The Register Report, Fall 2007 Working Together: Integrated Health Care Graduate School Practica in Primary Care Settings: Building Identity and Competencies by Linda Berg-Cross, Ph.D., Denee Thomas Mwendwa, Ph.D., Stacey L. Crump, M.S. and Richard Griffith, M.S. Return to Table of Contents

There are many definitions emerging to define a primary care psychologist. McDaniel, Hargrove, Belar, Schroeder, & Freeman (2003) succinctly and aptly state “a psychologist who works in primary care is a general practitioner of common health problems experienced by patients and families throughout the lifespan” (p.66). Training for primary care practice is happening at all career levels.

Seasoned practitioners take fellowships, self-study, and continuing education to retool for this new professional opportunity. There are postdoctoral settings now devoted to primary care practice, including the University of Mississippi Family Medical Center and the Bethesda Family Practice Residency Program in Cincinnati (Talen, Fraser, and Cauley, 2002). Many pre-doctoral internships are developing a rotation in primary care, including Wright State University and Yeshiva University (Talen et al., 2002 and Zweig et al., 2005). At the doctoral level, Howard University strives to give interested students a strong academic foundation and appropriate practicum experiences to shape their identity as primary care psychologists.

In the following article we discuss: a) the evolution of our primary care practicum through the 5W exercise, b) the competencies required of a primary care psychologist, and c) the experiences of practicum students at the sites, with an emphasis on the relational dimension, collaboration, and ethical issues.

THE EVOLUTION OF HOWARD’S PRIMARY CARE PRACTICUM

Howard University’s clinical psychology program, with support from the Department of Health and Human Services HRSA grant #4D40HP00004-04-02, developed a doctoral behavioral health practicum located in an ambulatory primary health care facility. The People’s Community Wellness Center (TPCWC), in conjunction with The People’s Community Baptist Church and the Montgomery County government, founded an ambulatory healthcare facility to provide low-income uninsured residents with primary health care service. The center utilizes a multidisciplinary approach to provide medical prevention and treatment services to underserved populations in efforts to address the growing health care disparities within the county. Howard University students are integrated into this system of care to deliver critical psychological and behavioral health services to patients presenting a multitude of health-related problems. The behavioral interventions vary from lifestyle modifications to cognitive behavioral therapy to helping individuals’ access job searches on the Internet. Consultations range from treating stress-related medical problems, such as hypertension and gastrointestinal disorders, to medication adherence or apprehension about treatment regimens.

Howard’s program is not the only doctoral program training graduate students to work in primary care settings. Howard has chosen to focus on the management of chronic illness, medication adherence, and previously undiagnosed mental health problems.

When developing a primary care psychology model for our graduate students, we had to answer the five basic questions: who, what, where, why and when.

WHY DO WE WANT TO TRAIN STUDENTS TO WORK IN A PRIMARY CARE SETTING?

Behavioral health services are desperately needed in primary care settings. After all, 60% of primary care visits involve some behavioral health need (Cummings, Cummings and Johnson, 1997). Chronic illnesses constitute the overwhelming number of cases seen in primary care. Proper management of chronic care involves mobilizing patients to change their life styles, maintain positive social networks, and learn effective coping skills (e.g. to deal with pain, disability, and loss). Primary care settings allow psychology students to intervene in patient-physician and patient-family relationships, which are critical to the overall care of patients. Talen and colleagues (2002) note the importance of practica trainees acquiring the skills to identify relationship dynamics and the impact of these relationships on treatment outcomes. Doctoral students assist other practitioners with patient treatment adherence. Psychosocial factors often contribute to patients’ reluctance to adhere to a treatment regimen. Practicum trainees offer recommendations to physicians and patients to ensure better treatment compliance. In addition, doctoral students use psychological interventions to help minimize the negative impact of the illness and prevent co-morbid conditions from developing, such as depression and anxiety.

Indeed, depression and anxiety are the most common unrecognized and untreated mental health conditions seen by primary care practitioners. Studies in primary care settings indicate many patients who meet the criteria for affective or anxiety disorders are never identified and/or treated (Beck, 2001; Coyne, Thompson, Klinkman, and Nease, 2002). When considering anxiety and other psychological disorders, the percentage of undiagnosed and untreated patients in a given year is nearly 28 percent according to epidemiological research studies (Narrow, Reiger, Rae, Manderscheid, Locke, & Goodwin et al., 1993).

In cases where primary care physicians correctly diagnose their patients with psychiatric conditions, many are unaware of the most effective psychological interventions or do not have the time or expertise to deliver such interventions. Therefore, psychologists situated in primary care settings help fill this treatment gap. APA (1998) has strongly endorsed the training of psychologists for primary care noting, “Given the nature of problems presented in primary care, psychologists need to be an essential part of that inter-professional primary healthcare team (APA, 1998, p 5)”.

WHO DO WE WANT TO SERVE IN PRIMARY CARE SETTINGS?

Howard’s program is dedicated to training psychology health care service providers committed to treating African Americans and other racial and ethnic groups who historically have been denied equal access to quality health care. They are less likely to receive proper diagnoses and effective treatment for mental disorders as compared to Caucasian Americans (Satcher, 1999). This can be attributed to a myriad of factors. First, there is an under-representation of ethnic minority psychologists as practitioners. For example, only 2% of psychologists are African American (Holzer, Goldsmith, & Ciarlo, 1998), although African Americans constitute 12% of the US population (U.S. Census Bureau, 2002). Second, a lack of multi-cultural training has interfered with psychologists’ ability to form successful therapeutic relationships and working alliances with ethnic minority clients. This has led to the development of cultural biases by clinicians and contributed to ethnic minority clients being misdiagnosed and receiving inadequate treatment (Delbello, 2002). Finally, cultural mistrust and concerns about stigma has often interfered with ethnic minorities seeking and participating in mental health treatment (Satcher, 1999).

Ethnic minorities are more likely to suffer from health disparities (DHHS, 2000; CDC, 2002). Disparities exist for each of the top ten risk factors derived by Healthy Peoples’ 2010 nationwide disease prevention and health promotion initiative (DHHS, 2000). The leading health indicators are physical inactivity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental illness, injury and violence, poor environmental quality, lack of immunizations, and inability to access health care.

Therefore, we needed to form an alliance with a non-profit medical clinic that provided ambulatory services to the uninsured. By doing so, we hoped we would have a greater chance of capturing ethnic minorities in need of behavioral health services, who otherwise may have been reluctant to receive mental health treatment in more traditional settings.

WHAT MODELS EXIST FOR TRAINING IN PRIMARY CARE SETTINGS? AND WHAT COMPETENCIES DO WE WANT TRAINEES TO LEARN?

There are currently three major models for how to integrate behavioral health care into primary care settings: the co-location model; the integrated care model, and the consultant model. The co-location model involves a psychologist sharing the physical space with a primary care clinic and perhaps sharing the receptionist and billing personnel. The proximity leads to increased opportunity for referrals and easy communication about how to help particular clients. Psychologists in this capacity provide more traditional mental health services and function as separate entities within the same space (Garcia-Shelton, L., 2006; O’Donohue, Byrd, Cummings, & Henderson, 2005). This model of care is not conducive to a practicum setting since opportunities for students to interact with the other clinic professionals would be severely limited due to the pace of office practices in today’s world.

In the integrated care model, the psychologist is part of the treatment team and may see the patient with the doctor or facilitate family sessions or patient groups. The integrated care model might be a very attractive model for practicum placements, since one of the limitations of this model is that with so many professionals in the room, only the PCP gets to bill for their time. Usually, the integrated care model has salaried psychologists that function like the receptionist and nurse, helping the doctor deliver services effectively and efficiently. This model would work best at large clinics with multiple primary care physicians so that there would be enough appropriate cases to offer the integrated care recommended at the times the students were on site. continued

 

Page 1

Page 1 2 3