The emerging practice of primary care psychology is creating new opportunities for psychologists. Psychologists are adapting their skills to the primary care environment and primary care providers are welcoming them into their practices and sharing patients with them.  The Federally Qualified Health Centers (FQHC) are recruiting behaviorists to their mission of creating health care homes for underserved populations. Graduate schools that offer degrees in psychology are adding courses pertaining to practice in primary care settings and negotiating training rotations to provide this experience for their students. As psychologists enter main stream health care, the profession is poised to make significant contributions to the health status of the nation.

Cherokee Health Systems, a community-based health services organization in Tennessee, has been seeking to blend behavioral health perspectives and services into primary care for nearly three decades. Tracing the evolution of Cherokee Health Systems illuminates some of the factors promoting the emergence of primary care psychology in public sector programs. The reach and proven effectiveness of the care model at Cherokee and other safety net organizations assures that the model will continue to proliferate throughout the public sector.

Rooted in the community mental health ideology of the 1960’s, Cherokee now provides primary care with a Behavioral Health Consultant embedded in the primary care team. The clinical care model combines the skills and energies of mental health and primary care providers, thereby reducing the customary isolation of mental health services and blending behavioral health interventions into the primary care visit. The array of specialty mental health services typical of contemporary Community Mental Health Centers (CMHS) is also available when patients need, and are motivated for, more intensive mental health care. This clinical care model appeals to a wide spectrum of the community, including many patients with commercial insurance who have the freedom to select from a wide range of treatment options. Cherokee provided services to more than 50,000 different area residents over the past year. The clinical staff currently includes 42 primary care providers and 36 psychologists.

At Cherokee Health Systems, Behavioral Health Consultants work as core members of the primary care team, following a flexible schedule similar to that of their primary care colleagues. The Behavioral Health Consultant, generally a psychologist with a behavioral medicine orientation, is available at the time of the primary care visit for assessment, triage and intervention for all those mental health, stress-related, and family problems which flood primary care practices. More than 80% of the mental health problems are managed in primary care without referral to specialty psychiatric services. Often behavioral alternatives to psycho-pharmaceutical interventions are utilized and, when these medications are necessary, behavioral strategies are also employed, which enhance the effectiveness of care.

BLENDING BEHAVIORAL HEALTH INTO PRIMARY CARE CHEROKEE HEALTH SYSTEMS’ CLINICAL MODEL BEHAVIORISTS ON THE PRIMARY TEAM The Behavioral Health Consultant (BHC) is an embedded, full-time member of the primary care team. The BHC is a licensed Health Service Provider in Psychology.A Psychiatrist is available, generally by telephone, for medication consults. SERVICE DESCRIPTION The BHC provides brief, targeted, real-time interventions to address the psychosocial aspects of primary care. TYPICAL SERVICE SCENARIO The Primary Care Provider (PCP) determines that psychosocial factors underlie the patient’s presenting complaints or are adversely impacting the response to treatment. During the visit the PCP hands off the patient to the BHC for assessment or intervention. Typically, there will be four 15-minute follow-up visits, often in tandem with the PCP. As a member of the Primary Care Team, the BHC will see 8 to 15 patients per day and will likely be consulted on a similar number by members of the Primary Care Team.

The Behavioral Health Consultant is involved in a wide range of patient presentations, not just when mental health or substance use disorders are detected. These behaviorists assist in chronic disease management by providing support and teaching patients to modify their behavior in accord with their readiness to change their lifestyle. They help patients select and monitor self-management goals. The overarching goal of this integrated practice model is to enhance the skills and resiliency of patients in the practice. This clinical model has a high degree of both patient and provider satisfaction. Patients declare their strong preference for the convenience of receiving assistance for their mental health concerns in the familiarity and comfort of their primary care provider’s office. Primary care providers relish the complementary skills a behaviorist adds to the practice. Access to behavioral health interventions is increased, stigma is averted, and the effectiveness of the primary care visit is enhanced. Because mind and body are interactive and inseparable, a primary care practice best matches the needs of its patients when it blends the expertise of behaviorists and primary care physicians.

Experience with patients in a clinical setting has guided Cherokee’s development during its 30-year odyssey from community mental health center to integrated delivery system. Initially, Cherokee committed to outreach into primary care clinics in the service region. Springing from a population-based perspective, the motivation was to reach those with mental health treatment needs who did not come to the mental health center for care. Circuit riding behaviorists discovered psychopathology identical to that encountered at the mental health center and quickly learned that the sheer number of patients in need of mental health intervention within primary care could not be accommodated utilizing the usual methods of psychotherapy. Efficient but effective strategies of assessment and intervention were required in order to match up with the demand.

THE BEHAVIORAL HEALTH CONSULTANT IN PRIMARY CARE • MANAGEMENT OF PSYCHOSOCIAL ASPECTS OF CHRONIC AND ACUTE DISEASES • APPLICATION OF BEHAVIORAL PRINCIPLES TO ADDRESS LIFESTYLE AND HEALTH RISK ISSUES • EMPHASIS ON PREVENTION AND SELF-HELP APPROACHES, PARTNERING WITH PATIENTS IN A TREATMENT APPROACH THAT BUILDS RESILIENCY AND ENCOURAGES PERSONAL RESPONSIBILITY FOR HEALTH • CONSULTATION AND CO-MANAGEMENT IN THE TREATMENT OF MENTAL DISORDERS AND PSYCHOSOCIAL ISSUES

Attempts to refer or transfer care from primary care to specialty mental health settings was usually not successful, even if the mental health professional who consulted the patient in primary care would become the treating professional. Stigma was, and is, a significant barrier. The vast majority of individuals prefer to receive their mental health care in the primary care setting. Primary care proved to be the best platform for mental health intervention. Most people visit their primary care provider every year, therefore, the blended model provides significant penetration into the overall population.

In distinct contrast to the broad access primary care affords, community mental health centers have narrowed their focus to target priority populations, generally individuals with serious or pervasive psychiatric problems. This trend has been dictated by the state governments and Medicaid programs that provide most of their funding. As psychopharmacological treatments and psychosocial rehabilitation approaches became the vogue in community mental health, psychotherapy was often de-emphasized and many psychologists departed the system. Cherokee resisted this trend and continued to provide broad-based access to mental health interventions through the blended clinical model as well as psychotherapy when indicated.

While community mental health centers have been restricting access based on specific criteria, including financial, diagnostic or level of functioning, FQHCs have been adding mental health service capacity. The FQHCs receive partial subsidy through grants from the Federal Bureau of Primary Health Care to provide medical care to underserved populations. FQHCs have become a significant component of the healthcare landscape serving over sixteen million patients last year and providing care at six thousand locations spread across every state in the Union. Their overarching goal is to reduce health disparities among low income and minority populations. A high percentage of FQHC patients present with a psychiatric diagnosis or have a mental health problem co-occurring with a medical condition. Depression is the third most common diagnosis in these health centers. Only hypertension and diabetes are more commonly diagnosed and treated. Providing open access regardless of ability to pay, FQHC have become the mental health safety net in many communities.

In addition to continuing its circuit riding tradition of visiting primary care clinics in the area, Cherokee opened a primary care practice with a nested behaviorist in 1984. When the opportunity to become a FQHC presented itself, Cherokee converted its system to meet the expectations of that program, becoming one of only a few merged CMHC-FQHC programs in the country.

In the early days of the CMHC movement, the centers were a key training ground for graduate school programs in Clinical and Counseling Psychology. Many psychologists not only received most of their clinical training in a CMHC but also launched their professional careers in community mental health. FQHC now hold the potential to assume the training and employment role previously offered by CMHC.

Training health service providers is at the core of Cherokee’s mission. Training affiliations with nearby universities provides a steady stream of health-professionals-in-training, including physicians, nurse practitioners, social workers, nurses, health care administrators, and psychologists. Pre-internship doctoral candidates in Clinical, Counseling and School Psychology are assigned 16-hour per week, year long rotations. All trainees experience the multidisciplinary clinical services model of Cherokee. In the past four years, Cherokee has offered an APA-approved internship in Clinical Psychology which features training in primary care psychology. In addition, Cherokee has participated in a consortium for many years that provides an APA-approved School Psychology internship.

IMPACT OF BHC ON SUBSEQUENT CHS SERVICE UTILIZATION • 28% DECREASE IN MEDICAL UTILIZATION FOR MEDICAID PATIENTS • 20% DECREASE IN MEDICAL UTILIZATION FOR COMMERCIALLYINSURED PATIENTS • 27% DECREASE IN PSYCHIATRY VISITS • 34% DECREASE IN PSYCHOTHERAPY SESSIONS • 48% DECREASE IN CRISIS VISITS

FORKS IN THE ROAD • COMMITTING TO PROVIDE PRIMARY CARE • CHOOSING THE PRIMARY CARE CULTURE • PROVIDING OPEN ACCESS, EVERY PATIENT OUR PRIORITY • RETAINING A BIOPSYCHOSOCIAL CARE MODEL • STICKING WITH POPULATION-BASED CARE • ACCEPTING FQHC

New data detailing the medical co-morbidities and premature mortality of persons with serious mental illnesses is compelling mental health specialty providers, including CMHCs, to take a closer look at the medical treatment needs of their patients. Persons with serious mental illness are dying 25 years earlier than their peers and at least 60% of the early mortality is due to medical conditions which could have been prevented, or at least moderated, if common risk factors such as poor nutrition, lack of exercise and smoking would have been addressed (Parks et.al. 2006). This population, especially, needs the prevention, screening, treatment and on-going support and monitoring of a health care home. The question now has even more relevance: Why do we have two distinct and separate community-based safety net systems -the Community Mental Health Centers and the Federally Qualified Health Centers - when the patients of each so often need the services of both?

As Cherokee’s psychologists find their footing in the primary care suite, new service opportunities continue to emerge: coordinating group medical visits for patients with chronic medical conditions like diabetes, participating in well-child checks with pediatricians, tackling childhood obesity and designing and implementing smoking cessation efforts. The opportunities to address the behavioral aspects of primary care patients and improve their treatment outcomes are endless. Cherokee’s Behavioral Health Consultants have become indispensable members of the primary care team. In effect, in collaboration with their primary care colleagues, these behaviorists are re-engineering the primary care visit to respond to the complex needs patients frequently bring to the clinical encounter.

Mission driven, clinically guided. It’s been a rewarding journey and, no doubt, the best is yet to come.

AUTHOR

Since 1978, Dennis S. Freeman, Ph.D. has served as Chief Executive Officer of Cherokee Health Systems, Inc., a community-based provider of integrated primary care and behavioral health services in East Tennessee. The company now has more than 500 employees, an annual budget of $37 million, and two-dozen service locations. Dr. Freeman is a licensed psychologist in the State of Tennessee and has been credentialed by the National Register of Health Services Providers in Psychology since 1975. His professional interests include health services development and management, preservation of the safety net, managed care, and the blending of behavioral health and primary care services.

Reference
Parks J, Svendsen D, Singer P, Foti M, Mauer B. Morbidity and mortality in people with serious mental illness. National Association of State Mental Health Program Directors, 2006. www.nasmhpd.org

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