As medical care moves well into the 21st century, there are increasing calls for enhanced integration of psychology and medical practice. With the focus on healthcare quality improvement we have seen efforts to increase coordinated care, eliminate unnecessary steps or hand offs, increase use of patient-centered teams, and improve access to care (IOM, 2001; Berwick, 2008). At the same time efforts focus on lowering per capita cost of healthcare for a population (Berwick, 2008). Integration of behavioral healthcare in primary care can help achieve these challenging goals. This paper illustrates our experiences in teaching and working in this type of training environment.
INTEGRATED CARE MODELS
The term integrated healthcare (IHC) can be defined by the dimensions considered (staffing, organizational framing, population treated, system of care structure and other variables). Doherty, McDaniel, & Baird (1996) suggest a five step hierarchical model of increasing levels of integration and collaboration between mental health professionals and medical physicians and nurses. Their model describes the strengths and limitations of each level of integration and the settings and types of problems appropriate to each. Strosahl (1996) outlines a three level model for partitioning care according to the needs of the population. Additional models focus on integration for different types of patients (i.e., the chronic high utilizing patient, a specific age of disease category, etc.). For the purposes of this article, we focus on three levels of collaboration: co-location of services, consultative/collaborative, and fully integrated. Co-location is a natural given that a working relationship starts with physical proximity. Our model goes beyond this entry point to develop more consultative/collaborative care in which there is a shared medical record, efforts to coordinate care, and a basic understanding and appreciation for each other’s roles in the care of the patient. Finally, some elements of our program operate in a fully integrated care model where psychology and medicine function as a coordinated team.
PRIMARY CARE
The point of care for our integrated environment is the primary care setting. A major portion of mental health care is rendered in the primary care setting, and always will be (deGruy, 1996). Nearly half of all mental health care is delivered through primary care settings and non-psychiatric physicians prescribe approximately 75% of all psychotropic agents in the U.S. (Gallo, 2000; Williams, 1989). Surveys have shown that for patients diagnosed as either generalized anxiety disorder or clinical depression, it was the primary care/family physician (48%) who first made the diagnosis. (National Mental Health Association, 2001). At the same time, numerous primary care physicians (PCPs) experience frustration that many of the most common physical complaints in primary care often have no diagnosable organic etiology.
On a broader level, primary medical care has placed a new emphasis on the “Medical Home” that promotes strengthening and supporting the patient-physician relationship (American Academy of Family Physicians, 2008). This model entails a central resource with a competent team and active involvement by informed patients. It focuses on accessible, continuous, comprehensive, family- centered, coordinated, compassionate, and culturally effective care that promotes a continuous healing relationship. Integration of mental health care in this medical home opens the door to care that is more accessible to the patient, allows for whole person care (not carved out), is team focused and coordinated within the system, and improves overall quality and patient satisfaction.
TRAINING PROGRAMS FOR PRIMARY CARE HEALTH PSYCHOLOGY
In order for this type of integration to more fully develop, psychologists and PCPs need to be trained to work and function in this collaborative environment. It is unlikely that providers who have been schooled in their closed, non integrated systems will suddenly work as collaborators when they graduate from residency/fellowships and become practitioners. Since its conception in the 1970’s, family practice has appreciated and included behavioral science education into their residency curriculum (Garcia-Shelton & Vogel, 2002), welcoming psychologists and other mental health professions as a core part of their training faculty. More recently, the two physician residency accreditation bodies (ACGME and AOA), placed a strong emphasis on training in the Core Competencies. These competencies include, among other things, an emphasis on providing patient care that is compassionate, appropriate and effective and the demonstration of effective interpersonal and communication skills. These revised accreditation requirements have opened more opportunities for behavioral science faculty to be included in the training of physicians in internal medicine and pediatrics. Psychologists can and do contribute much to the training of physicians. But for psychologists to be considered effective educators and collaborators in a medical environment there is much they need to learn and appreciate about the medical culture.
Psychology training programs for learning this type of collaborative work are limited. Since 1987, Genesys Regional Medical Center (formerly St. Joseph Hospital and Flint Osteopathic Hospital) have offered a two-year postdoctoral fellowship in primary care health psychology. This program is part of the Consortium for Advanced Psychology Training (CAPT) and is affiliated with Michigan State University, Flint Area Medical Education. The CAPT fellowship program is accredited by the American Psychological Association.
During its evolution, the fellowship began with full integration within in a family practice residency and has expanded over the years to include internal medicine, obstetrics, and podiatry residency programs. The program was created to train psychologists to be consultants, collaborators, and teachers to PCPs in the broad area of the behavioral sciences. The overall goal is to bring the physician and psychology trainees together in an integrated and organized program to enable them to build relationships, increase collaboration, and learn from each other as colleagues.
CO-LOCATION & PHYSICAL ENVIRONMENT
The first place to start with developing collaborative working relationships is the physical environment. In our outpatient clinic settings, the health psychology fellows and faculty are integral to the residency teaching and clinical setting. Their offices are positioned in close proximity to the exam rooms and where the physician faculty precept cases. While more space might have been available to us on a separate floor or down the hall, we chose to be located as closely as possible to where physicians perform their daily tasks. If one colleague is in session with a client, we work to make sure that another has his/her door open and is available for the curbside consult. This reduces barriers to seeking consultative advice from the psychologist. In the inpatient environment, we work on the units of the hospital, make rounds with the medical teams, and are easily visible to residents. The goals are to be seen, considered, and utilized.
CONSULTATIVE/COLLABORATIVE CARE
Our model combines consultative and collaborative elements in various forms within the combined training program.
Didactic Teaching: The behavioral science curriculum for family medicine & internal medicine residency programs can be structured in various ways and still meet accreditation guidelines. While standard curriculum develops a working knowledge of common DSM-IV diagnoses and the PCP’s role in management of these conditions, our program places an increasing emphasis on patient-centered care and on the relationship building that is central to the medical home. The psychologist’s role is to help the physician appreciate the whole person approach to care and the value of a continuous healing relationship in effecting behavioral change. In addition, our didactic teaching examines the medical interview and helps the physicians be more effective at negotiating and setting an encounter agenda, developing focused interviewing skills, handling strong emotions, increasing collaboration with patients, and knowing when and how to transition to more traditional doctor-centered care.
Shadow/Video Precepting: One method of teaching and effecting change in the medical interview is for the psychologist to shadow or observe through video the encounter. Our teaching status in the residency programs makes this method of precepting a natural for both the physician and patient. When conducting this type of work the psychologist’s typical role is that of an observer who provides feedback to the physician outside the examination room, yet there are instances when our feedback is needed more immediately. Through this process, the psychology fellow learns more about medical culture, the pace of primary care, and the complexity of care with the primary care physician as their teacher. Likewise, the psychologist demonstrates and teaches new skills to the physician.
Hospital Consultation & Rounds: When the PCP transitions to the inpatient medical setting, the role of the psychologist may range from the traditional consultant (with formal referrals) to being part of the inpatient rounding team. The consultant role generally concerns patients with mental health disorders which are having an influence on the medical care and treatment of the patient. When rounding with the medical team, the psychologist’s emphasis is more on teaching and education of the team members, but in this situation too, the psychology fellow is also learning .
Individual Psychotherapy: When patients are referred to our outpatient psychology service our function is that of a consultant. These referrals include the full range of conditions and ages that are typical for a primary care setting. The patient’s diagnosis may be typical of general clinical practice (depression, anxiety, etc.) or may be more clinical health psychology in nature (coping with chronic or life changing illness, psychiatric conditions co-morbid with medical illness, pain management, adherence to medical advice, and lifestyle change). There is regular communication, face to face and written, about these shared patients with documentation typically in the same record. Both providers share an appreciation for what each brings to patient care.
CROSS TRAINING AND INTEGRATION: A CLINICAL APPROACH
Perhaps one of our most significant adaptations of psychology to medicine is approaching behavioral science teaching using the “see one, do one, teach one” training axiom, a method familiar to physicians. Unlike traditional psychology training, which often includes devouring textbooks and articles on a particular mental health condition before going near a patient, physician training occurs at a much more rapid pace over a significantly shorter time frame. Not surprisingly, resident physicians are much more interested in actually treating patients with behavioral health issues in vivo. Heeding their recommendations, we modified our behavioral science curriculum to include specialty clinics in which the psychology fellow and physician resident apply the didactic materials and interventions with actual patients. The result has been a cross-pollination of training, application of skills with immediate feedback for improvement, and improved patient care in our ambulatory clinic. Two of our specialty clinics are described below.
ADHD Assessment Clinic: PCPs are challenged to meet the demands for the evaluation of Attention Deficit/Hyperactivity Disorder (AD/HD). Baseline assessment of resident physicians within our family medicine residency program suggests that many are skeptical of a media driven diagnosis, unfamiliar with basic screening measures for AD/HD, and overwhelmed by how to address such a request during a 15-minute appointment. Didactic sessions alone did not seem to assist the residents with understanding the multifaceted approach to assessment and treatment. Further, traditional referrals to psychology for an initial evaluation left the psychology fellow overloaded with AD/HD assessment cases. This model was one in which services were co-located at best. In addition, there were disjointed work-ups of cases due to lack of continuity among referring and treating physicians. It appeared that utilizing a traditional method of teaching led to minimal application of learning.
The AD/HD Assessment Clinic allows the physician and psychologist to conduct a complete evaluation of the patient from start to finish. We were intentional in our choice of assessment measures, ensuring that the measures chosen were appropriate for use in a primary care clinic setting. Prior to being scheduled in the Clinic, assessment measures and a biopsychosocial history questionnaire are completed by parent and teacher and returned to our office for scoring by the psychologist. Resident physicians are educated in the interpretation of the results and the history questionnaire is reviewed by both the psychologist and physician to determine clarifying questions for the clinical interview. Physicians are trained in the implementation of a DSM-oriented differential diagnosis checklist for use during the clinical interview. They are also given a physical exam form specific to the Clinic that includes appropriate medical screening cues (e.g., vision, hearing, lead level, etc.). The Clinic is run by the psychology fellow and the resident physician on the Behavioral Science Rotation. The case is precepted by a psychology supervisor and faculty physician. Psychology fellows are trained to act in a supervisory yet collaborative role to the resident. The resident physician precepts the cases with a physician faculty member, to give them practice in formulating an assessment, treatment, and plan.
CASE 1
A recent patient evaluated in the AD/HD Assessment Clinic was a 17-year-old male who presented with his mother for the appointment. Assessment measures completed by both his parent and teacher suggested sub-clinical levels of inattention and hyperactivity but indicated clinically significant levels of both anxiety and depression. The biopsychosocial history questionnaire revealed a recently diagnosed learning disorder for which the patient was receiving services from the school system for the first time this year. It further noted a family history of depression and anxiety disorders. The physical exam conducted by the physician was within normal limits. The clinical interview co-conducted by the psychologist and physician clarified the anxious and depressive symptoms and indicated evidence for diagnoses of major depressive disorder and generalized anxiety disorder. The patient noted he has had depressive and anxious symptoms for several years and has never been treated. He indicated that the services he is receiving through the school system this year have been helpful to date, but he continues to experience difficulty concentrating. A discussion with the patient and parent regarding the results of the assessment measures in addition to the clinical interview and physical exam resulted in commencement of a psychotropic medication written by the physician and a referral to the psychologist for outpatient psychotherapy. Both patient and parent appeared satisfied with the results of the Assessment Clinic. Appropriate treatment based on accurate diagnosis occurred.
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Lifestyle Change Clinic: It is no surprise that promotion of healthy behavior and preventive medicine are cardinal features of primary care. What is surprising is just how challenged physicians are to successfully address such issues. Discussions with both our resident and faculty physicians indicated their frustration in managing behavior change in their patients (e.g., smoking cessation, weight management, sedentary lifestyle, non-compliance with medication and other treatment recommendations, etc.). Many engaged in overly directive, paternalistic approaches to the management of such issues (“You must quit smoking or you will die.”) and were left feeling less than satisfied with the outcome. Although we had been teaching didactics on health related behavior change and motivational interviewing, it appeared that the application of the model and motivational interviewing techniques were not occurring. And so, the development of the Lifestyle Change Clinic began. Resident physician and psychology fellow work together to address smoking cessation, weight loss, and sedentary lifestyle issues with patients referred by the physicians. It is during this Clinic that resident physicians have the opportunity to apply the stage of change model and motivational interviewing techniques while receiving immediate feedback from their psychology fellow colleague.
Cross-training continues to occur as resident physicians become aware of the importance of several key factors: patients’ readiness to change, levels of motivation, and confidence to change behaviors. Psychology fellows are enlightened by the impact smoking and obesity have on a variety of medical conditions and the long term health effects of medications to manage such conditions. Both trainees gain an appreciation for the slow progress of changing behavior while patient satisfaction appears to increase because dedicated time is made for addressing such concerns. As physicians’ confidence increases and efficiency improves via continued practice with such interventions in the Clinic, they are more likely to utilize such interventions with their own patients during scheduled office visits.
Perhaps what is most striking about this Clinic is the physician’s and psychologist’s ability to see several patients who are in various stages of change and have a fruitful discussion about the realities of successfully changing a patient’s behavior. This reflective discussion paired with patient encounters allows resident physicians the ability to measure success in changing their patient’s behavior with a different stick. Whereas previously they may have considered themselves unsuccessful, reporting dissatisfaction with patient encounters, they now view success via small yet measurable steps along the behavior change continuum.
The integration of psychology fellow and physician resident training via these specialty clinics has had significant positive impact on both types of trainees. Among the many benefits of this model, the psychology fellow gains clearer insight and understanding of the rapid pace of primary care and the needs of their physician colleagues while the physician residents acquires an appreciation and skill set for behavioral medicine interventions and techniques that improve patient care and satisfaction.
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