, 2003; World Health Organization & World Organization of Family Doctors, 2008).

The decision to organize integration efforts at our community health center was, in part, based on well-known data regarding primary care patients. For example, psychiatric conditions are common in patients who are seen in primary care practices (Cwikel, Zilber, Feinson, & Lerner, 2008) and many patients who have mental health needs seek treatment for these concerns through their PCP (Goldman, Rye, & Sirovatka, 2000; Petterson et al., 2008; Wang et al., 2006). Additionally, the majority of medical problems seen in primary care practices are undeniably linked with behaviors, and it has been estimated that 40% of premature deaths in the United States are attributable to health behavior factors (McGinnis & Foege, 1993; Mokdad, Marks, Stoup, & Gerberding, 2004). Behavioral health integration is an integral part of a solution to the complex health care needs of these patients.

Although the terms mental health and behavioral health are sometimes used interchangeably, we conceptualize them as different constructs. The term behavioral health applies to patients whose primary diagnosis is somatic and whose psychological symptoms, if present, are subclinical and related to the primary diagnosis. The term mental health applies when the focus of treatment is psychiatric; there may or may not be an accompanying medical condition. In this article, however, the term behavioral health will subsume both categories.

Founded in 1970, Salud Family Health Centers (Salud) is a federally qualified community health center consisting of nine health care clinics covering eight counties in North Central Colorado. Salud is an important part of the health care safety net, providing population-based, fully integrated medical, dental, and behavioral health services regardless of finances, insurance coverage, or ability to pay–Salud focuses on the needs of the medically indigent, uninsured, and underinsured populations. The national distribution of payer sources for federally qualified health centers is 35% Medicaid and 25% Medicare or private insurance, with 40% of patients falling into the uninsured category (Adashi, Geiger, & Fine, 2010). By comparison, 30% of Salud's patients have Medicaid, 14% have Medicare or private insurance, and 56% are uninsured, leaving Salud to support the health care of a greater proportion of patients with no funding source.

Salud employs 540 individuals, including 60 medical providers, 14 dentists, 9 dental hygienists, and 15 behavioral health providers (BHPs). In 2010, Salud served more than 80,000 patients with approximately 300,000 visits, making it the second largest health care provider in a six-state region. The most common visit types include well-child checks, prenatal visits, diabetes, and hypertension. About 3,000 of Salud's patients are migrant and seasonal farmworkers, and 65% of patients are Latino, many of whom speak Spanish as their primary or only language.

In response to the extraordinary number of patients with behavioral health needs, immigration-related stressors, and limited financial means, Salud's move toward integration began in 1997 under the leadership of its medical director, who had received training in an integrated model. The need for integration was apparent, but it soon became clear that incorporating a team of behavioral health providers into an established medical setting was a more complex proposition than it initially seemed. The program started with one BHP in one clinic. PCPs who found value in the service vocalized their desire for an expanded behavioral health presence. As Salud hired more BHPs, it became necessary to build an infrastructure designed to support integration at an organizational level. We set out to create a service-delivery model and develop job descriptions, billing and coding practices, policies, protocols, standard operating procedures, and data tracking mechanisms. In order to accomplish these tasks, the focus shifted toward securing administrative support from key members of the organization. Over time, with the collective mission to provide quality health care—and with the implicit acceptance that behavioral health needs must be addressed as part of its delivery—efforts materialized into an integrated care program. In an effort to measure the effectiveness of our program, we recently have begun to work toward an information-technology-driven, outcome-based approach, whereby we collaborate with university partners to measure and benchmark our data through regional and national comparative effectiveness research networks.

In 2010, we developed a mission statement that reads: “To deliver stratified, integrated, patient-centered, population-based services utilizing a diversified team of behavioral health professionals who function as PCPs, not ancillary staff, and who work shoulder-to-shoulder with the rest of the medical team in the same place, at the same time, with the same patients.” The implications of this mission include that BHPs have the ability to see a patient at any time, for any reason, without requiring a consult request from a PCP. This approach requires a paradigm shift from a superior/subordinate mentality to one of implicit understanding of the unique skills that all persons involved in the patient's care contribute to the patient's overall well-being. It gives BHPs the latitude to determine which patients they need to assess on a given day, and providers see each patient as “our patient” not “my patient.”

Components of Integrated Care

Over time, we have become familiar with many factors that influence the development, success, and sustainability of an integrated primary care practice. Below is a summary of what we have found to be essential components of integration, broken down into those variables related to clinical decisions and interventions and those related to system-level considerations.

Clinical Variables

One prospect of integration is the provision of real time interventions. As soon as a need is identified, a BHP is present to provide services. PCPs who might otherwise shy away from uncovering mental health issues are less likely to do so if they know they can call upon a BHP to address identified concerns. Just as some primary care visits are considered urgent, so are some behavioral health visits. Having a BHP available when these situations arise can mean that a patient actually receives care as opposed to falling through the cracks in a health care system in which timely access is often a problem (Pincus, 2003; Strosahl, 1998).

In any large primary care system, behavioral health services must be population-based and not disease specific. A population-based approach focuses on the needs of a defined community with an emphasis on evidence-based practice and effective outcomes as well as primary prevention (Ibrahim, Savitz, Carey, & Wagner, 2001). In order to meet the needs of an entire community, BHPs must be capable of assessing and addressing multiple presenting concerns of varying levels of severity. BHPs in primary care cannot be limited to utilizing interventions that target only a specific disease category, primarily because comorbidity is the rule rather than the exception (Klinkman, 2009). In response to this reality, treatment approaches must be geared toward the whole person, not the illness.

BHPs who work in a primary care setting need to have strong generalist training, with sufficient understanding of normal and abnormal developmental processes across the life span, and to be flexible. The nature of the setting requires BHPs to make instant connections with patients, to formulate quick assessments, and to communicate the relevant findings to the PCP immediately. From a logistical standpoint, BHPs must be willing to swap the comfort and controllability of a therapy room for the unpredictable and unsettling reality of seeing patients in the medical rooms, often with interruptions.

System Variables

Colocation is crucial for successful integrated primary care (Blount, 2003). For integration to be truly seamless, the BHP must be in the flow of the action occurring in the clinic and must be visible to patients and PCPs alike. Although 80% of patients with unexplained symptoms and psychosocial distress accept management by PCPs, only 10% will attend a psychosocial referral (Smith et al., 2003). Not having to travel to another facility or even a different area of the clinic to access behavioral health may help reduce the stigma associated with mental illness and thus increase the number of patients receiving services (Pincus, 2003; Strosahl, 1998).

Although the concept of a multidisciplinary team is not a new one, redefining the team approach to include PCPs and BHPs requires a willingness to accept a paradigm shift of shared responsibility for a patient. A reevaluation of the systems that maintain power differentials among providers at the expense of quality, comprehensive care is necessary, along with efforts to dismantle and rebuild those systems.

Using a shared medical record, in which PCPs and BHPs have access to each other's notes, can help support the paradigm shift. The Health Insurance Portability and Accountability Act (HIPAA) regulations clearly delineate the differences between psychotherapy notes and progress notes(Gillman, 2004) and it is the latter kind of note that we suggest BHPs use in integrated settings. Psychotherapy notes are granted special protection under HIPAA due to the likelihood that they contain particularly sensitive information, are considered the personal notes of the treating therapist, and must be kept separate from the medical record. Progress notes are limited to medication information, modality and frequency of treatment, and a summary of diagnosis, functional status, symptoms, prognosis, and progress to date. Unlike psychotherapy notes, these notes are part of the medical record.

An ideal integrated care system does not operate within a vacuum, but rather allows for coordination of care within and across health care settings. In order to achieve this goal, a service-delivery model must be defined. What patients will be referred out, to whom, and for what reasons? Similarly, what kinds of patients will be accepted from other agencies and for what reasons? In theory, patients with higher mental health needs are better-suited to receive treatment in specialized agencies such as community mental health centers (CMHCs). In practice, however, there are significant barriers to implementing this transition. These obstacles include patients' reluctance to go to a CMHC because of the stigma associated with mental illness, a previous negative experience, long waiting lists, limited transportation options, or failure to meet diagnostic or funding requirements. Moreover, some patients prefer having all health care needs met in one place even when the aforementioned barriers do not apply. Therefore, we argue that an integrated practice that emphasizes primary-care-level behavioral interventions must remain flexible enough to accommodate all patients, regardless of problem severity.

Putting It All Together: Salud's Integrated Care Model

There is tremendous variability in the kinds of behavioral health issues seen in our setting, and symptom severity in each patient is fluid rather than static. We argue that behavioral health is not a bimodal phenomenon determined by the presence or absence of health; rather, it exists along a continuum. We conceptualize this continuum as having four levels of severity; at any given time fewer patients fall into the more severe levels and more patients fall into the less severe levels. Conceptualizing our population in this fashion allows us to better allocate resources based on the distribution of patients.

Patients presenting at Level 1 are in a state of acute need, requiring immediate referral to emergency departments and/or inpatient care. Examples include imminent suicidal depression, acute psychosis, and manic crisis. Because of the seriousness and visible nature of their symptoms, these patients are more likely to present to an emergency room or to be detained by police than they are to present to PCP offices. Level 2 consists of patients who have severe and persistent mental illness. Although these patients can benefit from psychiatric follow-up in a specialized mental health setting, the need is not immediate. Many can be monitored in primary care settings when stable, especially when psychiatry consultation is available. Patients at Level 3 present with problems that are chronic and of lower severity. They are common in primary care practice and include somatization disorders, nonpsychotic depression, acute stress disorder, and anxiety disorders where functional impairment is present but the symptoms are not completely debilitating. Level 3 patients frequently seek care in primary care settings, but PCPs are not always equipped with the expertise and knowledge to address their needs (Goldman et al., 2000). Level 4 includes patients with temporary mental health and psychosocial problems, including concerns such as marital difficulties, parenting problems, bereavement, employment problems, financial stress, and so forth. Left untreated, Level 4 problems can progress, potentially leading to risky behaviors, unhealthy life choices, and worsening of chronic diseases. Last, at any given time, there are patients who do not qualify for assignment to a particular level but who nevertheless might benefit from educational and preventive interventions.

In an attempt to provide adequate services to the 80,000 patients in the Salud system in alignment with our mission, we grappled with how BHPs were going to spend their time. We wanted to maximize their ability to see a high number of patients while still maintaining a high standard of care. Based on the four-level model of severity just described, BHPs spend 30% of their time providing more traditional therapy services to Levels 1 and 2, the highest-needs patients, who make up a significant portion, though not the majority of our population. BHPs spend 70% of their time providing various integrated services to Levels 3 and 4 and the unassigned, whose symptoms are less severe or temporarily nonexistent but who make up a much larger portion of our patient population.

After careful consideration, we decided that the best service-delivery model for patients in our geographical area is a stepped-care approach. The initial point of contact with a BHP typically occurs during a medical visit. Of patients requiring follow-up care, some are referred out but many continue with onsite therapy services. Therapy appointments are scheduled separately from medical appointments and consist of a limited number of visits, which can be extended if necessary by department approval. Historically, referrals to CMHCs more commonly were driven by payer source (i.e., Medicaid) than by patient need, creating a dual standard of care whereby some but not all patients received integrated care. Recently, we have determined that this standard is unacceptable and have made modifications to our care model to allow primarily clinical determinants to inform referral decisions. These clinical determinants include when a patient a) needs services for a longer period than we can provide; b) requires specialty services such as vocational rehabilitation, day treatment, wraparound services, and so forth; and c) qualifies as severely and persistently mentally ill or severely emotionally disturbed.

Services Offered

BHPs at Salud offer a variety of evidence-based services, including screenings, consultations, psychotherapy, and psychological assessment. A report by the Institute of Medicine (2001) defined evidence-based practice in psychology as the “integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 147). Research suggests that sensitivity and flexibility in administering therapeutic interventions produces better outcomes than rigid application of manuals or principles (Castonguay, Boswell, Constantino, Goldfried, & Hill, 2010; Henry, Schacht, Strupp, Butler, & Binder, 1993; Huppert et al., 2001). Because clinicians with sound clinical judgment will be more effective when operating from treatment perspectives that are most consistent with their views (Benish, Imel, & Wampold, 2008; Luborsky et al., 1999; Wampold, Minami, Baskin, & Tierney, 2002), we encourage BHPs to utilize all of their clinical knowledge from an evidenced-based perspective, rather than limiting themselves to a narrow range of interventions.

As opposed to evidence-based practice, empirically validated treatments (EVTs) are specific treatments for defined groups of individuals who have particular disorders. We argue that, although there is certainly a place for EVTs in any setting, applying such interventions in a primary care setting is particularly challenging for several reasons. First, much of the work being done in primary care is brief, which can limit the ability of the BHP to provide the intervention in full-form. Second, the population in primary care is extremely heterogeneous. Primary care patients cover the entire life span, present with multiple comorbidities, and do not usually request treatment for a well-defined condition, thus making it extremely difficult to choose the appropriate EVT. Supporting evidence-based practice over EVT makes sense in an integrated primary care setting because it is research-based without being prescriptive. BHPs therefore have latitude to make difficult treatment decisions and to derive interventions from the research even when the available research does not fully address the population's clinical needs (American Psychological Association, 2005). The following section describes Salud's service-delivery model in greater detail.

Screening

The purpose of screening is to identify patients who may be at risk for behavioral health difficulties by detecting previously unrecognized symptoms. Establishing a smooth screening process that does not interrupt the workflow can be challenging. We found that there needs to be clear communication to all employees, including PCPs and support staff, of the expectation that the practice is integrated. Additionally, BHPs and PCPs must have open dialogues about workflow. Last, priority groups need to be established so that BHPs can decide which patients to screen first when it is not possible to screen every patient.

Screenings are intended to be structured and brief (5–10 minutes) and targeted at specific priority groups—for Salud, this includes pregnant patients, postpartum patients, new patients, and children. We designed our screenings to encompass conditions specified by the United States Preventive Task Force as well as those concerns commonly seen in our setting. For patients older than 16, we developed an eight-item prescreen the Screen for Life Stressors, containing Yes/No responses about symptoms of depression; anxiety; posttraumatic stress disorder (PTSD); tobacco, alcohol, and substance use; and safety in the current living environment. The questionnaire is a combination of items from the Primary Care Evaluation of Mental Disorders (PRIME-MD), a questionnaire designed to assist general practitioners in the diagnosis of minor psychiatric disorders (Spitzer et al., 1994); the Primary Care PTSD Screen, a 4-question screen for symptoms of PTSD (Prins et al., 2003); questions based on Screening Brief Intervention Referral to Treatment guidelines for substance use and abuse (Colorado Clinical Guidelines Collaborative, 2008); and questions we developed specifically for this purpose.

We typically administer the prescreen face-to-face to help establish a relationship with the patient and to provide the opportunity for immediate brief interventions. Positive prescreens trigger a more intensive screening with standardized instruments assessing depression, anxiety, alcohol abuse, substance abuse, and PTSD. Depending on the patient's literacy level, these questionnaires can be filled out by the patient or administered interview-style by the BHP. We currently use the following instruments: Patient Health Questionnaire - 9 from the PRIME-MD or Edinburgh Postnatal Depression Scale (Cox, Holden, & Sagovsky, 1987); Generalized Anxiety Disorder (7-item) Scale from the PRIME-MD; PTSD Checklist (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996); Drug Abuse Screening Test (Skinner, 1982); and Alcohol Use Disorders Identification Test (Saunders, Aasland, Babor, de la Fuente, & Grant, 1993). Children are screened using the Parents' Evaluation of Developmental Status (for ages 0–8; Glascoe, 2010) and the Pediatric Symptom Checklist (for ages 9–16; Jellinek, Murphy, & Burns, 1986).

Because false positives are inherent in any screening procedure, formal diagnoses are not based solely on the results of a screening. Screenings that turn into diagnostic assessments are documented separately. When patients screen positive, the BHP or PCP offers follow-up services, either onsite, if possible, or through an outside agency (Pignone et al., 2002).

Consultation

Although BHPs can see any patient at any time for any reason, PCPs will often ask a BHP to evaluate and/or treat a patient during a medical visit. Reasons for requesting consultation include but are not limited to psychoeducation or therapeutic interventions for a specific behavioral health concern, health behavior change interventions, and assessment for diagnostic impressions, suicide risk, and capacity to make health care decisions. PCPs also frequently request crisis management services and/or referral for onsite or offsite services.

Psychotherapy

Full time BHPs have the ability to schedule up to three patients per day for individual psychotherapy appointments. Patients seen in this capacity complete disclosure and informed-consent forms and work with their BHP to develop a treatment plan. The typical session length is 50 minutes, although some clinicians prefer shorter intervals. Scheduling is done either by the BHP directly or through a centralized call center. Given the nature of a primary care setting, termination for no-shows/cancellations is determined on a case-by-case basis. BHPs need to be flexible when scheduling patients as many will not fall into the traditional once per week model.

Psychological testing

Psychological testing for adults is provided through Salud's psychology training program, which includes six postdoctoral fellows and several graduate-level practicum trainees. A licensed psychologist on staff provides supervision to any trainee completing testing. Reasons for testing include diagnostic clarification to inform medication management and psychotherapy, to rule out a learning disorder, to evaluate memory (e.g., normal aging vs. abnormal memory functioning; specify type of memory impairment), to determine need for intensive neuropsychological testing, and to assess intellectual functioning.

Patient Contacts

Using the reporting functions from our electronic health record and billing system, we were able to capture the number of patients seen in 2010. Table 1 shows the results of the prescreenings described above. Table 2 reflects the other behavioral health services rendered in 2010. The behavioral health team provided approximately 3000 screenings, 5500 consults, and 1800 individual therapy visits in 2010. Prescreening Results 2010 Other Behavioral Health Contacts, 2010

Financing

In a health care system characterized by barriers to integrated practice, especially financial ones, it is surprising that so many practices are making the move toward integration. We think integration is essential for comprehensive patient care consistent with a patient-centered philosophy, but cost-effectiveness is hard to measure. Higher levels of integration are more costly due to the staffing and administrative demands associated with more complex service delivery. Integration reduces costs for the entire health care system to a point (Chiles et al., 1999; Katon et al., 2006; Mumford, Schlesinger, Glass, Patrick, & Cuerdon, 1984), but primary care practices may not share directly in the cost savings from effectiveness. From a strict revenue-producing standpoint, Salud's integrated care team does not generate enough revenue to support its staffing. Nevertheless, the cost of funding integration must be compared to the cost of not funding integration.

As a federally qualified health center, Salud receives 20% of its $50 million/year operating budget from the federal government, 20% from state grants, and 60% from direct patient fees. Enhanced Medicaid reimbursements for medical visits help offset the costs of providing services to such a large percentage of uninsured individuals. Federally qualified health centers cannot receive any additional reimbursement from Medicaid for behavioral health services during medical visits because the Medicaid rate is a flat per-patient rate regardless of the number or type of services rendered during a particular visit. It is possible to bill Medicaid for services outside a regular medical visit by contracting with the behavioral health organizations that administer Medicaid. However, for the time being, we have chosen not to pursue this funding stream because the current regulations are not favorable to integrated systems. Salud generates a small amount of revenue through direct patient fees for therapy and assessment services rendered to non-Medicaid patients. Third-party payers are not billed because of paneling and credentialing requirements for providers, same-day billing restrictions, administrative burden, and internal costs associated with electronic claims. We thus decided to pursue other funding for our integrated program.

The behavioral health program remains viable through two ongoing Health Resources Services Administration (HRSA) grants, included in Salud's annual HRSA funding for operating as a federally qualified health center. The psychology training program is sustained through a combination of grants, including a large one dedicated specifically to postdoctoral training. Finally, many of our BHPs are employed through collaborative arrangements with our CMHC partners or similar agencies. In these cases, Salud does not pay the BHP's salary; the outside agencies benefit by increasing their Medicaid penetration rate and/or by demonstrating that they are reaching more patients.

Conclusion

Primary care patients who have behavioral health problems are very expensive to the system (Petterson et al., 2008), and behavioral health affects overall health whether we address it or not. This article has been an attempt to describe how these basic considerations have driven the evolution of an integrated care practice in a large community health center system that serves vulnerable populations across North Central Colorado. With the caveat that there is no one correct way to achieve integrated care, we have presented the various considerations and decisions made along the way in hopes that others who are considering or are in the process of establishing an integrated care practice might learn from our experiences. We have detailed our thoughts about the necessary and sufficient components of successful integration, with special attention to the role of evidence-based practice. We have also argued that paradigm shifts from a medically focused mentality to a patient-centered mentality must be made at the organizational level.

For practices considering integrating behavioral health into primary care, is value measured by dollars brought into the organization, provider satisfaction, patient satisfaction, decreased utilization, fewer emergency room visits, or improvement in physical markers? If the only way to generate revenue through behavioral health services is by moving from an integrated to a colocated model, is this approach consistent with the organizational mission? Do the administrative burdens and costs of billing fee-for-service outweigh the benefits? Do they impact the organization's ability to offer high-volume quality services? These are merely a few of the questions that will arise when setting up an integrated care practice.

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Submitted: March 21, 2011 Revised: June 9, 2011 Accepted: June 15, 2011

This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user. Source: Professional Psychology: Research and Practice. Vol. 42. (5), Oct, 2011 pp. 391-397) Accession Number: 2011-19049-001 Digital Object Identifier: 10.1037/a0024982

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Integrating behavioral health services into a university health center: Patient and provider satisfaction.

Authors:

Funderburk, Jennifer S.. VA Center for Integrated Healthcare, Syracuse, NY, US, [email protected] Fielder, Robyn L.. Department of Psychology, Syracuse University, NY, US DeMartini, Kelly S.. Department of Psychology, Syracuse University, NY, US Flynn, Cheryl A.. Center for Health and Wellbeing, University of Vermont, VT, US

Address:

Funderburk, Jennifer S., Center for Integrated Healthcare, 800 Irving Avenue, Room 116C, Syracuse, NY, US, 13210, [email protected]

Source:

Families, Systems, & Health, Vol 30(2), Jun, 2012. pp. 130-140.

NLM Title Abbreviation:

Fam Syst Health

Publisher:

US : Educational Publishing Foundation

Other Journal Titles:

Family Systems Medicine

Other Publishers:

US : Brunner/Mazel Publishers, Inc. US : Families, Systems & Health, Inc. US : Family Process, Inc. US : Family Systems Medicine, Inc.

ISSN:

1091-7527 (Print) 1939-0602 (Electronic)

Language:

English

Keywords:

integrated behavioral health care, integrated primary care, mental health care, university health center, patient satisfaction, provider satisfaction

Abstract:

The goals of this study were to (a) describe an Integrated Behavioral Health Care (IBHC) program within a university health center and (b) assess provider and patient acceptability and satisfaction with the IBHC program, including behavioral health screening and clinical services of integrated behavioral health providers (BHPs). Fifteen providers (nine primary care providers and six nurses) and 79 patients (75% female, 65% Caucasian) completed program ratings in 2010. Providers completed an anonymous web-based questionnaire that assessed satisfaction with and acceptability of behavioral health screening and the IBHC program featuring integrated BHPs. Patients completed an anonymous web-based questionnaire that assessed program satisfaction and comfort with BHPs. Providers reported that behavioral health screening stimulated new conversations about behavioral health concerns, the BHPs provided clinically useful services, and patients benefited from the IBHC program. Patients reported satisfaction with behavioral health services and reported a willingness to meet again with BHPs. Providers and patients found the IBHC program beneficial to clinical care. Use of integrated BHPs can help university health centers support regular screening for mental and behavioral health issues. Care integration increases access to needed mental health treatment. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Document Type:

Journal Article

Subjects:

*Client Satisfaction; *Colleges; *Integrated Services; *Mental Health Services; *Primary Health Care

Medical Subject Headings (MeSH):

PsycINFO Classification:

Health & Mental Health Services (3370) Educational/Vocational Counseling & Student Services (3580)

Population:

Human Male Female

Location:

Age Group:

Adulthood (18 yrs & older)

Tests & Measures:

Alcohol Use Disorders Identification Test-Consumption Insomnia Severity Index Patient Satisfaction Questionnaire DOI: 10.1037/t16317-000 Provider Satisfaction Questionnaire DOI: 10.1037/t33723-000 Patient Health Questionnaire-9 DOI: 10.1037/t06165-000

Grant Sponsorship:

Sponsor: American College Health Association, US Other Details: United Healthcare Student Recourse Initiatives in College Mental and Behavioral Health grant Recipients: No recipient indicated

Methodology:

Empirical Study; Quantitative Study

Format Covered:

Electronic

Publication Type:

Journal; Peer Reviewed Journal

Publication History:

First Posted: May 21, 2012; Accepted: Mar 26, 2012; Revised: Jan 5, 2012; First Submitted: Sep 6, 2011

Release Date:

20120521

Correction Date:

20141020

Copyright:

American Psychological Association. 2012

Digital Object Identifier:

http://dx.doi.org.proxy-library.ashford.edu/10.1037/a0028378

PMID:

22612527

PsycARTICLES Identifier:

fsh-30-2-130

Accession Number:

2012-12934-001

Number of Citations in Source:

2. Our Integrated Behavioral Health Primary Care Program

Integrating Behavioral Health Services Into a University Health Center: Patient and Provider Satisfaction

Contents

1. Method

3. Procedure

4. Participants

5. Measures

6. Data Analytic Plan

7. Results

8. Provider Satisfaction

9. Patient Satisfaction

10. Discussion

11. Limitations

12. Conclusions

13. References

By: Jennifer S. Funderburk VA Center for Integrated Healthcare, Syracuse, New York; Department of Psychology, Syracuse University; Department of Psychiatry, University of Rochester; Robyn L. Fielder Department of Psychology, Syracuse University Kelly S. DeMartini Department of Psychology, Syracuse University; Department of Psychiatry, Yale University School of Medicine Cheryl A. Flynn Center for Health and Wellbeing, University of Vermont

Acknowledgement: The views expressed in this article are those of the authors and do not reflect the official policy of the Veterans' Affairs' department or other departments of the U.S. government. This material is based upon work supported by the American College Health Association United Healthcare Student Recourse Initiatives in College Mental and Behavioral Health grant.

Integrated behavioral health care (IBHC), in which primary care providers (PCPs) and behavioral health providers (BHPs) collaborate to provide coordinated care, is an emerging model of patient care. Over the past decade, research has identified IBHC as a clinically effective and cost-effective method for improving clinical outcomes within primary care settings (Blount et al., 2007; Bryan, Morrow, & Appolonio, 2009; Cigrang, Dobmeyer, Becknell, Roa-Navarrete, & Yerian, 2006; Goodie, Isler, Hunger, & Peterson, 2009). Typically, this research has focused on integrating mental and behavioral health care within adult primary care settings, such as private family medicine practices, academic medical center primary care clinics, and primary care services offered within the Veterans Health Administration or Federal Qualified Centers. However, there is little research examining IBHC in university health clinics.

University health centers share many features with standard primary care settings. For example, university health centers tend to offer ambulatory care and other basic medical services to a wide range of patients (Christmas, 1995). These clinics tend to be students' first option when seeking medical care in nonemergency situations. University health centers may coordinate referrals to off-campus specialists as necessary. Thus, in terms of services offered and general approach to care, university health centers and primary care clinics are quite similar. Nevertheless, compared with typical primary care practices, university health clinics are somewhat unique in that they generally serve a restricted age range (i.e., 18–24 years of age) for a limited period of time (i.e., academic semesters) that has predictable elevations in stress/illness as a result of the increased workload that occurs toward the end of the semester. In addition, a majority of students are developmentally just beginning to take care of themselves while continuing to maintain significant ties to their parents, sometimes limiting their financial resources and ability to travel off campus for additional specialty services. Another caveat is that most university health clinics provide services to students using a general health fee that is wrapped into their tuition, eliminating difficulties with insurance claims (Mills, Gold, & Curran, 1996).

The lack of research examining the integration of mental health services into university health clinics is surprising because of the alarming rates of mental health issues on college campuses (American College Health Association [ACHA], 2010a; Mowbray et al., 2006) and the fact that most college students with clinically significant psychological distress do not receive mental health treatment (Rosenthal & Wilson, 2008). For instance, only 15% of students with moderately severe to severe depression or past-month suicidal ideation received any mental health care (Garlow et al., 2008). A recent ACHA white paper (2010b) argued for the integration of campus medical and counseling clinics, given the great potential for integrated care to increase treatment access, enhance clinical outcomes, and improve patient satisfaction.

Similar to other primary care settings, IBHC in university health centers can provide an avenue to address many of the obstacles to treatment access for college students. For instance, a higher proportion of students use campus health clinics than campus mental health clinics (79% vs. 10% in one recent study; Eisenberg, Golberstein & Gollust, 2007), and many students feel more comfortable seeing PCPs than therapists (ACHA, 2010b). Moreover, because many mental health issues cause physical symptoms, many students seek evaluation at health clinics first (ACHA, 2010b). The few studies examining IBHC within university health settings have reported numerous benefits, including increased accessibility of mental/behavioral health care, increased referral follow-through, and higher quality patient care (Masters, Stillman, Browning & Davis, 2005; Tucker, Sloan, Vance, & Brownson, 2008; Westheimer & Steinley-Bumgarner, 2008).

Besides clinical outcomes, another vital component in the process of evaluating a new program of service, and whether others should consider implementing such a program within college health, is obtaining feedback from the “consumers” involved in the program (Gallo et al., 2004; Reiss-Brennan, Briot, Daumit, & Ford, 2006; Runyan, Fonseca, & Hunter, 2003). For IBHC, primary consumers include PCPs and patients. A lack of acceptability and/or satisfaction among the PCPs with the various components of the IBHC program would ultimately sabotage the program because of (a) the pivotal role PCPs have within IBHC (i.e., referring patients to BHPs) and (b) the focus all IBHC programs have on increasing collaboration between PCPs and BHPs. Similarly, it is extremely important that the patients are satisfied with clinical services provided by a new program, otherwise patients may not remain engaged or comply with treatment recommendations, which could compromise treatment success. Patient satisfaction is an important outcome measure that identifies problems with health care (Sitzia & Wood, 1997) and is associated with treatment adherence and provider/program selection (Fitzpatrick, 1991).

Preliminary studies have begun to examine patient and provider opinions about IBHC within the college health setting. Tucker et al. (2008) examined an international student's experience of the Integrated Health Program at the University of Texas at Austin using a case study design and found his overall experience to be positive. Westheimer and Steinley-Bumgarner (2008) examined provider behaviors, opinions, and experiences during the integration process of IBHC within the same university and found PCPs ascribed a high level of value to the collaborative effort integrated BHPs could provide in helping with a diverse number of conditions. However, neither of these studies provided a sound understanding of patient or provider satisfaction with the IBHC program and its various components.

Two studies have examined the use of screening questionnaires designed to increase discussion of mental and behavioral health issues during university health center visits. In a pilot study, Cowan and Morewitz (1995) found that use of a screening questionnaire prompted discussion of psychosocial concerns that may not have otherwise come up. However, this study did not use a validated screening measure or examine provider or patient satisfaction with use of the screening measure. Alschuler, Hoodin, and Byrd (2008) examined provider and patient satisfaction with the integration of a screening questionnaire for behavioral health issues in a college health center. They found that patients who were randomly assigned to fill out the screening questionnaire reported it helped them discuss concerns with their providers and they would like its use to continue in the future. The providers reported that they also found the screening questionnaire helpful and would be happy to collaborate with integrated BHPs on-site. Although this study provided preliminary evidence toward patient and provider satisfaction with IBHC, it focused on integrating the screening measure and it did not involve the actual integration of BHPs, which is a fundamental component of IBHC programs.

In sum, IBHC is an emerging approach to health care that can increase access to mental and behavioral health care while reducing the burden on PCPs and specialty mental health centers. University health centers are an opportune setting in which to implement the IBHC model. However, despite the importance of ensuring provider and patient acceptability and satisfaction when implementing new clinical programs, little research has examined these factors with respect to IBHC in university health centers. Therefore, the purpose of this study was to collect feedback from PCPs and patients to assess the acceptability and satisfaction with all aspects of integrating an IBHC program at Syracuse University, which included the implementation of a behavioral health screening questionnaire as well as the integration of several BHPs. It was expected that PCPs and patients would indicate a high level of satisfaction and acceptability with all aspects of the program.

Method

Our Integrated Behavioral Health Primary Care Program

We developed our IBHC program by adapting a common model of integrated health care called the Primary Mental Health Care model described by Strosahl (1998). Syracuse University Health Services (SUHS), which serves approximately 9,038 patients per year, collaborated with the Syracuse University doctoral program in clinical psychology to integrate three to five advanced doctoral students as BHPs per academic year (for additional information regarding this type of collaborative effort, see Masters et al., 2005). The BHPs provided clinical services 20–35 hours per week as part of an Advanced Practicum course. Working under the supervision of a licensed psychologist and an onsite medical provider, the BHPs saw approximately 152 students per semester for various presenting problems (e.g., insomnia, depressive symptoms). BHPs acted as consultants to the PCPs, seeing patients for brief sessions (i.e., one to three sessions lasting approximately 15–30 minutes each; Strosahl, 1998). The average number of sessions per patient was 1.43 (SD = 0.83, range 1–5) for the Spring, 2010 semester and 1.61 (SD = 0.97, range 1–6) for the Fall, 2010 semester.

In this IBHC model, the PCP ultimately maintains responsibility for patient management throughout the course of treatment. Nonetheless, the PCPs can utilize the BHPs in several ways: (a) to conduct further assessment of behavioral health issues; (b) to provide brief interventions for patients reporting mild-moderate mental health symptomatology, behavioral health issues (e.g., sleep problems), or symptoms associated with chronic disease; (c) to triage patients reporting more severe mental health symptoms to more specialized services; and (d) to provide crisis assessment. BHPs maintain an open access schedule, keeping at least 15 minutes free between half-hour appointments to allow PCPs to walk patients down for same-day visits. Assessments and patient progress notes are shared among the team via verbal and/or written communications within the electronic medical record. Therefore, this IBHC model is strikingly different from the colocation of specialty mental health services within a university health clinic, which often continues to maintain separate medical records, provide more intensive treatment (i.e., a higher number of sessions, longer sessions), see patients for more severe symptomatology, and is often unable to accommodate same-day noncrisis appointments.

To help facilitate referrals and to follow national recommendations regarding screening for depression and at-risk alcohol use among young adults (American Academy of Pediatrics, 2001; Nimalasuriya, Compton, Guillory & Prevention Practice Committee of the American College of Preventive Medicine, 2009; U.S. Preventive Services Task Force, 2009), we implemented a screening tool as part of our IBHC program. Specifically, all students seen by PCPs for any reason were screened for the following symptoms: (a) depression and suicidal ideation with the Patient Health Questionnaire-9 (PHQ-9; Spitzer, Kroenke & Williams, 1999); (b) at-risk alcohol use with the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C; Saunders, Aasland, Babor, de la Fuente & Grant, 1993); (c) sleep problems with two items from the Insomnia Severity Index (ISI; Bastien, Valliéres & Morin, 2002); and (d) tobacco use with three items to assess smoking habits. Students were given the screening tool by nurses as they waited for the medical providers following the nurse obtaining vital signs. The screening tool clearly describes the purpose of the questionnaire, the confidentiality of the information, and that the items ask about symptoms unrelated to any current acute illness (e.g., cold, flu).

Procedure

This study was approved by the Syracuse University Institutional Review Board. To obtain the provider satisfaction data, we sent three recruitment emails, one week apart, to all PCPs and nurses working at the university health clinic over a 4-week period during the Spring semester of 2010. The email provided a brief description of the study and linked the provider to an anonymous web-based questionnaire. After providing informed consent, participants provided information on whether they were a PCP (MD, NP) or nurse and filled out a provider satisfaction survey. Providers were not given any compensation for participation.

To obtain the patient satisfaction data, we obtained a list of all students who had at least one session with an integrated BHP during the Spring (i.e., January 15 to May 15, 2010) or Fall semester in 2010 (i.e., August 15 to December 15, 2010) by pulling a list of all patients who were included in the electronic medical record as having the specific encounter code used only by the BHPs to identify behavioral health visits. Then, email addresses were located using the publicly available student email address directory. In addition, basic demographics of all IBHC patients were obtained from a tracking database maintained by the BHPs. We sent three recruitment emails, approximately 3–4 weeks apart, to each identified patient at the end of each semester to their university-provided email address to ask them to participate in an anonymous web-based patient satisfaction survey. After completing informed consent, participants completed the questionnaire. As an incentive, participants were offered a chance to win one of 12 $25 gift cards to an online retailer.

Participants

All PCPs (n = 9, two physician and seven nurse practitioners) and nurses (n = 10) working in the university health clinic were eligible to complete the provider satisfaction questionnaire. Fifteen participants (nine PCPs and six nurses) did so, yielding a 79% (100% for PCPs and 60% for nurses) response rate. Because of the small number of providers at the clinic and the need to maintain their anonymity to encourage higher response rates and candid responding, we did not collect demographics from the participants.

A total of 303 (175 Spring semester, 128 Fall semester) unique IBHC patients were identified using the electronic medical record. A total of 27 (23 from Spring semester and four from Fall semester) had recruitment emails returned because of a nonexistent address error likely resulting from the fact that the student left the university for some reason (e.g., graduation). Of the remaining participants who were eligible (n = 276), 79 participants (32 Spring semester, 47 Fall semester) completed the patient satisfaction survey, resulting in an overall 29% response rate (n = 152, 21% for Spring semester and n = 124, 38% for Fall semester). The majority of the participants were female (n = 59, 75%), white (n = 51, 65%), and not Hispanic or Latino (n = 72, 91%). To understand the representativeness of our sample, Table 1 presents the demographics for those who participated in the study and for the total sample of patients (n = 303) who saw a BHP during the Spring and Fall semesters of 2010. Because the patient satisfaction survey was anonymous, we were unable to test for demographic differences between responders and nonresponders. Demographics of Survey Participants and All IBHC Patients

Measures

Provider satisfaction questionnaire

Participants rated their level of agreement with 18 statements about the acceptability and usefulness of each component of the IBHC program on a Likert scale that ranged from strongly disagree (1) to neutral (3) to strongly agree (5). The 18 items (see Table 2) were generated by the first and fourth author and focused on each element of the IBHC program implemented. For several items, the participant could choose “not applicable” because of the lack of relevance of the statement to nurses versus PCPs and vice versa. Cronbach's alpha for the scale was .80. Provider Ratings of IBHC Acceptability and Satisfaction

Patient satisfaction questionnaire

Participants answered five demographic questions (i.e., age, sex, race, ethnicity, and class in school), and three yes/no questions (i.e., whether they remembered filling out the screening measure, whether their PCP discussed one of the topics on the screening measure with them, and whether they met with an integrated BHP). Those who remembered filling out the screening measure and meeting with the integrated BHP completed an additional six statements (see Table 3) which asked participants to rate their level of satisfaction, comfort, or willingness on a Likert scale that ranged from (1) extremely unsatisfied/uncomfortable/unwilling to (3) neutral to (5) extremely satisfied/comfortable/willing on a variety of elements associated with the IBHC program. These items were generated by the first and fourth author. For those participants who completed the Likert portion of the questionnaire, Cronbach's alpha for those six items was .75. Patient Ratings of IBHC Satisfaction and Acceptability

Data Analytic Plan

Because of the descriptive nature of the objectives of this study, our data analytic plan focused primarily on examining distributions and calculating the frequencies, modes, means, and standard deviations of individual survey items.

Results

Provider Satisfaction

As shown in Table 2, both PCPs and nurses reported a high level of support for regular implementation of the screening measure across all four screening domains and reported that patients were comfortable answering the questions on the screening measure. Providers strongly agreed that the screening measure helped stimulate discussion on topics that would not have come up during the visit otherwise. There was a greater level of variability yielding average (i.e., means ranging from 2.5–3.0) and modal responses within the neutral range for the two items assessing whether the screening measure took too much time away from other clinical duties and was difficult to score and interpret.

PCPs and nurses considered the integrated BHPs a part of the primary care team and felt the IBHC program helped patients receive treatment more quickly. PCPs perceived that patients benefited from seeing the BHPs. Both PCPs and nurses would recommend this service to other colleagues within college health and would like IBHC to continue in the future.

Patient Satisfaction

Results of the satisfaction assessment indicate that a majority of the sample of patients were satisfied with their overall care at SUHS (see Table 3). A number of students did not remember filling out the screening questionnaire (n = 13, 17%) or meeting with a BHP (n = 26, 33%), so they did not rate their satisfaction or report on those elements of the IBHC program in Table 3. Of those who remembered completing the questionnaire, the majority reported that they talked to the medical provider about a topic on the screening measure (n = 57, 86%). Of those who remembered meeting with a BHP, the majority reported that they felt that the BHP helped them with the topic that they discussed (n = 38, 73%).

As shown in Table 3, overall participants reported a general level of comfort filling out the screening measure, were satisfied with the service provided by the integrated BHP, and would be willing to seek help from the BHP again if necessary. Although the average response was within a level of agreement (M = 3.6), there was a greater level of variability when it came to having the service within the university health setting as compared with a specialty mental health clinic on campus, with a mode of 3.0 indicating a neutral response.

Discussion

As expected, this study found that PCPs, nurses, and patients reported positive experiences with the two major components of the IBHC program: the implementation of a behavioral health screening assessment and the integration of BHPs into the university health center. The results provide further evidence that this model of care can be used on college campuses with success in terms of provider and patient satisfaction.

Similar to past research (Alschuler et al., 2008; Cowan & Morewitz, 1995), this study found that providers indicated that having brief screening items to assess sleep problems, depression, alcohol use, and tobacco use was helpful to their clinical practice. In addition, the assessment items reportedly helped stimulate discussions with patients about topics that would not have otherwise been discussed. Alschuler and colleagues (2008)found a similar result such that those providers whose patients were randomly assigned to fill out a mental health questionnaire discussed those issues with their patients more than those providers whose patients were not assigned to fill out the questionnaire. Not only did providers perceive the screening questionnaire as having a high level of utility within their clinical practice, but the patients also reportedly were comfortable with filling out the questionnaire during their appointments.

Our findings highlight the importance of selecting an appropriate screening questionnaire that can be completed and scored quickly. A common concern among providers when discussing the implementation of regular screening for mental health issues is the time involved in integrating the screen within the clinical appointment (Thomas, Waxmonsky, McGinnis, & Barry, 2006). Within this study, a majority of the providers and nurses reported responses within the neutral range when asked about whether the screening measure took time away from other clinical duties. This is not surprising as the questionnaire obviously does add time to the patient visit, as noted in prior research (Alschuler et al., 2008). The typical patient appointment at this clinic is only 15 minutes, so allocating 1–2 minutes to review the screen with the patient would reduce the time left to focus on the patient's presenting complaint. The fact that providers endorsed a modal response within the neutral range suggests that the screening can be incorporated without a significant negative impact. One study on behavioral health screening found that using a measure that includes areas specific to college students (e.g., academic stress, risky sexual behavior) improved detection of students struggling with adjustment issues compared to a more general screening measure (Alschuler, Hoodin, & Byrd, 2009). However, the benefit of added sensitivity from a college-specific screening measure may not offset the cost of greater administration and scoring time. As completion time increases, the rate of compliance with screening may decrease.

Another element that was identified within this study was the importance of not only designing the screening questionnaire to be easily comprehended by patients but to make sure it is easily scored and interpreted by providers. Most providers did not indicate difficulty scoring or interpreting the screen. However, anecdotally there were some problems with patients incorrectly self-scoring the PHQ-9; this may have led to some confusion or the need for providers to double-check or recalculate scores. The screening tool was later modified to discourage patients from totaling their own scores. To maximize screening coverage and efficiency, it is important to select brief, user-friendly, validated measures that are easy to score and interpret (Kirkcaldy & Tynes, 2006).

As university health centers work toward improving the identification and treatment of mental health issues as well as implementing recommended screening guidelines for depression, suicidal ideation, tobacco use, and alcohol misuse, this study suggests that an IBHC program may be one way to effectively accomplish this while maintaining provider and patient satisfaction. A previous study of behavioral health screening in university health centers found that screening increased discussion of behavioral health issues among patients and PCPs (Alschuler et al., 2008). However, PCPs reported that they did not have the time or the expertise to adequately address behavioral health issues with patients, but they were open to collaborating with BHPs. Likewise, our results suggest high willingness to refer patients to BHPs to improve attention to behavioral health issues. Thus, the IBHC program can help PCPs deal with positive screens by providing the integrated BHPs, who are trained to assess mental health issues and provide brief treatment on-site or facilitate a referral to a specialty mental health clinic.

Regarding the integrated BHPs component of the IBHC program, PCPs also strongly indicated that their patients benefited from the services provided by the BHPs. The providers felt that having the integrated BHPs helped patients receive treatment faster (compared to referring them to specialty mental health) and that the BHPs functioned as part of the overall care team. All of the providers reported that they would strongly recommend the IBHC to other colleagues working in college health. Taken together, these results indicate satisfaction among the medical providers, which is essential for the success of IBHC. Strong buy-in on the part of PCPs is needed to sustain the implementation of a new clinical program like IBHC, which requires procedural changes and additional effort (i.e., reviewing screens, referring patients to BHPs). Acceptability among the nurses is also important, as they were the ones responsible for offering patients the behavioral health screens in our IBHC program.

Similarly, satisfaction and acceptability were high among patients. Patients who were seen by BHPs reported feeling comfortable with the services received and were willing to be seen again should the service be needed in the future. These results corroborate Westheimer and Steinley-Bumgarner's (2008) finding that patients were accepting of referrals to BHPs. Patients may like the convenience of being seen quickly by BHPs in health centers. In the case of BHPs having open access schedules, patients can be seen immediately after their PCP visit, which eliminates the need for scheduling another appointment or returning to the health center; in contrast, specialty mental health centers may have long (e.g., up to 2–3 weeks) wait times (Mowbray et al., 2006). Also, health centers carry less stigma compared with specialty mental health settings. On average, the patients were comfortable seeking services at the university health center, but there was a greater level of variability suggesting some individual differences as to the comfort of seeking those services at a specialty mental health clinic.

Limitations

Interpretation of the findings should take into account the limitations of the study. First, although slightly higher than that found in other research using similar methodology (Shih & Fan, 2009), our response rate for the patient satisfaction survey was 29%. The response rate may be improved by contacting patients soon after their final IBHC visit instead of at the end of each semester, which is generally a busy time for students. Second, a significant proportion of the patients did not remember completing the screening questionnaire or meeting with a BHP. Patients may not have remembered completing the screening questionnaire because it was a brief (i.e., 2–3 minutes) activity and/or because their health center visit was up to four months before completing the satisfaction survey. It is possible that the students who did not remember meeting with a BHP had a more neutral experience than the students who remembered the program. Thus, the satisfaction ratings could be artificially elevated because of this lack of data. It is also possible, however, that these students did not remember the meeting with the BHP because they simply considered the components of the IBHC part of standard medical care. Authors have noted that primary care has become the “de facto mental health care system” (Kessler & Stafford, 2008, p. 9), so these students may have expected to discuss behavioral health problems during their visit and may not have perceived the BHP as different from a regular medical provider.

Third, patient data were obtained via anonymous self-report. Though this method of data collection was necessary because of the scope of this study, it prohibited collection of identifying information, including diagnostic information. The ability to compare satisfaction across diagnostic categories would have provided beneficial information, including whether patients with more severe diagnoses (e.g., major depressive disorder vs. adjustment disorder with depressed mood) had equally positive experiences with the program. In addition, the satisfaction ratings are limited to only those patients who were seen by an integrated BHP. Future research should compare satisfaction between patients seen within IBHC and patients seen within standard care (i.e., the PCP provides any treatment for behavioral health concerns or makes a referral to specialty mental health). Fourth, the provider and patient satisfaction measures were created specifically for this study. The limited range of response options (1–5) may contribute to restricted range/variability and ceiling effects. These limitations should not be ignored when considering the generalizability of the study.

Finally, the scope of this study did not allow us to obtain information on the clinical outcomes associated with the IBHC program. Although providers reported that patients benefitted from meeting with BHPs, their perceptions were based solely on behavioral observations of and/or self-report from patients, not on clinical outcome data. Future research should evaluate the clinical effectiveness of interventions delivered by integrated BHPs. From an IBHC perspective, other markers of success that are worthy of future study include increased access to mental/behavioral health services, improved identification of mental/behavioral health issues through screening, increased referral uptake (i.e., BHPs referral attendance compared to specialty mental health referral attendance) attributable to colocation and “warm hand-offs,” improved provider communication (e.g., between BHPs and PCPs), reduced burden on specialty mental health centers from patients with subthreshold or mild symptoms, and reduced burden on PCPs from repeat visits because of psychosocial issues.

Conclusions

In summary, providers and patients indicated a high level of satisfaction with this IBHC program. Accordingly, providers are likely to refer patients to BHPs, and patients are likely to engage in brief treatment within the IBHC program. Given the increasing demand on university primary care clinics to address the mental health needs of students, IBHC offers a promising method whereby to address this need. Particularly in light of data that indicate that most college students do not seek needed mental health treatment (Rosenthal & Wilson, 2008), the finding that IBHC patients would feel comfortable seeing a BHP again in the future is a positive step toward making mental health care more accessible to patients who need treatment.

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Submitted: September 6, 2011 Revised: January 5, 2012 Accepted: March 26, 2012

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Integrated health care and professional psychology: Is the setting right for you?

Authors:

Kelly, Jennifer F.. Independent Practice, Atlanta, GA, US, [email protected] Coons, Helen L.. Independent Practice, Philadelphia, PA, US

Address:

Kelly, Jennifer F., Atlanta Center for Behavioral Medicine, 2325 Log Cabin Drive, Ste. 105, Atlanta, GA, US, 30080, [email protected]

Source:

Professional Psychology: Research and Practice, Vol 43(6), Dec, 2012. Visions for the Future of Professional Psychology. pp. 586-595.

NLM Title Abbreviation:

Prof Psychol Res Pr

Publisher:

US : American Psychological Association

Other Journal Titles:

Professional Psychology

ISSN:

0735-7028 (Print) 1939-1323 (Electronic)

Language:

English

Keywords:

clinical health psychology, collaboration with physicians, integrated care, primary care, professional issues

Abstract:

Over the last decade, integrated care models have increased in both public and private sectors. This trend is especially apparent in primary care settings. Integrated care is designed to offer comprehensive and coordinated health services while addressing the economic realities and failures of the current health care system. Proposed integrated care models such as Accountable Care Organizations and Patient Centered Medical Homes include marked changes in health care delivery, financing, and reimbursement, which are designed to create a more cost-effective health system. This article provides an overview of integrated care to help practicing psychologists develop a better understanding of interprofessional health care and evaluate their interest in and readiness to provide professional services in health care. The advantages and challenges associated with integrated care will be provided. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Document Type:

Journal Article

Subjects:

*Collaboration; *Health Care Delivery; *Health Care Psychology; *Integrated Services; *Primary Health Care; Physicians

PsycINFO Classification:

Professional Psychological & Health Personnel Issues (3400)

Population:

Human

Format Covered:

Electronic

Publication Type:

Journal; Peer Reviewed Journal

Publication History:

Accepted: Jul 12, 2012; Revised: Jun 30, 2012; First Submitted: Dec 30, 2011

Release Date:

20121217

Copyright:

American Psychological Association. 2012

Digital Object Identifier:

PsycARTICLES Identifier:

pro-43-6-586

Accession Number:

2012-33696-001

Number of Citations in Source:

1. Differences Between Integrated Care and Multidisciplinary Care

Integrated Health Care and Professional Psychology: Is the Setting Right for You?

Contents

2. Differences Between Integrated Primary Care and Integrated Specialty Care

3. Accountable Care Organizations (ACOs) and PCMHs

4. Levels of Collaboration and Integration in Health Settings

5. Collaboration and Communication in Integrated Care Settings

6. Is Integrated Health Care a Good Professional Fit?

7. Culture and Language of Integrated Care Settings

8. Physical Environment in Integrated Care Settings

9. Do You Have the Clinical Skills to Work in Integrated Health Settings?

10. Making the Transition to Integrated Health Settings

11. Ethical Considerations

12. Summary

13. References

Differences Between Integrated Care and Multidisciplinary Care

By: Jennifer F. Kelly Independent Practice, Atlanta, Georgia; Helen L. Coons Independent Practice, Philadelphia, Pennsylvania

Biographical Information for Authors: Jennifer F. Kelly received her PhD in clinical psychology from Florida State University. Board Certified in Clinical Health Psychology, she is the director of the Atlanta Center for Behavioral Medicine in Atlanta, Georgia. Her primary area of professional interest in research and clinical practice is health psychology, with particular interest in pain management, health disparities, and mental health advocacy.

Helen L. Coons received her PhD from Temple University, Philadelphia. She is a board certified clinical health psychologist; President and Clinical Director of Women's Mental Health Associates—an independent practice that is colocated in women's primary care and obstetrics and gynecology; and a Clinical Associate Professor of Psychiatry, Drexel University College of Medicine. Her professional interests include women's health and mental health across the life span, behavioral health in primary care and specialty medical settings, continuing education, and advocacy.

Acknowledgement: Miguel Gallardo served as the action editor for this article.

Note: This article is one of 11 in this special section on Visions for the Future of Professional Psychology.—MCR

The use of integrated care models has dramatically increased over the last decade in both public and private health care sectors. This trend is especially apparent in primary care settings, such as family practice and internal medicine, pediatrics, and women's health (Trivedi & Grebla, 2011; Weisfeld, 2009), although integrated teams routinely provide care in specialty practices as well. This article will provide an overview of integrated care to help practicing psychologists develop a better understanding of interprofessional health care and evaluate their interest in and readiness to provide professional services in health care.

Integrated care is in marked contrast to the more traditional and often fragmented approach to patient care, where providers across the health disciplines operate on their own with consultative relationships. Under this traditional silo approach, patient care is often compromised and usually costly. According to the Department of Health and Human Services, since the late 1990s, United States' spending on health care increased at a faster rate of growth than the gross domestic product (GDP) and inflation (http://aspe.hhs.gov/health/costgrowth, 2005). In 2004, a survey of American CEOs indicated that employee health care costs was the most prominent concern (Business Roundtable, 2004), and that many employers responded by requiring employees to increase their contribution or provided different forms of coverage. These changes consequently reduced the amount of household income available. Efforts to reform the American health care delivery system reflect the importance of improving the quality of care and reducing high costs associated with providing fragmented services (Amadeo, 2011; Patient Centered Primary Care Collaborative [PCPCC], 2011).

In addition to financial costs, there is significant and important research on the human cost of the traditional health care approach. In the United States, it is estimated that over 130 million people have chronic health conditions and that 70% of all deaths are related to the chronic diseases (Loeppke, 2008). Effectively addressing the challenges of increasing rates and disability associated with chronic conditions requires greater emphasis on the full continuum of prevention and basic primary care (Pelletier, Herman, Metz, & Nelson, 2009).

The Institute of Medicine (2001) defines integrated care as health care that is comprehensive, continuous, coordinated, and culturally competent and consumer centered.

The organization, delivery, and management of services are brought together for the purpose of improving diagnosis, patient care, rehabilitation, and health promotion (Gröne & Garcia-Barbero, 2002). It is assumed that when services are integrated, there will be improved quality and efficiency of services. Kodner and Spreeuwenberg (2002) view the integration model as a step in the process of the health care delivery becoming more complete and comprehensive.

Integrated care models are routinely used in a host of public and private health delivery systems. The Department of Veterans Affairs and the Department of Defense are national leaders in integrated care consultation and treatment models, team communication, outcomes evaluation, and training (Trivedi & Grebla, 2011). In addition, Federally Qualified Health Centers in urban and rural communities and the Indian Health System have increasingly implemented integrated care models. Academic health centers routinely employ psychologists in primary and specialty care departments (Association of Psychologists in Academic Health Centers, 2011). Kaiser Permanente and the Mayo Clinic are the two largest health care companies in the private sector that embrace the integrated model to patient care (Lawrence, 2005). Other managed care organizations as well as private insurance companies such as Blue Cross Blue Shield and Aetna appear to be actively positioning their network providers to embrace this approach as well (Collaborative Family Healthcare Association, 2011; Patient Centered Primary Care Collaborative, 2011).

There is a growing body of knowledge that supports the clinical efficacy of integrative care practices. Research has evaluated physical and mental health outcomes, as well as health care utilization (Pelletier, Herman, Metz, & Nelson, 2009). The Patient Centered Primary Care Collaborative (2011) provides an excellent summary of the clinical and financial benefits of integrating behavioral health in Patient Centered Medical Homes (PCMHs; see www.pcpcc.net).

There are a broad range of benefits associated with integrating behavioral health care in primary care and specialty settings related to decreasing the complexity of care while improving both access and satisfaction. First, mental health issues are routinely treated in primary care and specialty settings (Bray, Frank, McDaniel, & Heldring, 2004; James & Folen, 2005). In addition, in our busy world with competing responsibilities, “one stop” care is quite convenient for many women and men (Coons, Morgenstern, Hoffman, Striepe, & Buch, 2004). One coordinated and efficient visit, for example, can readily include a routine check-up and HbA1C blood test for diabetes, a follow-up visit with the nutritionist to address appropriate food choices, and a brief session with a psychologist to identify strategies to improve adherence to medications and exercise.

Individuals across ethnic groups and class are often reluctant to seek mental health treatment (Gary, 2005). However, when a patient is introduced to a psychologist as a “member of the team” by a provider with whom they already have a trusting relationship, they may be more receptive to a consultation in this setting compared with making an appointment with an unknown mental health provider at an unfamiliar location. When mental health, substance abuse and health psychology services are delivered in an integrated care setting, patients can consequently avoid the stigma all too often associated with traditional outpatient mental health/psychiatric settings. Furthermore, integration of these services minimizes the lack of parity in insurance coverage for mental versus physical health services. When integrated health care teams are in the same community as patients, there are also often fewer geographic, cultural and linguistic barriers which further reduce health disparities in receiving mental health care (Coons et al., 2004).

Historically, health care settings have used multidisciplinary models in contrast to integrated care teams. Multidisciplinary health settings are characterized by individuals from diverse health professions (e.g., psychologists, physicians, nurses, and physical therapists) who all bring their own expertise to patient care, collaborate and communicate in a consultative model, but they may not necessarily work as a cohesive team. For example, multidisciplinary pain management programs often include pain management physicians such as anesthesiologists and physiatrists, physical therapists, and psychologists working at the same facility. All the disciplines are present but they do not necessarily integrate their care. In contrast, integrated care models are characterized by interprofessional team collaboration and communication in all aspects of patient care, coordination, outcome evaluation, health profession training, and so forth. For excellent discussions of core team competencies for primary and behavioral health integration, see Interprofessional Education Collaborative Expert Panel (2011) and Team-Based Competencies Conference Proceedings (2011), as well as the books listed in Table 1. Useful Books On Psychologists in Integrated Primary Care Settings

Differences Between Integrated Primary Care and Integrated Specialty Care

The difference between primary and specialty care relates to the focus, time, and the scope of services provided. Delivering all the available evidence-based services can be a challenge to the primary care provider, especially when the patients have severe, chronic, and persistent disorders. These patients will likely require consultation with the specialist (Wilson, 2008). Typically, in an environment where the provision of services are integrated, the primary care providers serve as the gatekeepers and are responsible for the allocation of resources and controlling costs (Grumbach & Bodenheimer, 2002). The more the care is commingled between primary care clinicians and the specialists, there will be more of a need to develop strategies to coordinate the care (Peikes, Chen, Schore, & Brown, 2009; Schappert & Rechtsteiner, 2008). An example is a study conducted by Liss et al. (2011). They concluded that the high use of specialty care could adversely affect the ability of primary care providers to effectively coordinate care. They noted that the future studies should look at care coordination interventions that would allow for appropriate referrals for specialty care without diminishing primary care providers' ability to manage overall patient care.

Accountable Care Organizations (ACOs) and PCMHs

ACOs and PCMHs are examples of current efforts to greatly expand the use of integrated care models in the U.S. health care delivery system. These settings are designed to provide comprehensive, patient-centered primary care services to patients, facilitate partnerships between patients and providers and involve families if appropriate, improve access to health care, ensure seamless coordination of clinical services with the continuum of care on site or through referrals assess health outcomes and care quality, and increase satisfaction and reduce costs (Allred, Wooten, & Kong, 2007; Berenson, Devers, & Burton, 2011; Homer, Klatka, & Romm, 2008; Schoen et al., 2007).

Underlying the development of PCMHs and ACOs is the belief that more effective health care could be delivered if the intervention is better organized and coordinated (Betbeze, 2010). According to the Centers for Medicare and Medicaid Services (2011), Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program (para 1).

ACO programs offered by Medicare include Medicare Shared Savings Program, a fee for service program, Advance Payment Initiative and the Pioneer ACO Model which is a population based payment initiative for experienced providers. ACO are currently written into Federal Health Care legislation (i.e., the Affordable Care Act) with entirely different financial and reimbursement structures compared with the traditional fee for service currently used by Medicare and Medicaid (Centers for Medicare and Medicaid Services, 2011). The entity or organization, not the individual providers, receives a capitation or a fee to take care of patients' health care needs and functions under a pay for performance model, which includes financial penalties and rewards. The premise is that the capitated system provides economic incentives to keep people healthy, as opposed to the fee-for-service model that needs to keep providing services for the ill to benefit economically.

There are some concerns about this model of health care, including the fee schedule, which provides lower reimbursement than for traditional care (Mathews, 2012). It is not clear how psychology as a profession will fit into this model. While private insurance companies are developing and piloting PCMHs, many do not include psychologists in their new health delivery models. There are possible promising components of ACOs for psychologists. For example, psychologists trained in integrated care are well trained to provide behavioral services and outcome evaluation in ACOs and PCMHs that have organizational structures and financial arrangements that emphasize prevention and maintenance care.

PCMHs and ACOs reflect a dramatic paradigm shift in health care delivery, financing, and reimbursement. While it is not known what the time frame will be for full implementation of these models, health care will increasingly be delivered in integrated care settings in the public and private sector. Psychologists will need the fund of knowledge and clinical competencies to provide a host of psychological services within an interprofessional team under a different reimbursement structure (Coons, 2011; Rozensky, 2011, 2012).

Levels of Collaboration and Integration in Health Settings

According to Doherty, McDaniel, and Baird (1996), while the goal of integrated care is ultimately to provide effective, seamless, coordinated care to patients across the life span and their families, levels of collaboration and integration in health settings vary greatly among psychologists and other health care providers. They describe five levels of collaboration and integration from none to off-site collaboration, colocation with collaboration but not integrated into the system, to fully integrated with systematic support. Most psychologists in independent or group practice have not been colocated or integrated into health settings, and often have little to no routine communication with referring health care providers (Ruddy, Borresen, & Gunn, 2008). Off-site collaboration with health providers involved in the care of mutual patients may include routine communication via phone, consult letter, and/or e-mail. More recently, psychologists in independent practice have started to colocate in medical settings in the private sector, although their services and roles are rarely fully integrated into the system (Coons & Gabis, 2010; Ruddy et al., 2008; Wender, Day, DiCaprio, & Un, 2011). Finally, psychologists may be fully integrated into the interprofessional team for patient assessment and treatment; communication during onsite patient encounters and through both electronic medical records (EMRs) and team meetings; program development and outcomes evaluation; health professional education; organizational leadership; and a host of other roles and responsibilities (James & Folen, 2005). Table 2 summarizes the common roles and responsibilities of psychologists in integrated health care settings and provides a comparison with traditional psychological services. Comparison of Integrated Behavioral Health Care (IBHC) and Traditional, Nonintegrated Psychological Services

Collaboration and Communication in Integrated Care Settings

The models of mental health and behavioral health care in integrated care settings are quite different than traditional psychotherapy in outpatient or inpatient settings (James & Folen, 2005). Differences are apparent in the way referrals are made; approaches to assessment; the choice, implementation, and length of treatment modalities; communication with other providers on the team; documentation options and details; and confidentiality among other issues (Hunter, Goodie, Oordt, & Dobmeyer, 2009). In integrated care settings, referrals and shared evaluation and treatment may take place with any member of the health care team. Referrals may come directly from physicians, nurse practitioners, physicians' assistants, nurses, nutritionists, genetic counselors, physical therapists, social workers, medical assistants, and so forth. In some integrated settings, all patients are routinely seen by the psychologist as part of a comprehensive physical and psychosocial assessment. In Departments of Surgery, psychologists may see all patients who are candidates for organ transplants or bariatric procedures. In Reproductive Endocrinology, psychologists may see any woman who wants to be an ovum (egg) donor. In other integrated practices, referrals are made on an “as needed” basis. Colleagues on the team may see the patient, couple or family with the psychologist, provide a brief introduction and do a “warm hand off” so that the psychologist continues the evaluation and immediately initiates treatment. For example, in integrated primary care, the physician or nurse practitioner, physician's assistant or another provider may introduce a patient with stress related symptoms (e.g., headaches, gastrointestinal problems, initial and middle insomnia), and the psychologist would most likely immediately provide an initial assessment and start treatment instead of waiting to schedule another appointment (Hunter et al., 2009; James & O'Donohue, 2009).

In many integrated care settings, patients are routinely screened with validated assessment tools such as the Patient Health Questionnaire (PHQ; Kroenke, Spitzer, & Williams, 2001) to assess for depression and anxiety disorders; alcohol screening tools such as the Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993), and numerous other evidenced-based, problem-specific measures to screen for behavioral health issues and track clinical outcomes (Hunter et al., 2009; James & O'Donohue, 2009).

While patients are routinely seen for the 45- to 50-min hour in traditional mental health settings, in integrated care settings, the treatment model is quite different. Often times, the teams use the 5A's model to care or the Screen, Brief Intervention, and Refer for Treatment (SBIRT) approach to care. The 5A's refer to assess, advise, agree, assist, and arrange. These models emphasize rapid assessment; brief, problem-focused psychological intervention; and referral as necessary (SAMHSA, 2012). Assessment and treatment sessions may last only 15 to 30 min for 3–5 sessions or just when the patient returns to follow-up with another member of the interprofessional team. In addition, other members of the team may conduct and document the follow-up.

It has been estimated that primary care physicians prescribe 60% of psychotropic medications (Mark, Levit, & Buck, 2009; McGrath & Sammons, 2011), and 43% of patients that psychologists treat take psychotropic medications (VandenBos & Williams, 2000). Psychologists are increasingly being consulted by primary care physicians on psychotropic medications, and it is believed that with increased training in psychopharmacology, psychologists will be of even greater value to the treatment team (McGrath, 2010; McGrath & Sammons, 2011).

Integrated care settings frequently involve increased use of technology such as EMRs to facilitate clear and effective communication with other members of the treatment team as well as outside collaborating providers. Psychologists in traditional practice settings have been less likely to implement EMRs in general or with interoperability for several reasons, including the high cost associated with setting up the system. In addition, psychologists have not been included in the Medicare incentive program that would provide benefits to implement EMRs. The APA Practice Organization has been addressing this issue because of its importance to the profession.

ACOs and PCMHs emphasized in health care reform focus on interprofessional teams, prevention of disease, as well as outcome evaluation, such as improvement in health status, screening and prevention rates, patient satisfaction ratings and reduced costs. Consequently, psychologists in integrated care settings will have the opportunity to take leadership roles in team development; design, implementation, and evaluation of evidenced-based prevention programs; as well as outcome evaluation and health systems research.

Is Integrated Health Care a Good Professional Fit?

If you are considering applying for a position as a psychologist in integrated care settings, engage in a careful self-assessment and self-study to make sure the professional setting is right for you and that you have the competencies to function effectively in a team-based health practice (Ruddy et al., 2008). Are you comfortable with differences in the culture of clinical medicine; differences in communication and confidentiality; shorter, problem-focused assessment and treatment; less control over when and where you see patients, couples. and families, and so forth? How will you feel if you are the only psychologist on site? Are you ready to work under a different payment structure? Do you have the clinical competencies necessary to work as a clinical health psychologist in integrated primary care or specialty health settings (Belar & Deardorff, 2009; Frank, McDaniel, Bray, & Heldring, 2004)?

Culture and Language of Integrated Care Settings

It is important to ask yourself whether you will enjoy a patient care setting that is problem focused with concrete, goal-driven recommendations. For example, when patients come with stress-related headaches and neck pain, assessment and treatment focuses on reducing symptoms (Arena & Blanchard, 2005; James & Folen, 2005; James & O'Donohue, 2009). Specific, action-oriented recommendations are made, such as medications, cognitive–behavioral techniques, relaxation or mindfulness training, and/or a referral to physical therapy, and so forth. Discussion may or may not focus on underlying factors contributing to stress, and the patient may be referred to an outside mental health provider for ongoing treatment of complex psychosocial issues such as trauma, domestic violence, and ongoing caregiving challenges. Furthermore, treatment and communication are problem focused to rapidly reduce symptoms and improve well-being.

The language of health settings is also remarkably different from mental health settings (Ruddy & Schroeder, 2004). Providers across disciplines typically speak to each other using technical words in a succinct manner with abbreviations and rapid communication to the team and outside providers via the phone, e-mail, EMR, or dictations that are quickly disseminated (the same day or within a few days). Examples include using abbreviations such as “PRN” for “as-needed” and “po” for “by mouth.” In addition, communication with patients tends to be rather problem specific with concrete recommendations.

Physical Environment in Integrated Care Settings

It is important to ask whether you have a strong need to have control over your professional environment when working with patients. In addition, are you comfortable working with children and adults across the life span with acute, chronic, life threatening, and end stage physical conditions, including infectious diseases?

In integrated health settings, you may see patients in examination rooms instead of consultation rooms. You may have minimal input into how the office is set up or decorated, how treatments rooms will look, and so forth. Furthermore, health settings are fast paced and may be fairly noisy, depending on the practice location. Inpatient integrated care settings typically have bright lights, with routine messages on overhead speakers. In pediatric settings, you may hear children crying. These fast-paced environments are exciting for many, but can be stressful for other psychologists.

Do You Have the Clinical Skills to Work in Integrated Health Settings?

Working effectively in integrated care settings requires the fund of knowledge and clinical competencies necessary to provide high-quality, evidenced-based assessment, treatment, and prevention interventions within an interprofessional team (McDaniel, Hargrove, Belar, Schroeder, & Freeman, 2004). Core training in clinical health psychology; supervised experience in the specific integrated site; highly developed communication skills to work as part of an interactive team with providers from varied disciplines; health and mental health outcomes assessment, and so forth are, at a minimum, essential as core training (Belar, 2011). It is also essential for psychologists to have the cultural competence necessary to work in both public and private integrated care settings. While core competencies in clinical health psychology are available, many professional organizations developed competencies for interprofessional practice (Interprofessional Education Collaborative, 2011) and workforce development in primary and behavioral health care integration (American Psychological Association, 2011; SAMHSA-HRSA Center for Integrated Health Solutions, 2011).

An increasing number of doctoral candidates participate in practicum and internships in integrated health settings. The Council of Clinical Health Psychology Training Programs (CCHPTP) has been providing opportunities to Directors of Clinical Training Programs to learn about curriculum in both clinical health psychology and integrated primary care. In contrast, psychologists in independent practice have fewer formal options to develop the competencies to provide services in integrated settings. Some individuals will choose to apply to a one or two year fellowship in integrated settings such as family practice, obstetrics and gynecology, pediatrics, neuropsychology, oncology, and so forth. While attending day-long continuing education workshops on integrated care are excellent opportunities for introductory training, they do not provide sufficient depth or onsite training to effectively work in these settings (Linton & Coons, 2011). While the certificate programs on integrated primary care do not typically require clinical supervision in the practice settings, some psychologists have arranged to shadow colleagues on a limited or regular basis to learn about brief models of assessment and treatment, interprofessional team communication, and documentation, among other roles and responsibilities. Bray (2004) and Bray et al. (2004) provide comprehensive information on training opportunities in integrated and primary care. In addition, students can check the Association of Psychology Postdoctoral and Internship Centers (APPIC) directory to locate internships and postdoctoral programs with primary care experiences.

Making the Transition to Integrated Health Settings

Psychologists who are serious about making the transition to integrated settings are encouraged to engage in a formal self-assessment (Ruddy & Schroeder, 2004) and self-study over a year or two to obtain the necessary competencies to function effectively and contribute to interprofessional team care in this practice environment. If you are new to the health setting, you will likely need to establish competencies in both clinical health psychology and integrated primary or specialty care so that you can deliver evidenced-based services as part of an interprofessional team (Belar & Deardorff, 2009). Day-long continuing education workshops and ongoing certificate programs in integrated primary care are available in person and on line (Blount, 2011). In addition, contact colleagues in integrated health settings to discuss the possibility of shadowing them (Linton & Coons, 2011), and perhaps establishing a formal supervisory relationship for six months to a year.

If you are considering colocation or integrating your work in a health setting, establish a formal contract with the medical practice or parent organization (Coons & Gabis, 2010). Psychologists have established various agreements with providers and/or organizations. For example, some individuals become formal employees of the practice while others are independent contractors. In both of these employment models, integration is more likely with shared use of patient records, fee schedule and billing of services. A number of psychologists have been paid by foundation grants to provide services on site. Some early career psychologists are also employed by and serve on integrated care teams in Federally Qualified Health Centers and receive loan repayment (Graduate Psychology Education Program, 2012).

A small but growing number of psychologists are colocating in primary care settings but are self-employed or work for a mental health group (Coons, 2011; Ruddy et al., 2008; Wender et al., 2011). Irrespective of the employment or independent model, it is essential to clarify expectations of the providers and administrative staff, secure a contract, and collaboratively develop the agreement. At the very minimum, the contract should address the following: roles and responsibilities; the time frame spent on site; where patients will be seen; whether you will be able to chart in the practice's paper or EMR; who will do billing; access to computers, Internet and copy machines; property and malpractice insurance; details related to signage, public relations/advertising and proprietary issues; and the terms of the agreement (Coons & Gabis, 2010). Furthermore, if you are colocating but are either self-employed or employed by another organization (but not the medical practice), the contract should include formal lease arrangements and cost of the space, as well as all the issues listed above. In addition, the contract should include grievances processes and the quality assurance or evaluative requirements.

It is important to note that contractual and payment issues for psychologists working on integrated care teams in ACOs and PCMHs will differ from the arrangements for psychologists who are integrated or colocated in health settings with different fiscal structures. ACOs and PCMHs will have different financing and reimbursement structures because care for individuals is capitated. States also differ in regards to whether psychologists can partner with physicians to contractually establish interprofessional practices. For example, in Washington State, psychologists may establish practice entities with physician partners while in other states, this arrangement is illegal (Anton, 2012). Obtaining legal counsel from a health law attorney is essential if you are considering the colocation model or partnership in an integrated care practice.

Ethical Considerations

Integrated care is an exciting and rewarding environment to provide evidence-based professional services to diverse children and adults with complicated and interacting physical, mental health and psychosocial issues. Core competencies also include understanding the complex ethical issues which can emerge in health settings when caring for patients as part of an interprofessional team, including providers from a range of health disciplines. In addition to understanding the often complex ethical issues in integrated care settings, the psychologist must know how to address these matters in practice with other providers.

First and foremost, the psychologist must have knowledge and training in clinical health psychology and in integrated care. According to Principle 2.01 of the APA Ethics Code (American Psychological Association [APA], 2010), psychologists should only provide services “within the boundaries of their competence, based on education, training, supervised experience, consultation, study or personal experience” (p. 5). If they plan to work within this new area, they must obtain the necessary training, consultation, or supervised experience. As discussed earlier in this article, the psychologist should consider in depth continuing education and supervised experience in health care settings, especially in integrated primary and specialty care. The training should also include working with interprofessional teams and knowledge of psychopharmacology. Psychologists in integrated health care settings are routinely approached about various medications, in particular psychotropic medications. Unless the psychologist is practicing in a state with prescription privileges or within the Department of Defense areas that allow psychologists to prescribe, they should acknowledge the limits of their practice (Haas & DeGruy, 2004; Papas, Belar, & Rozensky, 2004; Tovian, 2006).

For our psychology workforce to be fully prepared to respond to changes in health care delivery, training in integrated primary care needs to be part of the core training in graduate programs, internships and during the postdoctoral fellowships. In addition, credentialing in the health setting will become increasing important as ACOs and PCMHs focus on providing evidenced based care with measurable outcomes. Psychologists should consequently seriously consider board certification (Kaslow, Graves, & Smith, 2012) in clinical health psychology (Tovian, Rozensky, & Sweet, 2003), and possibly in the future, in integrated primary care (Coons, 2011).

Another key ethical consideration in integrated care settings involves confidentiality. Providers across the health professions have different expectations and experiences around private health and mental health information (Ruddy & Schroeder, 2004). It is well known that there is not the same degree of confidentiality when working in a medical facility as one would have in an independent practice facility (Robinson & Baker, 2006). Numerous health care providers will have access to the health records, including physicians, nurses, and office staff. This is even more evident now with the use of EMRs. Furthermore, in some health systems, patient portals allow adults to access portions of their own health records (University of Pennsylvania Health System, 2011). Psychologists should strive to adhere to the APA Record Keeping Guidelines (American Psychological Association, 2007), which also addresses EMRs. According to the Guidelines, electronic records should be created and maintained in a way that will protect their security and confidentiality, as well as appropriate access, and they should be compliant with ethical and legal requirements. Psychologists need to become aware of the unique aspects of electronic record keeping in their particular integrated practice settings. The possible limits of confidentiality, methods of handling release of information requests, charting or electronic data storage practices, consultation, and team meeting practices should be presented to the patient at the outset of treatment, and ideally, should be presented in written and oral form.

Another ethical consideration relates to informed consent and patient autonomy. Specifically, there may be situations when a patient is required to be evaluated or treated by a psychologist before they receive certain forms of medical care, such as medications and certain procedures. For example, adults requesting bariatric surgery or the spinal cord stimulator device typically undergo a required psychological evaluation. The patient may be resistant to participate in such services but feels they are being forced to do so in order to receive the desired treatment (Taylor, 2001). Not only does this create an ethical dilemma for psychologists in integrated care settings, but it also can impact psychological intervention. According to Code 3.10 of the APA Code of Ethical Principles (American Psychological Association, 2010), it will be important for the clinician to obtain the informed consent of the patient using language that the patient can understand, and the consent needs to be appropriately documented.

The principle of beneficence requires that a psychological component is offered if it is deemed to be an appropriate and positive treatment for the patient, but when a patient feels coercion to treatment, it can violate patient autonomy. The psychologist working in the integrated care setting needs to work cooperatively and jointly with members of the treatment team to ensure autonomous consent. In addition, the psychologist should explore these possible concerns with patients.

Finally, termination of services may pose a challenge in integrated care settings. There may be times when termination of services is a decision that is influenced by factors outside of the psychologist's control, such as when the physician may decide to no longer treat the patient because of adherence related issues (e.g., repeated no shows for appointments). Code 10.10 of the APA code of Ethical Principles notes that “Except where precluded by the actions of clients/patients or third party payers, prior to termination psychologists provide pretermination counseling and suggests alternative service providers as appropriate” (American Psychological Association, 2010, p. 13). If this situation were to arise, psychologists in integrated care settings need to work with their interprofessional team to ensure that patients or families have appropriate referrals for mental health, substance abuse and/or health psychology services.

Summary

As health care reforms are implemented across both public and private health systems, and the integrated care model becomes more common for the delivery of mental health, substance abuse, and health psychology services, the future of traditional small and independent mental health practice becomes unclear (Coons, 2011). Some psychologists will no doubt continue to provide fee-for-service mental health care to some sectors of the population. In addition, psychologists with specialty practices (e.g., forensic psychology and executive coaching, etc.) are likely to continue to work in their private models, although others, such as some sports psychologists, may be employed by orthopedics/sports medicine settings (Hays, 2012).

Working in an integrated care setting can be an extremely satisfying professional and personal experience. In both primary care and specialty settings, psychologists typically provide consultation and treatment on an impressive range of physical, mental health, substance abuse, psychosocial, health behavior, and other complex issues. Often times, problems are interacting, and require careful differential diagnostic skills and flexible, multimodal treatment approaches. In addition, care may be focused on children, teens, and adults across the life span, and diverse families coping with a host of challenges. Evaluation, consultation, and brief treatment are also provided in the context of the interprofessional care team. The fast-paced work setting consequently allows for rapid intervention and is far less isolating than traditional psychology practices. Integrated settings are defined by the diverse range of health providers with the shared goals of evidenced based, collaborative and effective care.

With proposed Federal and State changes in the delivery, financing, and payment of health care, as well as private and public sector shifts to comprehensive care models, more children and adults will be receiving their care in integrated settings. A portion of psychologists are already well positioned in these practices as key members of effective and efficient interprofessional health care teams. We need, however, to greatly expand our workforce credentialed for work in primary care (Belar, 2011; Rozensky, 2011) and specialty settings, as well as our advocacy efforts at the Federal, State, local, and private insurance company level to ensure that we are included in the broad range of integrated medical practices for the decades to come. Although there may be challenges associated with the integrated care model to health care, it clearly has numerous advantages, such as providing a more coordinated and less fragmented approach to patient care. The data underscore that this practice approach is being embraced by public and private organizations. It is up to the individual practitioner to determine if it is the right approach and professional home for them.

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Submitted: December 30, 2011 Revised: June 30, 2012 Accepted: July 12, 2012

This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user. Source: Professional Psychology: Research and Practice. Vol. 43. (6), Dec, 2012 pp. 586-595) Accession Number: 2012-33696-001 Digital Object Identifier: 10.1037/a0030090

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An integrated primary care approach to help children B-HIP!

Authors:

London, Lorna H.. Family Medicine Residency Program, Rush-Copley Medical Center, Aurora, IL, US, [email protected] Watson, Erin C.. Adler School of Professional Psychology, Chicago, IL, US Berger, Jared. Adler School of Professional Psychology, Chicago, IL, US

Address:

London, Lorna H., Family Medicine Residency Program, Rush-Copley Medical Center, 2000 Ogden Avenue, Aurora, IL, US, 60504, [email protected]

Source:

Clinical Practice in Pediatric Psychology, Vol 1(2), Jun, 2013. pp. 196-200.

NLM Title Abbreviation:

Clin Pract Pediatr Psychol

Publisher:

US : Educational Publishing Foundation

ISSN:

2169-4826 (Print) 2169-4834 (Electronic)

Language:

English

Keywords:

family residency, integrated care, Pediatric Symptom Checklist, pediatrics, primary care, health care initiative, B-HIP, Be Happy & Involved & Positive

Abstract:

This article outlines a collaborative health care initiative entitled 'Be Happy, Involved, and Positive (B-HIP)'—a grant-funded program through the Illinois Children’s Healthcare Foundation. The B-HIP program was developed in January 2009 at the Rush-Copley Medical Center to address the previously undiagnosed mental health care needs for pediatric patients in a primary care setting. This article seeks to illustrate how, through collaborative care, efforts are being made to assess and address the mental health care needs for pediatric patients, and is furthermore an attempt to share information about implementing a pediatric mental health screening for best practices of the proposed prevention program, 'B-HIP.' The investigators applied the Pediatric Symptom Checklist (PSC) as a standard of care for identified pediatric patients. Along with anecdotal data of the B-HIP program, an outline of the theory, design, and implementation behind the program’s inception is presented. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

Document Type:

Journal Article

Subjects:

*Health Service Needs; *Integrated Services; *Pediatrics; *Primary Health Care; *Screening Tests; Best Practices; Checklist (Testing)

PsycINFO Classification:

Health & Mental Health Treatment & Prevention (3300)

Population:

Human

Tests & Measures:

Pediatric Symptom Checklist DOI: 10.1037/t01445-000

Format Covered:

Electronic

Publication Type:

Journal; Peer Reviewed Journal

Publication History:

Accepted: Mar 10, 2013; Revised: Mar 6, 2013; First Submitted: Feb 14, 2013

Release Date:

20130617

Correction Date:

20180517

Copyright:

American Psychological Association. 2013

Digital Object Identifier:

PsycARTICLES Identifier:

cpp-1-2-196

Accession Number:

2013-20877-007

Number of Citations in Source:

1. Theory: Why Must We Build This Home?

An Integrated Primary Care Approach to Help Children B-HIP!

Contents

2. Design: Our Blueprint

3. Development and Implementation: Building a Strong Foundation

4. Education for Our Providers

5. Screen Our Pediatric Patients Using Valid Measures

6. Enhance Multidisciplinary Collaboration and Communication

7. Take It to the Community!

8. Open House: Final Thoughts and Preliminary Results

9. References

Theory: Why Must We Build This Home?

By: Lorna H. London Family Medicine Residency Program, Rush-Copley Medical Center, Aurora, Illinois; Erin C. Watson Adler School of Professional Psychology, Chicago, IL Jared Berger Adler School of Professional Psychology, Chicago, IL

Acknowledgement:

Medical residents, who are training to become independent practicing physicians, will often have patients who present with both medical and psychological illnesses. It is, therefore, increasingly important that they understand ways to effectively assess and provide basic care for these patients, and know when it is appropriate to refer these patients on for more in-depth mental health services. Primary care providers, who are a central part of health care for the majority of patients, are often the first source of information and guidance for patients and their medical and personal needs (Kelleher, Campo, & Gardner, 2006; McDaniel, Campbell, & Seaburn, 1995).

More recently, studies have recommended the collaboration of mental health and primary care to provide comprehensive care of pediatric populations with mental disorders, given the unique competencies professionals from these disciplines can offer (American Academy of Pediatrics, 2009; Kelleher et al., 2006). Health professionals in the realm of family medicine and pediatrics are at the forefront of working with pediatric patients and their families. According to the literature, between 10% and 21% of children who present to primary care offices have mental health disorders that require treatment (Polaha, Dalton, & Allen, 2011). When available, mental health resources are often underused, and communication between providers is lacking (Wissow et al., 2008). Early diagnosis and multidisciplinary management of children who need both medical and psychological management can lead to greater benefits for children and their families (McDaniel et al., 1995).

The “Be Happy, Involved, and Positive (B-HIP)” program involves the practice of integrating medical and psychological services colocated in one setting to provide early identification and treatment of pediatric mental health problems. In light of the unique team composition of the Rush-Copley’s Family Medicine Residency Program and in concurrence with the Medical Center’s mission to enhance and share strategies and educational tools, the authors aim to outline the theory, design, development, and implementation of our B-HIP program.

The B-HIP project was generously funded by the Illinois Children’s Healthcare Foundation and conducted in a Family Medicine Center and Residency Program located in a community hospital in a suburban region. The National Committee for Quality Assurance (NCQA) recognizes the Family Medicine Center as a Patient-Centered Medical Home (PCMH). The PCMH emphasizes individual, organizational, and systemic change, in addition to encouraging providers to participate in advocacy and policy endeavors to optimize primary care collaboration (Holtrop & Jordan, 2010). The goals of PCMHs are to integrate patients as active participants, integrate services and providers, offer the best available evidence-based and appropriate interventions, and achieve a comfortable and convenient coordination of treatment for the patient.

The benefits of mental health and medical care integration have been well documented. In the integrated care model, “providers support improved detection of behavioral health problems through targeted or universal screening, focused assessment, brief interventions, and follow-up” (Rowan & Runyan, 2005, p. 11). Our tertiary integrated model positions all of our treatment team as collaborative providers including primary care physicians at the frontline, mental health providers supporting the primary care providers by bringing their expertise and support, and the patient and his or her community as collaborators in this population-based care approach (Rowan & Runyan, 2005).

In addition to providing ongoing support for medical professionals, pediatric psychologists are well poised for a role within the integrated care team (Clay & Stern, 2005). They have an existing capacity to assess and provide treatment for children with Attention-deficit/Hyperactivity-Disorder (ADHD), Anxiety, Depression, and Autism Spectrum Disorders. They are able to provide psycho-education material to colleagues and patients, and provide consultation to improve patients’ care. As educators, pediatric psychologists can promote effective exchange of information through collaboration and coprecepting to improve medical residents’ confidence in identifying and treating pediatric mental health concerns (American Academy of Pediatrics, 2009). As evidenced by the B-HIP project, pediatric psychologists can write grants and initiate program development to benefit pediatric care.

Design: Our Blueprint

In an effort to achieve the goals outlined by the NCQA, the B-HIP project promotes the effective identification, coordination, and treatment of pediatric mental health problems to help children achieve an optimal state of physical and emotional well-being. B-HIP has five principal objectives:

· Curricular enhancements for primary care clinicians (PCCs) and mental health specialists to broaden skill sets to better assess the psychological needs of children in the Family Medicine Center.

· Implementation of a universal mental health screening to promote early detection, prevention, and intervention among children and adolescents aged 5 to 17.

· The development and use of a tiered and individualized treatment based on the severity of symptoms and identified needs of patients, using evidence-based interventions and patient and family education.

· Utilization of case coordination to manage the needs of patients and families within the clinic and to facilitate linkage to community support services.

· Involvement of psychiatric consultation for patients diagnosed with disorders requiring psychotropic medication management and/or inpatient hospitalization.

Development and Implementation: Building a Strong Foundation

B-HIP focuses on training family medicine physicians in child development so that they may be better equipped to identify and assist with the treatment of childhood mental disorders. The B-HIP approach to enhancing the treatment of pediatric mental health involves the following four strategies.

Education for Our Providers

The first step in enhancing the treatment of childhood mental disorders is educating our primary care providers, particularly our family residents. Because family residents are often the first point of contact for our patients, they are provided with the opportunity to screen for mental health issues and facilitate a discussion about treatment goals.

Our pediatric psychologist contributed to educating our residents by offering weekly lectures to residents with topics including Communication with Families, ADHD School-Based Interventions, Human Development, Suicide Prevention, and Bipolar Disorder in Children.

Additionally, residents were required to attend the “B-HIP Connections Conference: Integrating Primary Care and Pediatric Mental Health,” where experts in mental and medical pediatric health presented on topics including the following: Adolescent Health Issues, ADHD Management in Primary Care, and Biopsychosocial Characteristics of Pediatric Obesity. PCCs and mental health specialists were required to attend the sessions, and secondary providers were strongly encouraged to also attend.

Lastly, our residents are observed by attending medical faculty, pediatric psychologist, and child psychiatrist via the precepting process. Immediate feedback is given by attending physicians’ pre-, during, and postvisit process. Most visits are also recorded via electronic video system and reviewed and evaluated by the pediatric psychologist. Finally, a consulting child psychiatrist is available for case discussion. To enhance the process for everyone, psychology practicum students are also given the opportunity to precept our family residents as they assess psychosocial symptoms and needs of our primary care pediatric patients.

Screen Our Pediatric Patients Using Valid Measures

B-HIP also strives to screen and detect mental health issues, so pediatric patients may receive appropriate intervention at an early stage. Initially, the Pediatric Symptom Checklist (PSC) is used to assess pediatric patients that present with psychosocial issues, whether observed by the health care provider or reported by the patient and/or caregiver. The PSC is a 35-item questionnaire designed to improve the recognition and treatment of psychosocial problems in children. Identified patients and caregivers were given the option to complete one of several versions of the form: the English or Spanish PSC parent form (PSC), the English or Spanish PSC-Youth Report (Y-PSC), or the pictorial version (available in both English and Spanish). The Y-PSC can be administered to adolescents ages 11 and up. For children and adolescent ages 6 through 16, a cutoff score of 28 or higher indicates psychological impairment. For children ages 4 and 5, the PSC cutoff score is 24 or higher. The PSC is an empirically supported measure with 95% statistical validity (Navon, Nelson, Pagano, & Murphy, 2001). Importantly, the PSC tool allows us to screen both child and caregiver, broadening our conceptualization of health and demonstrating the importance of collaborative care. Because the PSC is available in both Spanish and English, we are able to respond to the growing needs of the diversity of our patients.

Our patients have mixed psychosocial conditions, including ADHD, Anxiety Disorder, Depressive Disorder, Adjustment Disorder, Autism Spectrum Disorders, and V-Codes (e.g., relational or academic issues). Children who, based on their preliminary assessment, fall in the moderate to severe range of psychopathology are then assigned a mental health specialist. When necessary, the mental health specialist administers additional assessments and collaborates with the primary care providers to develop an appropriate treatment plan.

After the initial identification and assessment phase, treatments consist of empirically-based, individualized interventions, to try to address each child’s needs. Treatments include a combination of individual, group, and/or commonly address bullying, conflict resolution, time management, anger management, trauma/loss, living with ADHD, and self-esteem issues. There is no random assignment to treatment groups, nor is there withholding of treatment for any identified child. Fees associated with the operation of the program were initially covered by the grant. As the conclusion of the grant cycle has come to a close, psychology practicum students supervised by the pediatric psychologist continue services at no cost. Should the need arise for psychiatric care, the consulting child psychiatrist provides such services, and is reimbursed from the Family Medicine Residency budget.

Enhance Multidisciplinary Collaboration and Communication

A key component of this program is the multidisciplinary collaboration that is used to provide assessment, education, and intervention. Our primary care providers consist of 12 residents, four attending physicians, one pediatric psychologist, one consulting child psychiatrist, and four psychology practicum students. Throughout the last several years, we have also had two community licensed professional counselors and consulting community social workers. Because many of our patients and their families are Spanish-speaking, we have consistently had one or more Spanish-speaking mental health specialists.

Collaboration between providers is facilitated through the educational components just discussed, as well as on-site warm hand-offs, and electronically through the use of All-Scripts—an electronic program used by family physicians to enhance the delivery of integrative care. Warm hand-offs consist of a member of the clinical team being invited into the examination room where a plan is coordinated for further care. Having the resident introduce the mental health specialist in a collaborative manner further assists the patient. This approach helps the patient understand the supplemental services available, increases compliance, and decreases the myths that often accompany clinical therapy (McDaniel et al., 1995).

Importantly, we continue to find new ways to address the barrier of a high turnover rate in trainees. Because our residents reside with us for three years and our psychology students for one year, we strive to develop a common mission, appreciate respectful professional differences, and promote a caring patient-centered community (McDaniel et al., 1995).

Take It to the Community!

This project coordinates mental health care and medical care, in the primary care setting, while allowing the health care team to also collaborate with schools and community-based organizations as needed. Importantly, the B-HIP project promotes collaboration beyond the professional interaction of medical and mental health professionals, to incorporate community members as part of the treatment team (McDaniel et al., 1995). In an effort to provide ongoing comprehensive health care to pediatric patients, mental health specialists are able to provide school-based interventions at participating local school districts to monitor and ensure compliance of recommendations in alternative settings. In turn, schools act as a catalyst to minimize stigma associated with mental health concerns and maximize opportunity to serve as a community partner.

Open House: Final Thoughts and Preliminary Results

To date, 625 pediatric patients have been screened and 110 have received clinical services. Preliminary data demonstrate positive outcomes regarding pediatric mental health screenings, utilization of outpatient counseling and psychotherapy services, and the effectiveness of working within the school–community system to enhance children’s medical and psychological well-being. The pediatric patients were almost equally male (49%) and female (51%), with a median age of 10 years. The patients self-identified as Hispanic (43%), Black (20%), White (20%), Biracial (5%), Asian (2%), or chose not to identify (10%). Pediatric patients’ visited the clinic mainly for school physicals (58%) or well-child visits (23%). In a matched comparison, youth reported significantly more symptomatology than their parents at initial screening. In general, parents rated male children with higher symptom scores than female children, and youth present for sick child visits rated their own symptomatology higher than other youth. Further data collection is necessary to demonstrate effectiveness and outcomes of the B-HIP project.

Anecdotally it has been reported by our patients that they benefit from receiving care in one location that can effectively coordinate services, reduce the obstacles in receiving treatment in a timely fashion, and promote early detection and intervention of mental health problems. By coordinating care with community-based organizations, we can provide comprehensive services to our youngest, and often most vulnerable patients. To ensure that the mental health needs of our pediatric population are met, we continue to train our physician residents, to assist them in becoming more adept at assessing, diagnosing, and providing brief treatment for common psychiatric issues. We, as mental health specialists, create ongoing opportunities to break down the barriers of interdisciplinary collaboration.

We have learned that even with the offer of free mental health services, offered at their medical home, there are still some barriers to overcome, including stigma of mental health services, environmental barriers (e.g., transportation), bilingual services, and access to invaluable team members (e.g., child psychiatrists, social workers). Additionally, parents who initially express concern about their children’s emotional health are often delayed in seeking treatment, until matters reach a critical level. Prevention is still something that may not be seen as a priority for some of the participating families. Our future work will explore ways to minimize these barriers and increase opportunities for continued interdisciplinary assessment and intervention.

American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. (2009). The future of pediatrics: Mental health competencies for pediatric primary care. Pediatrics, 124, 410–421. doi:10.1542/peds.2009-1061

Clay, D. L., & Stern, M. (2005). Pediatric psychology in primary care. In L. C.James & R. A.Folen (Eds.), The primary care consultant: The next frontier for psychologists in hospitals and clinics (pp. 155–172). Washington, DC: American Psychological Association. doi:10.1037/10962-008

Holtrop, J. S., & Jordan, T. R. (2010). The patient-centered medical home and why it matters to health educators. Health Promotion Practice, 11, 622–628. doi:10.1177/1524839910378485

Kelleher, K. J., Campo, J. V., & Gardner, W. P. (2006). Management of pediatric mental disorders in primary care: Where are we now and where are we going?Current Opinion in Pediatrics, 18, 649–653. doi:10.1097/MOP.0b013e3280106a76

McDaniel, S., Campbell, T. L., & Seaburn, D. B. (1995). Principles for collaboration between health and mental health providers in primary care. Family Systems Medicine, 13, 283–298. doi:10.1037/h0089075

Navon, M., Nelson, D., Pagano, M., & Murphy, M. (2001). Use of the pediatric symptom checklist in strategies to improve preventive behavioral health care. Psychiatric Services, 52, 800–804. doi:10.1176/appi.ps.52.6.800

Polaha, J., Dalton, W. T., & Allen, S. (2011). The prevalence of emotional and behavior problems in pediatric primary care serving rural children. Journal of Pediatric Psychology, 36, 652–660. doi:10.1093/jpepsy/jsq116

Rowan, A. B., & Runyan, C. N. (2005). A primer on the consultation model of primary care behavioral health integration. In L. C.James & R. A.Folen (Eds.), The primary care consultant: The next frontier for psychologists in hospital and clinics (pp. 9–27). Washington, DC: American Psychological Association. doi:10.1037/10962-001

Wissow, L. S., Gadomski, A., Roter, D., Larson, S., Brown, J., Zachary, C., . . .Wang, M. C. (2008). Improving child and parent mental health in primary care: A cluster-randomized trial of communication skills training. Pediatrics, 121, 266–275. doi:10.1542/peds.2007-0418

Submitted: February 14, 2013 Revised: March 6, 2013 Accepted: March 10, 2013

This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user. Source: Clinical Practice in Pediatric Psychology. Vol. 1. (2), Jun, 2013 pp. 196-200) Accession Number: 2013-20877-007 Digital Object Identifier: 10.1037/cpp0000014

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Psychology can be indispensable to health care reform and the patient-centered medical home.

Authors:

Runyan, Christine N.. University of Massachusetts Medical School, Worcester, MA, US, [email protected]

Address:

Runyan, Christine N., University of Massachusetts Medical School, Department of Family Medicine and Community Health, Hahnemann Family Health Center, 279 Lincoln Street, Worcester, MA, US, 01605

Source:

Psychological Services, Vol 8(2), May, 2011. pp. 53-68.

NLM Title Abbreviation:

Psychol Serv

Publisher:

US : Educational Publishing Foundation

ISSN:

1541-1559 (Print) 1939-148X (Electronic)

Language:

English

Keywords:

health care reform, integrated primary care, patient-centered medical home, psychologists, psychology training

Abstract:

The Patient Protection and Affordable Care Act (PPACA) was passed into legislation in March 2010, making health care reform a reality. Perhaps the most well-developed model of primary care that aligns with the PPACA's agenda is the patient-centered medical home (PCMH). Integrated care, as defined by collaborative care between mental health and primary care providers and systems, will undoubtedly play a critical role in the success of the PCMH. The role of psychology and integrated care in the PCMH as well as training implications for psychologists are discussed. This article is intended to challenge our discipline to embrace psychology as a health care profession that must prepare for and solidify its added value in the health care delivery models of the future. Requisite skill sets for primary care psychologists and existing training opportunities are presented. Finally, possible mechanisms for training psychologists in integrated care and the professional roles primary care psychologists can expect to fill are proposed. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Document Type:

Journal Article

Subjects:

*Health Care Delivery; *Primary Health Care; *Psychologists; *Psychotherapy Training; *Health Care Reform; Home Care

PsycINFO Classification:

Home Care & Hospice (3375)

Conference:

Midwinter Conference for the National Council of Schools of Professional Psychology, Feb, 2010

Conference Notes:

This article is based on two presentations given at the aforementioned conference.

Format Covered:

Electronic

Publication Type:

Journal; Peer Reviewed Journal

Publication History:

Accepted: Feb 1, 2011; Revised: Dec 29, 2010; First Submitted: Jun 2, 2010

Release Date:

20110516

Copyright:

American Psychological Association. 2011

Digital Object Identifier:

PsycARTICLES Identifier:

ser-8-2-53

Accession Number:

2011-09614-001

Number of Citations in Source:

1. Health Care Reform and Integrated Care

Psychology Can Be Indispensable to Health Care Reform and the Patient-Centered Medical Home

Contents

2. The Patient-Centered Medical Home

3. The Economic Rationale

4. Epidemiology of Mental Illness and Behavioral Health

5. Evidence Supporting Integrated Care

6. Training Psychologists as Health Care Professionals

7. Implications for Training

8. References

Health Care Reform and Integrated Care

By: Christine N. Runyan University of Massachusetts Medical School;

Acknowledgement: This article is based on two presentations given at the midwinter conference for the National Council of Schools of Professional Psychology in February 2010.

The United States has finally exhausted the luxury of time and endless debate about how to reform health care. The Patient Protection and Affordable Care Act (PPACA) was signed into law in March 2010, representing the result of highly contentious and laborious deliberation on health care reform. Infused with ideas and funding for pilot programs and demonstration projects, the PPACA is a complex assortment of policies and finance reform that seeks to contain costs, improve access to high-quality health care, and expand insurance coverage. Considerable funding is allocated for research and clinical demonstration projects to elucidate effective and efficient models of health care that include prevention, health care maintenance, acute care, and chronic illness management. Parallel to the enactment of the PPACA, the patient-centered medical home (PCMH) was gathering steam as one of the most widely accepted health care delivery models for high-quality, cost-effective primary health care (National Committee for Quality Assurance, 2009). If the PCMH is widely implemented, behavioral health will no longer be an afterthought in routine health care. Not a moment too soon, the dawning of the age of integrated health care is upon us. This article, a summary of the keynote address from the annual midwinter National Council of Schools of Professional Psychology conference held in Orlando, Florida, in February 2010, addresses the core components of integration, supported by available evidence, along with the rationale for integrated care in the PCMH, from various perspectives. The rationale will challenge the field of clinical psychology to embrace and prepare our workforce for this reality. The second portion of this article describes core competencies for integrated health care practitioners and briefly identifies current training programs and emerging trends for training primary care psychologists. The workforce shortage for integrated care providers and potential means to shrink this gap are discussed. Finally, suggestions for how to create and sustain training initiatives at the predoctoral level and possible professional roles for primary care psychologists are offered.

In addition to increasing health care coverage for Americans and improving the quality of health care, cost containment is inarguably the primary impetus for health care reform. Proportionately, the United States spends more on health care as a percentage of the gross national product compared with other developed countries for astoundingly worse global health outcomes, including much higher rates of infant mortality and lower projected life expectancies (World Health Organization, 2008). Medicare, the largest single health insurer in the United States, provides coverage for people 65 and older and for people under 65 with certain qualifying disabilities. The financial welfare of the Medicare system is bleak, and projected costs are not sustainable without substantial modifications in the program or the number of covered lives. As was true in 2008, the Medicare Hospital Insurance Trust Fund paid out more in 2009 in hospital benefits and other expenditures than it received in taxes and other dedicated revenues (Social Security and Medicare Boards of Trustees, 2009).

The Medicare Supplementary Medical Insurance Trust Fund, which pays doctors' bills and other outpatient expenses, and Medicare Part D, which pays for access to prescription drug coverage, are both projected to remain adequately financed into the indefinite future because current law automatically provides financing each year to meet next year's expected costs. However, expected steep cost increases will result in substantial increases in Medicare beneficiary premium charges at a rate that exceeds any expected income increases for this population. That is, a much larger proportion of their (often fixed) incomes will have to be allocated for health care premiums, a solution that is hotly debated and understandably not well received by Medicare beneficiaries.

Similarly, private health insurance is becoming increasingly cost-prohibitive. Employers, particularly small business owners, are increasingly unable to offer health care coverage as a benefit for employees. Health care premiums increased 114% between 1999 and 2007, whereas earnings over this same time period increased only 27% (Robert Wood Johnson Foundation, 2009). Although many tout medical malpractice payouts as the primary explanation for excessive health care costs, the actual driver appears to be expensive, highly sophisticated technology accounting for an estimated two thirds of health care spending growth (Ginsburg, 2008). Changing demographics in the United States, worsening health risk behaviors, and increased prevalence of chronic diseases are also undoubtedly contributing to excess costs. As previously noted, we are paying more and more for health care without any notable improvements in quality of care—an outcome that would not be tolerated or sustainable in any other American industry. Health care reform legislation must be simultaneously corrective on costs as well as improve access to high-quality care.

One of the essential ingredients of cost-effective, high-quality health care delivery systems includes a holistic perspective on disease and wellness, as well as a consideration of the social context in which health behaviors—both good and bad—are adopted and maintained. These concepts represent the fundamental assumptions underlying the PCMH. Primary care is the largest platform for health care delivery; however, it will remain an incomplete solution to comprehensive, biopsychosocially informed and delivered health care without adequately trained and competent providers to offer these services. Positioning behavioral health providers where people routinely access care (e.g., primary care clinics, emergency rooms) offers one avenue for increasing penetration into the population by identifying and addressing behavioral health needs (i.e., integrated care). Of note, ample research suggests that many patients are receptive to receiving psychological assessment and intervention in primary care clinics (Lester, Tritter, and Sorohan, 2005). The PCMH model recognizes the vast unmet need for behavioral health care in primary care and advocates a central role for a variety of collaborative providers, including mental health specialists. Other arguments make a compelling case for integrating care as well, but health care reform and, specifically, primary care reform through the adoption of the PCMH hold substantial promise for taking this vision into a reality.

Adopting this perspective requires a philosophical stretch for clinical psychology as a discipline, which has generally functioned within a specialty model of health care delivery. Similar to other types of medical specialties, clinical psychology services have largely tended toward a narrow focus on emotional and behavioral factors (i.e., above the neck). Moreover, psychological services often require prior authorizations from insurance companies and offer a restricted range of covered services, similar to other types of specialty health care. Operationally, psychology has embraced this model by using diagnostic-oriented, reductionist, and time-limited services that focus on the individual seeking care for relatively uncommon events. Most of our research is also exclusionary and aimed at identifying the best interventions for psychiatric diagnoses meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria. Moreover, in funded, large-scale clinical research trials, patients with various comorbidities are usually screened out to ensure a diagnostically pure sample. This research agenda has undoubtedly yielded credible data to support specific psychological interventions. However, even an intervention with a moderate or high rate of success will have a limited impact on the population's well-being because it is tied to a service model that is highly selective. That is, the overall impact of any intervention, or of health care as a whole, depends not only on effectiveness but also on the degree to which such interventions can penetrate into the population of interest (i.e., Impact = Effectiveness × Penetration; Rose, 1992).

A contrast to this existing model is a slightly more global but still clinic-based model of service delivery. It is a problem-oriented model (i.e., specific diagnosis is less relevant than the problem and symptoms) based on continuity of care and service delivery for symptoms that may not meet conventional diagnostic thresholds and can be understood within the context of the family and community. As a description, this encapsulates a primary care perspective of health care delivery. Although our discipline has not had a psychological equivalent of primary care to date, integrated care, embedded within the PCMH, offers such a model.

The Patient-Centered Medical Home

The PCMH is an approach to providing comprehensive primary care for children, youth, and adults. Patients are cared for by a physician who leads a medical team and coordinates all aspects of preventive, acute, and chronic care needs of patients using the best available evidence and appropriate technology (National Committee for Quality Assurance, 2009). The American Academy of Pediatrics, the American Academy of Family Practice, the American Osteopathic Association, and the American College of Physicians have developed the following joint principles to describe the characteristics of the PCMH (March 2007; excerpted from the Patient-Centered Primary Care Collaborative website: http://www.pcpcc.net/behavioral-health):

· Personal physician: Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.

· Physician-directed medical practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

· Whole-person orientation: The personal physician is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life, acute care, chronic care, preventive services, and end-of-life care.

· Care is coordinated or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

· Quality and safety are hallmarks of the medical home (selected elements):

· —Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care-planning process driven by a compassionate, robust partnership between physicians, patients, and the patient's family.

· —Evidence-based medicine and clinical decision support tools guide decision making.

· —Patients actively participate in decision making, and feedback is sought to ensure that patients' expectations are being met.

· —Information technology is used appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.

· Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physician, and practice staff.

· Payment appropriately recognizes the added value provided to patients who have a PCMH. The payment structure should

· —reflect the value of physician and nonphysician staff patient-centered care management work that falls outside the face-to-face visit;

· —pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources;

· —support adoption and use of health information technology for quality improvement;

· —support provision of enhanced communication access such as secure e-mail and telephone consultation;

· —recognize the value of physician work associated with remote monitoring of clinical data using technology;

· —allow for separate fee-for-service payments for face-to-face visits;

· —recognize case mix differences in the patient population being treated within the practice;

· —allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting; and

· —allow for additional payments for achieving measurable and continuous quality improvements.

Although behavioral health integration was not explicitly included in the original PCMH principles, the spirit of the biopsychosocial model (Engel, 1977) in primary care is evident. There have been numerous pundits advocating for the explicit inclusion of behavioral health, including the Behavioral Health Task Force of the Patient-Centered Primary Care Collaborative (PCPCC), whose member organizations are listed in Table 1. The PCPCC, developed to advance the PCMH, is a coalition of more than 600 members, including major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, and clinicians. The Task Force is working tirelessly to promote the absolute necessity of behavioral health, including prevention, tobacco cessation, substance abuse and mental health services, in order to fulfill the PCMH vision of whole person orientation and team approach to care (http://www.pcpcc.net/behavioral-health). In practice, it is hard to imagine a primary care practice being an effective PCMH without integrated behavioral health services. Of note, the American Academy of Family Practice Board Chairman Ted Epperly recently gave an interview entitled “How Health Care Reform Could End the Stepchild Status of Primary and Behavioral Health Care,” in which he argued for how the PCMH can serve as the bridge between the historical silos of medicine, mental health, and substance abuse services (Behavioral Health Central, 2010). Patient-Centered Primary Care Collaborative Behavioral Health Task Force Participating Organizations and Individuals

The two specific core principles of the PCMH most central to the inclusion of behavioral health are whole-person orientation and integrated service delivery. Integrated service delivery models use a team-based approach to care for all patients and the full range of patient needs, including emotional and behavioral needs, as well as problems of living that routinely surface in primary care settings. A whole-person orientation implies that primary care will have the capacity to identify and address physical health care needs as well as mental health needs, such as depression and anxiety; behavioral medicine needs, such as chronic illness management and chronic pain; and preventive medicine needs, such as tobacco use, obesity, health risk behaviors, and medical nonadherence. Well-functioning team-based care would involve providers and staff actively communicating collaboratively to ensure that patients experience holistic, nonfragmented, and comprehensive health care encompassing the full spectrum of needs ranging from preventive services to chronic disease management.

Recently, the National Committee for Quality Assurance published updates to the PCMH standards. These changes unambiguously recognize the dynamic interdigitation among emotional, behavioral, and physical health. Although much of our existing language hamstrings us into discussing these as distinct entities, the recognition that overall health status is a fluid compilation of all of these components is unmistakable in the new standards. The proposed standards incorporate other new concepts and have been reorganized through consolidation or retirement of components. The draft standards include:

· Provide access and continuity,

· Identify and manage patient populations,

· Plan and manage care,

· Support self-management,

· Track and coordinate care, and

· Improve performance measurement and quality.

With regard to behavioral health, the new standards propose that primary care include: (a) a comprehensive assessment including substance abuse, health behaviors, and depression screening with a standardized tool; (b) that one of the three clinically important conditions identified by the practice must be a condition related to unhealthy behaviors (e.g., obesity) or a mental health or substance abuse condition; and (c) tracking referrals and coordinating care with external mental health and substance abuse providers.

The Economic Rationale

Annual medical expenses among those who suffer from both chronic medical and behavioral health conditions cost roughly 46% more than those with only a chronic medical condition (Unützer et al., 2009). Moreover, of the top-five conditions driving overall costs (including utilization costs, lost work-related productivity, and pharmacy costs), clinical depression tops the list (Murray & Lopez, 1997). Particularly for recognizing and treating depression in primary care, numerous studies to date have demonstrated both cost-effectiveness and cost-offset when behavioral health care is integrated into primary care settings (Von Korff et al., 1998). Studies have also documented improvements in medical costs when behavioral health treatment is provided for a variety of illnesses. For example, in a meta-analysis of 91 studies, Chiles, Lambert, and Hatch (1999) found that medical utilization decreased 15.7% for those with a mental health condition who received behavioral health care, whereas it increased 12.3% for those who did not. No well-controlled studies to date have demonstrated the cost advantages of placing primary care services within specialty mental health clinics, although the lack of evidence is primarily a function of the lack of rigorous studies as opposed to any evidence to the contrary. An exhaustive list of the studies exploring the economics of integrated health care will not be reviewed; however, interested readers are referred to an article by Blount et al. (2007).

The economics of improving primary care services can also help make a case for behavioral health integration. There is evidence that the overall costs of health care among Medicare beneficiaries tends to decrease as a function of the density of primary care providers in any geographical area according to Medicare Claims Data (Baicker & Chandra, 2004). That is, the more primary care providers there are in any area, the lower the overall costs of health care per person. One possible explanation for this is that fewer persons are referred to specialty services, which often involve expensive and sophisticated technology for diagnostics and interventions. Moreover, the relationship between quality indicators and numbers of primary care practitioners also trends fairly linearly and suggests that increasing the number of primary care providers improves standardized indicators for quality of care among Medicare beneficiaries. In fact, there is evidence to suggest a 5% decrease in mortality for every 20% increase in primary care physicians, whereas this same study reported a 2% increase in mortality per every 8% increase in specialist physicians (Shi et al., 2003). Unfortunately, in America, about 70% of physicians are subspecialists and only 30% are in primary care; in the past decade, nearly 90% of medical school graduates chose to enter a subspecialty and only 10% are going into primary care (American Academy of Family Physicians, 2006; American Medical Association Health Care Trends, 2006). This has resulted in an extremely out-of-balance workforce that not only has difficulties meeting the current demands, but will become even more under resourced and over burdened if access to care is improved for some portion of the currently 47 million uninsured Americans. Sadly, in a large study of 6,600 primary care physicians, two thirds reported not being able to access outpatient behavioral health for their patients (Cunningham, 2009). Shortages of mental health care providers, health plan barriers (i.e., in and out of network providers), and lack of coverage or inadequate coverage were all cited by primary care providers as barriers to mental health care access (Cunningham, 2009). With ample evidence to suggest the potential quality and cost savings to be realized by increasing the primary care workforce, the fiscal necessity of integrating behavioral health is unequivocal.

Epidemiology of Mental Illness and Behavioral Health

Two seminal articles have demonstrated remarkably consistent findings related to the underlying behavioral and lifestyle factors that contribute to the actual causes of mortality in the United States. Most recently, using 2002 mortality data from the Centers for Disease Control and Prevention, Mokdad, Marks, Stroup, and Gerberding (2004) used estimates of relative risks and prevalence reported in published reputable studies and estimated the cause of death by multiplying estimates of the cause-attributable fraction of preventable deaths with the mortality data to reveal the external, modifiable risk factors underlying mortality. In this study, tobacco use was the leading cause of death, accounting for 18.1% of all premature deaths in the United States, followed by poor diet and inactivity, which accounted for 16.6% of total deaths and represented an increase by nearly 3% from the prior, similar study (McGinnis & Foege, 1993). Alcohol consumption also accounted for another 3.5% of deaths. Collectively, nearly half (48.2%) of all premature deaths were accounted for by a fairly limited number of largely preventable and modifiable risk factors and exposures (Mokdad et al., 2004). Whereas genetics, access to health care, the environment, and other nonmutable factors undoubtedly play a role in morbidity and mortality, ample evidence suggests that health behaviors commonly lead to the occurrence of one or more chronic medical conditions before they cause death.

The number of Americans diagnosed with a chronic medical condition is steadily increasing, and health care expenses for chronic medical conditions account for 78% of all health care spending based on the Medical Expenditure Panel Survey data (Stanton & Rutherford, 2005). Expenditures rise proportionately when comorbid chronic conditions exist, which are more often the norm rather than the exception. Moreover, the costs associated with managing a chronic medical condition, such as diabetes or hypertension, are also significantly higher when there is a comorbid mental illness (Petterson et al., 2008), and there is a higher than random co-occurrence of depression with 11 chronic medical conditions (Welch, Czerwinski, Ghimire, & Bertsimas, 2009). For example, 20–30% of patients with diabetes experience depression (Anderson, Freeland, Clouse, & Lustman, 2001). A large study on depressed patients in primary care suggested that 75% presented to primary care with physical complaints and stated that the physical ailments were the reason they sought health care, not their mood (Unützer et al., 2003). Obesity exists in 30% of the population and nearly 60% of Americans live a sedentary lifestyle (Ogden, Carroll, McDowell, & Flegal, 2007). Racial and ethnic minorities are even less inclined than Whites to seek treatment from mental health specialists (U.S. Department of Health and Human Services, 1999). Instead, primary care becomes the point of entry for many minorities. Collectively, these data underscore a central role for nonphysician providers to address health behaviors, help manage chronic illnesses, and address traditional mental health needs. As experts in human behavior, psychologists are a natural fit to fill this role.

In addition to health behaviors, the most common epidemiological reason cited for integrating behavioral health into primary care is the high prevalence of mental illness that exists in the United States. The National Comorbidity Survey is conducted among U.S. households every 10 years (it excludes institutionalized and homeless populations) and is a reliable source for epidemiological data for mental illness. In the last survey, 26% of respondents reported symptoms sufficient to warrant a mental health diagnosis in the past 12 months, and a lifetime prevalence estimate for any mental health disorder was 46.4% (Kessler, Berflund et al., 2005). Of these, anxiety disorders were most prevalent, followed by mood disorders. Despite the scope of and severity of conditions, 59% of respondents with a mental health condition reported receiving no treatment for their mental illness; of the 41% who did receive treatment, only 44% received any mental health care. All others received care in the primary care clinic by primary care providers. Another more recent study conducted on the scope and nature of anxiety disorders in a primary care clinic found similar results in that 19.5% of the sample had one or more anxiety disorders but 41% were not receiving any treatment (Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007). Of those who were treated, 42% were treated with medication only (Kroenke et al., 2007). The reasons for the lack of treatment in general and lack of mental health treatment in particular are many, including access to care. However, stigma remains another common and substantial barrier to seeking mental health care. Based on a survey of 3,239 adults conducted in 2000, 42% of people with a mental health condition reported that they were embarrassed or ashamed of their symptoms (National Mental Health Association, 2000). Thirty-two percent of adults without a mental health condition stated they would likely turn to their primary care provider to help with mental health issues if the need arose; only 4% stated they would specifically seek mental health care (National Mental Health Association, 2000). Other data confirm this reality—approximately 50% of all behavioral health disorders are treated in primary care and 48% of psychotropic agents are prescribed by nonpsychiatric primary care providers (Kessler, Demler et al., 2005; Pincus et al., 1998). Mental health care is and will continue to be delivered in primary care clinics. Psychology can opt to integrate into primary care where the patients are, or remain in a specialty care model of practice and risk being marginalized from overall health care, thereby making little dent in the health and well-being of the population. The choice seems clear, but will it work?

Evidence Supporting Integrated Care

Integration takes many forms and there is no one best model of integrated care. However, most models of integration are predicated on the notion of stepped care and work well only in the context of a larger behavioral health delivery system that includes specialty mental health, substance abuse services, and behavioral services for common chronic and acute conditions. Just as primary medical care relies on the availability of specialists for consultation and management of complex patients, integrated primary behavioral health care relies on these other types of services and providers. Various models of integrated care have been described and, in practice, the implementation of integrated care tends to take on unique characteristics and permutations depending on the specific setting. Thus, rather than define a specific model of integrated care, the framework below (Kirk Strosahl, cited in Robinson & Reiter, 2007) identifies key components of integration as well as an illustration of how a fully integrated care model might function:

· Mission integration: the extent to which the behavioral and general medical service systems are pointing toward the same health objectives, goals, and strategies. In well-integrated systems, the overarching and shared constancy of purpose is to improve the health of the entire population, not just to treat the sick.

· Clinical service integration: the degree to which general medical and behavioral providers seamlessly engage in coordinated assessment, intervention, and follow-up activities with well-integrated systems using a lot of comanagement processes, protocols, and assessment tools.

· Physical integration: the degree to which the general medical and behavioral health providers work in the same space, allowing for instantaneous access to care, with well-integrated systems being colocated at a minimum.

· Operations integration: the degree to which the general medical and behavioral health providers work off the same clinic “platform,” with well-integrated systems sharing as many operational processes as realistic given that there are some nuisances to mental health care in any setting.

· Information integration: the degree to which the general medical and behavioral health provider can access real-time client care information, with well-integrated systems having shared and open access to documentation.

· Financial integration: the degree to which general medical and behavioral health services are funded as a “basic” form of health care, with well-integrated systems including some aspects of integrative behavioral care as a core primary care service and not exclusively dependent on fee for service/productivity to support the providers.

Evidence for integrated care has been accumulated on a variety of clinical outcomes, including symptoms as well as disease management indicators, process outcomes (e.g., no-show rates and recognition rates), economic outcomes (cost-effectiveness and cost-offset), as well as patient and provider satisfaction. A thorough review of all of the evidence is beyond the scope of this article, but interested readers are referred to several comprehensive reports summarizing this evidence, including the World Health Organization and World Organization of Family Doctors' (2008) report Integrating Mental Health Into Primary Care: A Global Perspective; the Agency for Health Care Research and Quality's report Integration of Mental Health and Substance Abuse in Primary Care (Butler et al., 2008); the Hogg Foundation for Mental Health's (2008) report Connecting Body and Mind: A Resource Guide to Integrated Health Care in Texas and the United States; and the Milbank Memorial Fund report Evolving Models of Behavioral Health Integration in Primary Care (Collins, Hewson, Munger, & Wade, 2010). The National Council for Community Behavioral Health Care's website is also an extraordinary one-stop online shopping resource for a variety of articles, reports, measures, research, and other information about integrated care (http://www.thenationalcouncil.org/cs/new_at_the_resource_center). In sum, these reports describe numerous successful programs employing various models of integrated care.

Several recent meta-analyses have not only further documented the effectiveness of integrating care but have tried to isolate the most critical elements of effective integration models. Gilbody, Bower, and Fletcher (2006) published a meta-analysis of 37 randomized studies, which included 12,355 patients with depression in primary care. Results suggested that integrated care improves depression outcomes at 6 months (standardized mean difference [SMD] = 0.25, 95% CI [0.18, 0.32]). Furthermore, a sustained benefit was found with clinical improvements after 12 months (SMD = 0.31), 18 months (SMD = 0.25), 24 months (SMD = 0.15), and even up to 5 years (SMD = 0.15, 95% CI [0.001, 0.31]). Effectiveness, as measured by the magnitude of the effect size, was directly linked to medication compliance (slope coefficient = 0.19; 95% credible interval [0.08, 0.30]); using care managers with mental health backgrounds (SMD = 0.34) compared with nonmental health backgrounds (SMD = 0.164); and regular, planned supervision of the care managers (SMD = 0.29) compared with unplanned supervision (SMD = 0.14; Gilbody et al., 2006). Bower, Gilbody, Richards, Fletcher, and Sutton (2006) completed a metaregression of 28 studies of collaborative care reporting outcome data on antidepressant use and 34 studies with data on clinical outcomes. Collaborative care had a positive and significant impact on antidepressant use (OR = 1.92, 95% CI [1.54, 2.39]) and reduction in depressive symptoms (SMD = 0.24, 95% CI [0.17, 0.32]). In further analyses, three unique components of collaborative care predicted improved depression outcomes. Specifically, systematic identification of depressed patients in primary care (p = .061), using case managers with a mental health background (p = .004), and regular supervision of case managers (p = .033) were the strongest predictors of effectiveness (Bower et al., 2006).

Although both meta-analyses found compliance with antidepressant medication to be a strong predictor of improvement on depression outcomes, there was no attempt to compare or include studies that used integrated care models with a nonmedication treatment condition. This is relevant because three large and methodologically sound studies document little evidence of the specific pharmacological effect of antidepressant medications, relative to pill placebo, for patients with mild to moderate depression (Fournier et al., 2010; Khan, Leventhal, Khan, & Brown, 2002; Kirsch et al., 2008). Results from the most recent patient-level meta-analysis (718 patients) indicate that the magnitude of the benefit from medication, compared with placebo, increases with the severity of the depression symptoms. For patients in the mild to moderate range of depression, the Cohen d effect size was 0.11 (95% CI [−0.18, 0.41]), and for patients in the severe range, d = 0.17 (95% CI [−0.08, 0.43]), both of which fall below the conventional threshold for a small effect size (d = 0.20). In contrast, for patients in the very severe range of depression, d = 0.47 (95% CI [0.22, 0.71]), suggesting a medium effect size. These data imply that psychologists might be enormously useful in helping primary care physicians identify depression symptoms early to prevent disease progression, assist with diagnostic clarification and severity classifications, and support primary care treatment for mild to moderate depression to help prevent excessive prescribing of potentially iatrogenic medications.

Studies on the effect of short-term behavioral interventions, and behavioral activation in particular, have demonstrated statistically and clinically meaningful effects on reducing depression at a level comparable to antidepressant medication, with few if any risks (Dimidjian et al., 2006). Moreover, a well-done study on the recognition and treatment of anxiety in primary care using cognitive–behavioral therapy (CBT) and medications also demonstrated that both types of treatment had a significant and sustained (12 months) improvement over treatment as usual (Roy-Byrne, 2005). In addition, patients receiving both medication and CBT were less symptomatic at 3 and 12 months as measured by the Anxiety Sensitivity Index (Reiss et al., 1986), the World Health Organization's Disability Assessment Schedule II (Epping-Jordan and Üstün, 2000), and the Social Avoidance subscale of the Fear Questionnaire (Marks & Mathews, 1979), compared with those receiving medication alone. There is also a sizable and growing body of literature demonstrating the clinical and economic benefits of treating mental health conditions associated with chronic medical conditions with a variety of pharmacological and nonpharmacological interventions. These studies consistently demonstrated positive effects on clinical outcomes, cost reduction, and decreased fragmentation of care, which often reduces redundancy in services that drive up health care costs (see Ouwens, Wollersheim, Hermens, Hulscher, & Grol, 2005, for a review of systematic reviews on this topic).

Research on the central organizational and process parameters associated with effective integration models suggests that integrating the principles of population health and chronic care management in the primary care setting helps achieve the goals of clinical quality, efficiency, and maximal return on investment. These principles include, but are not necessarily limited to, the following:

· Proactive identification of conditions of interest (screening);

· Timely access to services;

· Locus of service delivery within primary care

· Full involvement of a treatment team, including primary care practitioners, care coordinators, and behavioral health specialists;

· Inclusion of pertinent behavioral health interventions in a unified treatment plan;

· Careful and systematic monitoring of patients (registry) and treatment response;

· Patient engagement, reengagement, and active collaboration; and

· Reliance on evidence-based behavioral health practices and defined clinical/administrative workflows.

Although it remains unclear how to effectively finance models of integrated care, it is obvious that exclusively fee-for-service models are woefully insufficient and not commensurate with the guiding principles of the PCMH. Options such as bundled payments and payments based on processes and outcomes are being evaluated to include mechanisms for financing behavioral health providers and services within the PCMH. To the extent that these efforts are successful, psychologists who are trained, prepared, and willing to practice in such settings will undoubtedly be in high demand. As such, the requisite knowledge and competencies for psychologists to work effectively in the primary care setting, how to obtain this training, and the types of positions that will be available constitute the remaining topics of this article.

Training Psychologists as Health Care Professionals

It should be noted that the concept and practice of integrating behavioral health into medicine is not new. For many years, psychologists and social workers have been embedded in both primary care and tertiary care medical settings such as organ transplant units, oncology, rehabilitation units, and other hospital-based specialties. Thus, it is not surprising that many behavioral health providers migrating into primary care settings come from a few limited training models and traditions, namely behavioral medicine (clinic health psychology), medical social work, and family therapy. The two parallel disciplines that have contributed most to the understanding of behavioral health in primary care are clinical health psychology and family therapy—both with rich but varying education and training traditions. Family therapy is steeped in history, theory, and clinical practice, whereas behavioral medicine evolved as a more scientific discipline based in developing and conducting empirical studies on assessment and treatment approaches. Nonetheless, the two models can and do blend well in primary care practice. The requisite knowledge and skills for primary care practice incorporate and expand on both of these fields. Added concepts include population health, epidemiology, proactive screening, medical terminology, culture unique to primary care, privacy in medical settings, chronic disease management, pharmacology (not only psychopharmacology), care across the life span, a team of providers and medical staff, and continuous quality improvement. Table 2 provides an overview of the core knowledge base that would be ideal for practitioners entering primary care settings and how this differs from traditional curricula. Table 3 further delineates core competencies as well as some organizational knowledge and skills that tend to be helpful not only to become an effective practitioner in primary care but an effective and influential change agent as well. Comparison of Curriculum Components for Clinical Health Psychology, Medical Family Therapy, and Primary Care Psychology Specific Skills for Primary Care Psychology

The breadth and depth of knowledge and skills necessary for primary care cannot be contained within any single discipline as currently defined; the need for most practitioners to obtain additional training is clear. Currently, there are few opportunities for formal education and training. A few psychology graduate schools offer specialties in integrated care, including Forest Institute of Professional Psychology in Springfield, Missouri; the University of Nevada at Reno; and a newly developed program leading to a nonclinical doctorate in behavioral health has been established at Arizona State University. Fortunately, graduate programs are increasingly developing partnerships with medical agencies and offering practicum experiences of varying duration, intensity, and settings to students. Moreover, many predoctoral internships also offer integrated care minor or major rotations and primary care is now a searchable field in the Association of Psychology Postdoctoral and Internship Centers (APPIC) database (http://www.appic.org/directory/4_1_directory_online.asp). A recent search of this database identified 92 American Psychological Association-accredited predoctoral internship programs reportedly offering a major rotation in primary care. Finally, a limited number of primary care postdoctoral fellowships have been developed throughout the country; these can also be queried using the APPIC database—43 postdoctoral programs currently list a primary care experience, many of which are exclusively dedicated to offering a primary care training experience. This summer, the Health Resources and Services Administration's Graduate Professional Education division funded several training grants to American Psychological Association-accredited programs offering multidisciplinary training to psychologists, many of which are in primary care settings. Informally, conference presentations as well as webinars have become a common modality for disseminating knowledge and sharing experiences in integrated care. Various agencies have produced integrated care trainings videos, including the National Council for Community Behavioral Health Care, which recently completed a series of three webinars designed to educate providers and administrators about integrated care. Toolkits and manuals are also becoming a more common mechanism to distribute content knowledge and tools for integrated care practice (e.g., see Integrated Behavioral Health Project at http://www.ibhp.org/). Perhaps the flagship training opportunity in integrated care is at the University of Massachusetts Medical School under the direction of Alexander Blount (http://www.umassmed.edu/FMCH/PCBH/Welcome.aspx?linkidentifier=id&itemid=76312). This program is exclusively distance learning and comprises a 6-month curriculum delivered one Friday a month for 6 hours. The content of the program includes the following core topics: primary care culture and needs, evidence-based therapies and substance abuse, behavioral health care for chronic illness, the toolbox and overview of psychopharmacology, behavioral medicine techniques, caring for the seriously and persistently mentally ill in primary care, and families and culture in primary care. Continuing education credits are available for this program, which costs $1,600 per participant, per site.

Implications for Training

Despite all of the opportunities noted above, the skills necessary to work in an integrated clinic cannot be learned from didactic education and technology-enhanced distance learning alone. We need to develop a pipeline of trained clinicians who can then serve as clinical educators and supervisors for new learners and train those who demonstrate a proclivity toward primary care how to supervise and train others. The same model of clinical training that has been used for many years in clinical psychology, family therapy, and medical education (i.e., a combination of didactic education and experiential training) must be created for the practice of primary care. To accomplish this, a critical mass of well-trained and dispersed group of practitioners in various health care settings must be available to offer clinical training opportunities to students. As discussed in an article by Blount and Miller (2009), unless we can radically increase the workforce available to work in primary care, we run the risk of being marginalized as part of routine health care as it becomes redefined through health care reform legislation and clinical practice.

The mechanisms for achieving this goal are neither entirely clear nor easy. American Psychological Association-accredited graduate schools are, at least partially, in service to a somewhat prescribed and standardized curriculum that leaves little room for ingenuity and modification without extending the program. Adding material is not feasible in most programs that are already bursting at the seams with requisite coursework and requirements. In addition, curriculum change, even adding a new course, might require years and considerable committee involvement and approvals. Independent graduate schools of psychology might have a slightly advantageous position in this regard; however, regardless of setting, adding new curricula can be a long and laborious process. Thus, considerable reengineering of graduate psychology curricula is required to produce health care practitioners that can serve in primary care clinics. The educational requirements (guidelines and principles) set forth by the American Psychological Association Committee on Accreditation should embrace a curriculum that prepares all psychologists to practice within the full scope of psychology as a health profession. Material that holds historical interest but little applicability for clinical practice might be eliminated or required at the undergraduate level prior to admission to graduate school. This would allow time and room in the curriculum to add content that is more relevant to today's health care delivery system and derived from the latest scientific evidence. Fortunately, much of the material and competencies that are relevant to primary care provide robust scaffolding for generalist psychology training. For example, primary care psychologists should be well versed in the theory and applications of cognitive–behavioral techniques, dialectical behavior techniques, mindfulness techniques, motivational interviewing techniques, and psychopharmacology. Moreover, primary care practice requires a comfort with implementing techniques as opposed to full versions of manualized CBT protocols, which are not feasible in this setting. Patients in primary care are often less sick than those entering the mental health system and may not be willing or ready to accept a mental health diagnosis to explain their symptoms. Although the recommended knowledge and skills are clearly not unique to primary care, training these techniques exclusively in traditional mental health settings falls short given the population.

In primary care, patients may have a broad array of needs given their medical conditions, and behavioral health clinicians will need to be both aware of and relatively comfortable discussing these as a member of their health care team. Other critical shifts include assuming the role of an ancillary provider, rather than being exclusively in charge of a patient's treatment plan, adapting to a different workflow and pace as well as different confidentiality standards, and learning about the roles of nurses, medical assistants, and a variety of other workers who are less commonly encountered in traditional mental health settings. Didactic education is necessary, but experiential training will also be required to prepare behavioral health clinicians for the above realities to effectively practice in the PCMH.

A multitude of professional opportunities exist for psychologists who obtain the breadth and depth of expertise needed to work in a primary care setting given that it is an avenue to expand, not narrow, occupational growth. Well-trained primary care practitioners can expect to serve in clinical positions within community health centers, federally qualified health centers, and other types of primary care settings. In addition, the need for practice-based research in this field is enormous, and psychologists who have an interest in combining research and clinical practice will be in high demand and will undoubtedly offer meaningful contributions to a field hungry for more evidence. Another possible professional role includes becoming a behavioral science faculty member within family practice residency programs. Psychologists with the knowledge and skills to work in primary care will be able to teach future family practitioners about assessing and treating behavioral health conditions and how to work as a collaborative team member during their 3-year residency program, which always includes a behavioral science element per their education and training requirements. By its very nature, becoming a primary care behavioral health clinician requires one to specialize in a discipline that, similar to family medicine, is actually a generalist model in which one must be prepared to address patients across the life span and across all aspects of health, wellness, sickness, and death. In a rapidly changing environment, psychologists have and should seize the opportunity to position themselves at forefront by not only responding to but helping to define the future of high-quality, cost-effective health care in the United States.

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Submitted: June 2, 2010 Revised: December 29, 2010 Accepted: February 1, 2011

This publication is protected by US and international copyright laws and its content may not be copied without the copyright holders express written permission except for the print or download capabilities of the retrieval software used for access. This content is intended solely for the use of the individual user. Source: Psychological Services. Vol. 8. (2), May, 2011 pp. 53-68) Accession Number: 2011-09614-001 Digital Object Identifier: 10.1037/a0023454

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