Focus on Integrative and Collaborative Care
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Psychologycanbeindispensabletohealthcarereformandthepatient-centeredmedicalhome.pdf
Psychology Can Be Indispensable to Health Care Reform and the Patient-Centered Medical Home
Christine N. Runyan University of Massachusetts Medical School
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.
Keywords: integrated primary care, patient-centered medical home, health care reform, psychol- ogy training
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. Consider- able funding is allocated for research and clin- ical demonstration projects to elucidate effec- tive 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 ac- cepted health care delivery models for high- quality, cost-effective primary health care (Na- tional Committee for Quality Assurance, 2009). If the PCMH is widely implemented, behavioral health will no longer be an afterthought in rou- tine 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 Febru- ary 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 ra- tionale will challenge the field of clinical psy- chology 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 provid- ers and potential means to shrink this gap are discussed. Finally, suggestions for how to cre- ate and sustain training initiatives at the predoc- toral level and possible professional roles for primary care psychologists are offered.
This article is based on two presentations given at the midwinter conference for the National Council of Schools of Professional Psychology in February 2010.
Correspondence concerning this article should be ad- dressed to Christine N. Runyan, University of Massachu- setts Medical School, Department of Family Medicine and Community Health, Hahnemann Family Health Center, 279 Lincoln Street, Worcester, MA 01605. E-mail: christine [email protected]
Psychological Services © 2011 American Psychological Association 2011, Vol. 8, No. 2, 53– 68 1541-1559/11/$12.00 DOI: 10.1037/a0023454
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Health Care Reform and Integrated Care
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. Propor- tionately, the United States spends more on health care as a percentage of the gross national product compared with other developed coun- tries for astoundingly worse global health out- comes, 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 qual- ifying disabilities. The financial welfare of the Medicare system is bleak, and projected costs are not sustainable without substantial modifi- cations in the program or the number of covered lives. As was true in 2008, the Medicare Hos- pital 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 Insur- ance Trust Fund, which pays doctors’ bills and other outpatient expenses, and Medicare Part D, which pays for access to prescription drug cov- erage, are both projected to remain adequately financed into the indefinite future because cur- rent law automatically provides financing each year to meet next year’s expected costs. How- ever, 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 becom- ing increasingly cost-prohibitive. Employers, particularly small business owners, are increas- ingly 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 medi- cal malpractice payouts as the primary explana-
tion for excessive health care costs, the actual driver appears to be expensive, highly sophisti- cated technology accounting for an estimated two thirds of health care spending growth (Ginsburg, 2008). Changing demographics in the United States, worsening health risk behav- iors, and increased prevalence of chronic dis- eases are also undoubtedly contributing to ex- cess 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 sustain- able 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 sys- tems 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 as- sumptions 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 provid- ers 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 be- havioral health needs (i.e., integrated care). Of note, ample research suggests that many pa- tients 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 collab- orative providers, including mental health spe- cialists. 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 sub- stantial promise for taking this vision into a reality.
Adopting this perspective requires a philo- sophical stretch for clinical psychology as a discipline, which has generally functioned within a specialty model of health care delivery.
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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). More- over, psychological services often require prior authorizations from insurance companies and offer a restricted range of covered services, sim- ilar to other types of specialty health care. Op- erationally, psychology has embraced this model by using diagnostic-oriented, reduction- ist, and time-limited services that focus on the individual seeking care for relatively uncom- mon events. Most of our research is also exclu- sionary and aimed at identifying the best inter- ventions 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 psycho- logical interventions. However, even an inter- vention 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 im- pact 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 ser- vice 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 thresh- olds 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 pri- mary 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 com- prehensive 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 Phy- sicians have developed the following joint prin- ciples to describe the characteristics of the PCMH (March 2007; excerpted from the Pa- tient-Centered Primary Care Collaborative web- site: 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 respon- sibility 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 responsi- bility 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 in- formation 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 compas- sionate, robust partnership between physi- cians, patients, and the patient’s family.
—Evidence-based medicine and clinical decision support tools guide decision mak- ing.
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—Patients actively participate in decision making, and feedback is sought to ensure that patients’ expectations are being met.
—Information technology is used appro- priately to support optimal patient care, performance measurement, patient educa- tion, and enhanced communication.
• Enhanced access to care is available through systems such as open scheduling, ex- panded hours, and new options for communica- tion 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 non- physician staff patient-centered care man- agement work that falls outside the face- to-face visit;
—pay for services associated with coordi- nation of care both within a given practice and between consultants, ancillary provid- ers, and community resources;
—support adoption and use of health in- formation technology for quality improve- ment;
—support provision of enhanced commu- nication access such as secure e-mail and telephone consultation;
—recognize the value of physician work associated with remote monitoring of clin- ical data using technology;
—allow for separate fee-for-service pay- ments 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 Collabora- tive (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, con- sumer groups, patient quality organizations, health plans, labor unions, hospitals, and clini- cians. 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 per- son 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 inte- grated behavioral health services. Of note, the American Academy of Family Practice Board Chairman Ted Epperly recently gave an inter- view entitled “How Health Care Reform Could End the Stepchild Status of Primary and Behav- ioral 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).
The two specific core principles of the PCMH most central to the inclusion of behavioral health are whole-person orientation and integrated ser- vice delivery. Integrated service delivery models use a team-based approach to care for all patients and the full range of patient needs, including emo- tional 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 men- tal 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 col- laboratively to ensure that patients experience ho- listic, nonfragmented, and comprehensive health care encompassing the full spectrum of needs ranging from preventive services to chronic dis- ease management.
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Recently, the National Committee for Quality Assurance published updates to the PCMH stan- dards. These changes unambiguously recognize the dynamic interdigitation among emotional, be- havioral, and physical health. Although much of our existing language hamstrings us into discuss- ing these as distinct entities, the recognition that overall health status is a fluid compilation of all of these components is unmistakable in the new stan- dards. 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.
Table 1 Patient-Centered Primary Care Collaborative Behavioral Health Task Force Participating Organizations and Individuals
Access Psychiatry LLC Alere American Academy of Family Physicians American Academy of Pediatrics American College of Physicians American Osteopathic Association American Psychiatric Association Association of Medical
Education and Research in Substance Abuse
Baylor College of Medicine
Blue Cross and Blue Shield Association
Blue Cross and Blue Shield of California
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of Tennessee ClinicNet Collaborative Health Solutions LLC Colorado Behavioral Healthcare
Council Colorado Clinical Guidelines
Collaborative Empire Blue Cross Blue Shield
Family Medicine at University of California, San Diego
GlaxoSmithKline Health2Resources
IBM Johnson & Johnson Kaiser Permanente McKesson Merck National Business Group on Health National Council for Community
Behavioral Healthcare Novartis Pfizer
Sanofi-aventis St. Mary’s Hospital Thomson Reuters TransforMed Ultrais University of Massachusetts Memorial
Health Care University of Colorado Denver
School of Medicine Academy of Psychosomatic
Medicine Agency for Healthcare Research and
Quality American Psychological Association American Society of Addiction
Medicine Boehringer Ingelheim
Campaign for Mental Health Reform Commission on Accreditation of Rehabilitation Facilities
Cartesian Solutions LLC
Integrated Primary Care SIG, Society of Behavioral Medicine
Dartmouth Medical School George Washington University Medical Center, Center for Integrated Behavioral Health Policy
Goal QPC Healthspring Institute for Clinical Systems Improvement
Integrated Benefits Institute James Barr, MD, Central New Jersey Medical Home Network
Lilly
Marillac Clinic, Colorado Medfusion Morehouse School of Medicine National Association of State Mental
Health Directors National Naval Medical Center Presbyterian Healthcare Services
Rush University Medical Center Substance Abuse and Mental Health Services Administration
Sentara
Takeda Thomas Group University of Cincinnati University of Pittsburgh Medical
Center University of Rochester
Medical Center University of Vermont College of
Medicine University of Washington Utah Health Science Center Value Options
Source. http://www.pcpcc.net/content/pcpcc-behavioral-health-taskforce-participating-organizations-and-individuals
57PSYCHOLOGY IN PRIMARY CARE PCMHS
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With regard to behavioral health, the new stan- dards propose that primary care include: (a) a comprehensive assessment including substance abuse, health behaviors, and depression screen- ing 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 pro- viders.
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 uti- lization costs, lost work-related productivity, and pharmacy costs), clinical depression tops the list (Murray & Lopez, 1997). Particularly for recognizing and treating depression in pri- mary care, numerous studies to date have dem- onstrated 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 exam- ple, 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 behav- ioral 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 evi- dence 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 behav- ioral 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 spe- cialty services, which often involve expensive and sophisticated technology for diagnostics and interventions. Moreover, the relationship between quality indicators and numbers of pri- mary care practitioners also trends fairly lin- early 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 sug- gest a 5% decrease in mortality for every 20% increase in primary care physicians, whereas this same study reported a 2% increase in mor- tality per every 8% increase in specialist physi- cians (Shi et al., 2003). Unfortunately, in Amer- ica, 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 ac- cess 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 pa- tients (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 re- markably consistent findings related to the un-
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derlying 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 pub- lished 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, modi- fiable 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 consump- tion also accounted for another 3.5% of deaths. Collectively, nearly half (48.2%) of all prema- ture deaths were accounted for by a fairly lim- ited number of largely preventable and modifi- able 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 mor- tality, ample evidence suggests that health be- haviors 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, Ghi- mire, & Bertsimas, 2009). For example, 20 – 30% of patients with diabetes experience de- pression (Anderson, Freeland, Clouse, & Lustman, 2001). A large study on depressed patients in primary care suggested that 75% presented to primary care with physical com-
plaints 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 Hu- man Services, 1999). Instead, primary care be- comes 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 inte- grating 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 dis- order 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 re- ported 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, Wil- liams, 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, includ- ing access to care. However, stigma remains another common and substantial barrier to seek- ing mental health care. Based on a survey
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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 Associa- tion, 2000). Thirty-two percent of adults with- out 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 Associa- tion, 2000). Other data confirm this reality— approximately 50% of all behavioral health dis- orders are treated in primary care and 48% of psychotropic agents are prescribed by nonpsy- chiatric primary care providers (Kessler, Dem- ler 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 over- all 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 ser- vices for common chronic and acute conditions. Just as primary medical care relies on the avail- ability of specialists for consultation and man- agement of complex patients, integrated pri- mary 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 per- mutations 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 sys- tems are pointing toward the same health objec- tives, 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 pro- viders work in the same space, allowing for instantaneous access to care, with well- integrated systems being colocated at a mini- mum.
• Operations integration: the degree to which the general medical and behavioral health pro- viders work off the same clinic “platform,” with well-integrated systems sharing as many oper- ational 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 hav- ing 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 pro- viders.
Evidence for integrated care has been accu- mulated on a variety of clinical outcomes, including symptoms as well as disease manage- ment 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 Men- tal Health Into Primary Care: A Global Per-
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spective; 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 Pri- mary Care (Collins, Hewson, Munger, & Wade, 2010). The National Council for Community Behavioral Health Care’s website is also an extraordinary one-stop online shopping re- source for a variety of articles, reports, mea- sures, research, and other information about in- tegrated care (http://www.thenationalcouncil .org/cs/new_at_the_resource_center). In sum, these reports describe numerous successful pro- grams employing various models of integrated care.
Several recent meta-analyses have not only further documented the effectiveness of inte- grating care but have tried to isolate the most critical elements of effective integration mod- els. 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 out- comes at 6 months (standardized mean differ- ence [SMD] � 0.25, 95% CI [0.18, 0.32]). Fur- thermore, 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]). Effective- ness, as measured by the magnitude of the effect size, was directly linked to medication compli- ance (slope coefficient � 0.19; 95% credible interval [0.08, 0.30]); using care managers with mental health backgrounds (SMD � 0.34) com- pared 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; Gil- body 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 out- comes. 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. Spe- cifically, 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 predic- tors of effectiveness (Bower et al., 2006).
Although both meta-analyses found compli- ance 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 methodolog- ically sound studies document little evidence of the specific pharmacological effect of antide- pressant 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 pla- cebo, increases with the severity of the depres- sion symptoms. For patients in the mild to mod- erate 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 phy- sicians identify depression symptoms early to prevent disease progression, assist with diag- nostic clarification and severity classifications, and support primary care treatment for mild to moderate depression to help prevent excessive prescribing of potentially iatrogenic medica- tions.
Studies on the effect of short-term behavioral interventions, and behavioral activation in par- ticular, have demonstrated statistically and clin- ically meaningful effects on reducing depres- sion 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
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care using cognitive– behavioral therapy (CBT) and medications also demonstrated that both types of treatment had a significant and sus- tained (12 months) improvement over treatment as usual (Roy-Byrne, 2005). In addition, pa- tients receiving both medication and CBT were less symptomatic at 3 and 12 months as mea- sured 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 Avoid- ance subscale of the Fear Questionnaire (Marks & Mathews, 1979), compared with those re- ceiving 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 inter- ventions. These studies consistently demon- strated positive effects on clinical outcomes, cost reduction, and decreased fragmentation of care, which often reduces redundancy in ser- vices that drive up health care costs (see Ouw- ens, 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 in- tegration 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 prin- ciples include, but are not necessarily limited to, the following:
• Proactive identification of conditions of in- terest (screening);
• Timely access to services; • Locus of service delivery within primary
care • Full involvement of a treatment team, in-
cluding primary care practitioners, care coordi- nators, and behavioral health specialists;
• Inclusion of pertinent behavioral health in- terventions in a unified treatment plan;
• Careful and systematic monitoring of pa- tients (registry) and treatment response;
• Patient engagement, reengagement, and active collaboration; and
• Reliance on evidence-based behavioral health practices and defined clinical/administra- tive workflows.
Although it remains unclear how to effec- tively 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. Op- tions 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, pre- pared, 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 consti- tute the remaining topics of this article.
Training Psychologists as Health Care Professionals
It should be noted that the concept and prac- tice of integrating behavioral health into medi- cine 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, reha- bilitation units, and other hospital-based spe- cialties. Thus, it is not surprising that many behavioral health providers migrating into pri- mary care settings come from a few limited training models and traditions, namely behav- ioral medicine (clinic health psychology), med- ical 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 ed- ucation and training traditions. Family therapy is steeped in history, theory, and clinical prac- tice, 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
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(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 enter- ing primary care settings and how this differs from traditional curricula. Table 3 further delin- eates core competencies as well as some orga- nizational knowledge and skills that tend to be helpful not only to become an effective practi- tioner in primary care but an effective and in- fluential change agent as well.
The breadth and depth of knowledge and skills necessary for primary care cannot be con- tained within any single discipline as currently defined; the need for most practitioners to ob- tain 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 lead- ing to a nonclinical doctorate in behavioral health has been established at Arizona State
University. Fortunately, graduate programs are increasingly developing partnerships with med- ical agencies and offering practicum experi- ences of varying duration, intensity, and set- tings 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 Psy- chology 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 predoc- toral internship programs reportedly offering a major rotation in primary care. Finally, a limited number of primary care postdoctoral fellow- ships have been developed throughout the coun- try; 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 Administra- tion’s Graduate Professional Education division funded several training grants to American Psy-
Table 2 Comparison of Curriculum Components for Clinical Health Psychology, Medical Family Therapy, and Primary Care Psychology
Basic health psychology Basic (medical) family therapy Proposed primary care psychology
Biopsychosocial (spiritual) Biopsychosocial (spiritual) Biopsychosocial (spiritual) 1:1 patient care, groups Family therapy 1:1, families, teams, health care
systems, population based Specialist model Specialist model Generalist model in content Typically specialize in either
adults or children Families, couples Generalist model in population
served Medical literacy and language Medical literacy and language Medical literacy and language Pharmacology knowledge Limited pharmacology
knowledge Pharmacology knowledge and
application Mostly targeted assessments; some
more lengthy and comprehensive assessments
Little reliance on formal and objective assessments
Brief symptom-based questionnaires and screeners
Primary provider for behavioral health needs
Primary provider to patients and families for behavioral health needs
Collaborator, no case load
Chronic and acute illness Chronic illness Chronic and acute illness Cultural competence Cultural competence Cultural competence Adherence—Barriers to and
interventions for evidence-based medicine (motivational interviewing, health behavior change, etc.)
Adherence —Barriers to and interventions for family/ contextual interventions more likely
Theory-driven interventions; evidence based as available
Adherence—Barriers to and interventions for evidence-based medicine (motivational interviewing, health behavior change, etc.) but adopted for primary care and short-term treatment
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chological Association-accredited programs offering multidisciplinary training to psycholo- gists, many of which are in primary care set- tings. Informally, conference presentations as well as webinars have become a common mo- dality 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 com- pleted a series of three webinars designed to educate providers and administrators about in- tegrated care. Toolkits and manuals are also becoming a more common mechanism to dis- tribute content knowledge and tools for inte- grated care practice (e.g., see Integrated Behav- ioral Health Project at http://www.ibhp.org/). Perhaps the flagship training opportunity in in- tegrated care is at the University of Massachu- setts Medical School under the direction of Alexander Blount (http://www.umassmed.edu/ FMCH/PCBH/Welcome.aspx?linkidentifier� id&itemid�76312). This program is exclu- sively 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 persis- tently mentally ill in primary care, and families and culture in primary care. Continuing educa- tion 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 educa- tors and supervisors for new learners and train those who demonstrate a proclivity toward pri- mary care how to supervise and train others. The same model of clinical training that has been used for many years in clinical psychol- ogy, 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 train- ing 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 Psy- chological Association-accredited graduate schools are, at least partially, in service to a somewhat prescribed and standardized curricu- lum that leaves little room for ingenuity and modification without extending the program. Adding material is not feasible in most pro- grams 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. Inde- pendent 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 pro- cess. Thus, considerable reengineering of grad- uate psychology curricula is required to produce health care practitioners that can serve in pri- mary care clinics. The educational requirements (guidelines and principles) set forth by the American Psychological Association Commit- tee on Accreditation should embrace a curricu- lum that prepares all psychologists to practice within the full scope of psychology as a health profession. Material that holds historical inter- est but little applicability for clinical practice might be eliminated or required at the under- graduate 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 de- rived from the latest scientific evidence. Fortu- nately, 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 be- havior techniques, mindfulness techniques, mo- tivational interviewing techniques, and psycho-
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pharmacology. Moreover, primary care practice requires a comfort with implementing tech- niques as opposed to full versions of manual- ized 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 knowl- edge 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 dis- cussing 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 stan- dards, and learning about the roles of nurses, medical assistants, and a variety of other work- ers who are less commonly encountered in tra- ditional mental health settings. Didactic educa- tion 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 ex- ist 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 cen- ters, 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 in- terest in combining research and clinical prac- tice will be in high demand and will undoubt- edly offer meaningful contributions to a field hungry for more evidence. Another possible professional role includes becoming a behav- ioral 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 practi- tioners about assessing and treating behavioral health conditions and how to work as a collab-
orative team member during their 3-year resi- dency program, which always includes a behav- ioral science element per their education and training requirements. By its very nature, be- coming a primary care behavioral health clini- cian 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 oppor- tunity 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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Received June 2, 2010 Revision received December 29, 2010
Accepted February 1, 2011 �
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