The following two articles have been combined for CE credit: "Collaborative Care: Comprehensive Healthcare Done Right" and "The Impact of Behavioral Medicine on Primary Care Practice and Training in the Department of Family Medicine at Harbor UCLA Medical Center."
Collaborative Care: Comprehensive Healthcare Done Right
Benjamin F. Miller, PsyD, and Randall Reitz, PhD
Recent developments in primary healthcare portend exciting opportunity and broad changes in the mental health field. While these movements have their roots outside psychology, our field and practitioners are wise to pay them serious attention, or risk being caught unprepared in a deeply shifted healthcare landscape. This article will provide a primer on collaborative care and its role within the Patient-Centered Medical Home (PCMH). In concert, both these approaches are in their formative stage, and psychologists have an excellent opportunity to influence their role. Psychologists can also lead the practiced-based research that will ultimately inform the model of collaborative care included within the PCMH.
The fact that mental health and primary care are inseparable is well documented (Blount, 1998; deGruy, 1996; Regier et al., 1993). The convergent trajectory of these two areas is an example of how the silo mentality and dualistic approach to health is beginning to change. While there is consensus on the need to overcome the mind-body split, stakeholders are still refining and negotiating a clinical, operational, and financial system to accommodate comprehensive care. What is present in this country is not a system of care, as a system interacts to form a unified whole. Instead, we have fragmented silos. Therefore, we are faced with exploding costs in an attempt to maintain the status quo.
Despite paying more than double for healthcare than other industrialized countries (Anderson, Frogner, Johns, & Reinhardt, 2006), the United States scored only a 69 out of 100 on a National Scorecard on performance in healthcare (Schoen, Davis, How, & Schoenbaum, 2006). While many stakeholders have recommended reform for years (The Institute of Medicine, 2001), these same entrenched healthcare interests seem to have our model in paralysis. Fortunately, the small movements to stimulate medical and mental health services in primary care settings show the best promise of meeting the needs of the American public (Blount, 1998; Blount & Bayona, 1994; Institute of Medicine, 2002).
What does a system look like that integrates physical and mental health services in the same setting? Often, this is accomplished when psychologists and other mental health specialists collaborate with primary care physicians. Collaborative teams vary from rudimentary (i.e. developing a preferred referral relationship with a physician group), to complete integration (i.e. requiring an operational, structural, and financial transformation of a clinic). Doherty, McDaniel, and Baird (1996) have offered a five-level continuum describing levels of collaboration that can occur alongside varying degrees of integration. While this continuum does imply a certain hierarchy of values, it is one of the few models proposed which outline the different degrees of integration.
Many psychologists work in settings where collaboration typically falls between level one and level two categories. Psychologists may receive physician referrals through phone, fax, email, or written recommendation. This has often been the approach outpatient mental health services have used. These levels of collaboration have often sufficed in cases that do not involve psychotropic medications, for family therapy, or for specialty care such as court-mandated therapy and inpatient substance abuse treatment.
Collaboration at a distance
(Some direct communication)
Basic on-site Collaboration
Close Collaboration in a partly integrated system
Close Collaboration in a fully integrated system
The advantages of levels one and two collaboration are that the treatment strays little from familiar psychologist skill sets and the referral process is often typical. The shortcomings of off-site collaboration include:
- Poor follow through and high no-show rates for external referrals,
- Extra work required by the patient in establishing care with the psychologist,
- Lack of inter-professional familiarity,
- Difficulty scheduling interdisciplinary consults and joint interventions, and
- Disconnect in communication and treatment planning.
Common characteristics of highly integrated clinics (i.e. levels four and five) are on-site full-time mental health staff, combined medical record and billing services, universal screening for depression and substance abuse, enhanced assessment of mental health issues, and focus on treatment approaches that encourage shared patient care.
Psychologists’ graduate school training often prepares for more practical familiarity and facility with basic collaboration. Advance shared patient care requires an advance level of skills that psychologists may or may not have received in graduate school. Success can occur early in an integrated practice by facilitating “warm introductions” between disciplines at the time of a client visit. Other options include “bump in the hall” consults, joint appointments for more complex cases, mental health intakes, on-site psychiatry, group medical appointments, and case conferences.
Collaborative practices that have integrated psychologists excel through their ability to address any health issue, regardless of it being mental or physical (Robinson & Reiter, 2007; Strosahl, 1997; Strosahl & Robinson, 2008). For example, many primary care psychologists partner with physicians to provide population-based care on specific issues such as depression (Katon et al., 1996; Unutzer et al., 2002). This includes universal screening, assertive outreach, and tracking outcomes. Regardless of the type of model recommended, the more important point is that behavioral health is included within primary care vis-à-vis the patient centered medical home (Petterson et al., 2008).
Patient-Centered Medical Home
The medical home has gained more attention recently as policy makers, clinicians, researchers, and most importantly, patients recognize that something has to change within healthcare to create more positive health outcomes. Interestingly, however, the concept of the medical home is not new, as it was first recommended by the American Academy of Pediatrics in 1967 (Sia, Tonniges, Osterhaus, & Taba, 2004). Just as the American Academy of Family Physicians (AAFP) has defined primary care practices as a patient’s first point of entry into the health care system and continual focal point for all needed health care services, so too does the medical home build upon comprehensive care and continuity. It is at the crossroads of all-inclusive care and continuous service that psychology can have the most impact.
The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association have released the Joint Principles of the Patient-Centered Medical Home (AAFP, 2009), which address whole person orientation, coordinated and integrated care, and enhanced access. These principles could be considered appealing to psychologists and conducive to a collaborative care model. The Medical Home concept has received considerable backing from the medical mainstream, Medicaid, Medicare, the Obama administration, recent laws, and popular media. As the movement comes to fruition, primary care will increase its status as the portal to care, the coordinator of care, and the source of specialty referrals. The psychologist with an office in the medical home will be well-situated to affect change.
Support for Collaborative Care
Recent reviews of integrating mental health into primary care outline positive outcomes, but stop short of recommending a particular model or approach for the medical home (Butler et al., 2008). In fact, one area in need of future research is testing specific components of models in an attempt to determine which elements are most necessary for successful outcomes. Further, by deconstructing models and using preliminary metrics to examine what elements of collaborative care more positively affect clinical, operational, and financial outcomes, we will be able to better inform policy makers, administrators, and others if one collaborative care model outweighs another model (Miller, Mendenhall, & Malik, 2009).
One problem that remains is that collaborative care services have grown in regional pockets, and to date there has not been a centralized data set to answer the more complex empirical questions about the effectiveness of collaborative care. If psychology were to take a page from medicine’s book, practice-based research networks would be at the top of the page.
Why Practice-Based Research Networks?
According to the Agency for Healthcare Research and Quality (AHRQ), Practice-Based Research Networks (PBRN) are based in primary care, and involve community-based clinicians and staff in specific activities designed to understand and improve primary care. The AHRQ webpage states: “The best of PBRN efforts link relevant clinical questions with rigorous research methods in community settings to produce scientific information that is externally valid, and, in theory, assimilated more easily into everyday practice.”
AHRQ defines PBRNs as “a group of ambulatory practices devoted principally to the primary care of patients, and affiliated in their mission to investigate questions related to commitment to network activities and an organizational structure that transcends a single research project. PBRNs often link practicing clinicians with investigators experienced in clinical and health services research, while at the same time enhancing the research skills of the network members” (http://www.ahrq.gov/research/pbrn/pbrnfact.htm). See Green and Hickner (2006) for a history of PBRNs.
Building off the idea that a national network is stronger than individual practices in examining research questions, the Collaborative Care Research Network (CCRN), a sub-network of the American Academy of Family Physicians National Research Network, was created to implement a national, practice based research agenda to evaluate the effectiveness of collaboration between psychology, substance abuse interventions, and primary medical care. The CCRN is actively recruiting providers and practices to join its network (www.aafp.org/nrn/ccrn) in order to best answer questions about collaborative care that have yet to be answered.
|RISKS AND REWARDS FOR PSYCHOLOGISTS
What Can a Psychologist Do To Engage These Movements?
Attend Training: In many ways, collaborative care requires a different skill set and mentality from traditional psychology practice. One excellent opportunity for training is the Primary Care Behavioral Health Certificate Program offered by the University of Massachusetts Medical School (Blount & Miller, 2009). The certificate program consists of six monthly training sessions that are offered onsite or live via web-conference. The Collaborative Family Healthcare Association (CFHA) is a professional organization that champions collaborative care. They offer an annual conference (October 22-24, 2009 in San Diego, CA) that provides dozens of workshops to orient the beginner and enhance the practice of the seasoned collaborator (www.cfha.net).
Know How to Market Your Skills: At its heart, collaboration is a social interaction. When given an audience with possible physician collaborators, make the most of your face-time to explain how a psychologist can be helpful for numerous behavioral interventions, including advanced diagnostics, brief therapy, lifestyle interventions for chronic medical problems, and addictions treatment; and be able to do this in as little time as possible. Test things out with level one collaboration and if mutually agreeable, move toward closer integration or a partnership.
Make Your Voice Heard: Collaborative care and the medical home are actively being discussed at places like primary care associations and physician groups. These local, state, and national groups are often eager to talk with psychologists. State psychological associations need informed, determined psychologists who understand primary care to lead the way in medical home initiatives and engage other stakeholders in conversations on healthcare.
Through ongoing clinical practice and research, macrosystemic change can occur. Once metrics of collaborative care are empirically validated, specific recommendations on how mental health should be integrated into the medical home will be clearer. For now, it is psychology’s responsibility to advocate for inclusion within a system that has excluded them by separating the mind and the body. Fortunately, collaborative care and medical home movements have opened the primary care door for many psychologists.
Benjamin Miller, PsyD, is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine. Miller is a Board member for the Collaborative Family Healthcare Association and the Administrative Director and co-creator of the Collaborative Care Research Network (CCRN), a national network examining the research to support collaborative care.
Randall Reitz, PhD, is the Director of Behavioral Sciences at St. Mary's Family Medicine Residency in Grand Junction, CO. His clinical work and research has focused on group medical treatment in safety net family medicine clinics. He has organized and facilitated treatment groups on diabetes, chronic pain, obesity, depression, anxiety, OCD, lifestyle change, and health promotion.
Joint Principles of the Patient-Centered Medical Home. Available at: http://www.aafp.org/pcmh/principles.pdf. Accessed March 20, 2009
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The Impact of Behavioral Medicine on Primary Care Practice and Training in the Department of Family Medicine at Harbor UCLA Medical Center
Harriet Boxer, PhD, and Jed Grodin, PhD
It is undeniable that psychology has a great deal to offer primary care physicians. Historically, primary care physicians are at the front lines of providing mental health care to their patients. This has included both the initial identification of a mental health problem as well as ongoing mental health care, including providing psychotropic medication. There is a growing awareness in primary care of how mental health issues and behavioral patterns can influence the outcome of many medical issues.
The importance of mental health training in Primary Care has been recognized by the Accreditation Counsel for General Medical Education (ACGME) which has designed Core Competencies that emphasize psychological factors such as effective interpersonal and communication skills for physicians. In addition, residencies must provide a psychological support system for the residents during their training. Psychologists frequently fill the role of providing training in behavioral medicine and also provide the residents with individual and group opportunities to explore their own emotional and behavioral functioning in the context of providing care to their patients.
Primary healthcare is increasingly focused on providing lifelong healthcare and management of chronic medical conditions. With this focus, there is an increasing awareness of the necessity of a collaborative paradigm that includes the understanding that the patient is an active participant in his/her health rather than a passive receiver of treatment. The concept of self-management support emphasizes the need to enhance patients’ skill and self-efficacy in managing their chronic illness. For this paradigm to be successful, effective communication skills and self-management techniques need to be employed consistently. These concepts are fundamental to psychology and hold a great deal of promise in helping patients with medical issues. Consequently, the potential of behavioral medicine in helping patients is being recognized and the role of psychology is expanding. This article describes how behavioral medicine is integrated into the Department of Family Medicine at Harbor-UCLA Medical Center.
The Harbor-UCLA Department of Family Medicine operates within Harbor-UCLA Medical Center, a public academic hospital that serves as a safety net provider for a significant portion of the uninsured inhabitants of the Los Angeles County.
Dedicated to training physicians to provide primary care to underserved populations, the program has 36 residents (12 per year), 3 faculty development PGY 4 Fellows and 2 Sports Medicine Fellows. The Department operates two community-based training sites and a school-based clinic that provides a combined total of 54,000 primary care patient visits per year, plus additional specialized services including office procedures, geriatrics and sports medicine consultations, EKG treadmill testing, and prenatal care.
The department features a team of three Behavioral Medicine psychologists whose duties include direct patient care; consultation and training for the residents and faculty; and participation in departmental and personnel issues. The team is comprised of one full-time psychologist who exclusively provides assessment and psychotherapy; one half-time psychologist who splits time between consultation, training, patient care services, and departmental duties; and, in collaboration with the department of psychology at Harbor-UCLA, one behavioral medicine psychology post-doctoral fellow. The postdoctoral fellow’s time is divided between consultation, assessment, and psychotherapy services.
The Behavioral Medicine team works in collaboration with family medicine residents and attending faculty and provides services in the outpatient clinic (located a few miles from the main hospital campus) and the department’s inpatient service at the main hospital. Following is a description of these duties by category in the outpatient and inpatient setting.
Collaborative Direct Patient Care: Assessment and Psychotherapy
The psychology team provides assessment and short-term psychotherapy to patients served by the department. When a question regarding psychological issues is identified by the provider, either through precepting with an attending physician or in consultation with one of the psychologists, the patient is referred to the psychology team who will meet with the patient. Assessment referrals address identifying and clarifying diagnoses of psychopathology (e.g., depression, anxiety, psychotic disorders, substance abuse), psychosocial issues such as stress management, and mental states and basic neuropsychological problems. Additionally, referrals frequently entail assistance in identifying factors contributing to difficulties with treatment, i.e., problematic health behaviors (e.g., poor diet, medication and treatment noncompliance) and personality factors potentially associated with communication and treatment difficulties. A psychologist will schedule single or multiple assessment sessions, which may include structured and unstructured interviews and objective measures and will communicate findings and collaborate on treatment plans with the referring provider.
When requested and indicated, the psychologists will initiate short-term psychotherapy with patients to address psychopathology as it relates to health behavior issues. The course of psychotherapy can range from as few as two sessions to between ten and twenty sessions and are mostly CBT-based. Some of these interventions are specifically health behavior related such as Motivational Interviewing to increase treatment adherence or coping skills training to improve stress management; while other interventions are more focused on the treatment of depression, anxiety, and other Axis I disorders independent of a patient’s medical status. In some small number of cases, the psychologist elects to extend the treatment into longer-term psychotherapy when appropriate and possible given case-load and time constraints. The psychologist remains in communication with the patient’s medical provider insofar as issues in treatment relate to the patient’s physical health.
Consultation: Inpatient and Outpatient
The psychologists consult on cases for both the outpatient clinics and inpatient hospital services. These consults are somewhat less involved than assessment referrals in that they usually take place on the spot while the patient is in our facilities either with or without direct patient contact.
On the inpatient services most consults are generated during the inpatient rounds meeting. At these meetings the residents present current cases to the medical attending and the psychologists. Residents or attending physicians will request a formal consult when a patient is presenting with possible psychopathology, e.g., depression, anxiety, thought disorders, when the patient or patient’s family may be in need of support and counseling, or when the patient or patient’s family is exhibiting behavior that interferes with treatment. The psychologist will discuss the case with the inpatient team to determine the appropriateness of the referral and will either visit the patient at bedside or will provide consultation directly to the resident without visiting the patient. If a formal consult is performed, the psychologist will communicate directly with the referring provider about the findings so that the findings can help contribute to a collaborative care plan. For example, for a recent patient presenting with non-specific pain, the consulting psychologist helped the inpatient team understand and address the patient’s health anxiety in a culturally sensitive manner while necessary diagnostic testing was conducted to determine if there was a medical cause for the pain. It should also be noted that Harbor-UCLA Medical Center has an excellent Department of Psychiatry and an active medical Consultation-Liaison service which can be consulted for issues such as active psychosis, suicidality, homicidality, and other high risk psychiatric issues.
In the outpatient clinic, informal, on-the-fly consults are more common than formal consults (which more frequently take the form of more involved assessments). In these cases, residents and attendings will contact the psychologist when they have a question about a patient who is currently presenting in the clinic. As with the inpatient services, these informal consults range from helping the resident diagnose and address clinical and sub-clinical disorders to aiding the resident in managing complexities of doctor/patient relationships.
On both the inpatient and outpatient services, the psychologist often has to be very proactive in educating the providers about the utility of a behavioral medicine consult. This is often the case when working with a newer resident who is not aware of the role of psychology in the clinic. The psychologist, therefore, must be a full participant in the rounds and the conversations in the precepting room and has to actively inquire into psychological aspects of current cases. The psychologist must work to educate the residents about the psychological dimensions of medical care and the range of resources available via the consultation process. In this way, the consultation process is an opportunity for the psychologist to provide valuable training, the topic to which we now turn.
The role of psychologist as teacher takes place both informally and formally in several settings within the department. In terms of informal training, opportunities to train present themselves on a daily basis. Throughout the consultation process and the provision of assessment and psychotherapy services, our psychologists communicate and collaborate with the referring providers and, in doing so, are given multiple opportunities to provide education and training. For example, when providing a consultation on an inpatient with longstanding alcohol dependence, the psychologist may teach the referring provider about the signs, symptoms, and psychological sequelae of the disorder for the patient and the patient’s family. In addition, the psychologist may provide guidance on communication skills and strategies related to any number of encounters.
More formally, the psychologists deliver training lectures and workshops to the residents and the attending physicians on a variety of topics regularly. These include recent trainings in motivational interviewing and other brief interventions to address health behavior problems, lectures on the interaction between mental and physical health, the diagnosis and treatment of psychopathology, psychiatric emergencies, cultural aspects of mental health, as well as topics specifically related to patient care such as managing patient prescription drug use, “dealing with difficult encounters” communication skills training, and additional topics that fulfill the ACGME requirements.
In addition to these lectures and workshops, the psychologists regularly co-precept a series called “Interventions in Family Medicine”. In this series, residents regularly schedule patients presenting with issues related to a selected theme, such as our current themes of nutrition and diabetes. In the session, the resident will focus on using a psychological intervention technique such as motivational interviewing and the psychologist will observe and supervise alongside a medical attending. This provides the resident with the opportunity to be observed and coached in real-time as she/he applies the training material to actual patients.
The residents have several scheduled appointments with the psychologist during their training year to discuss a patient who has been particularly challenging or perplexing because of behavioral or psychological issues. Residents are encouraged to bring the patient in during these appointment times so that they can work collaboratively with the psychologist in interviewing the patient. In this way, the resident can observe how a psychologist would work with a patient.
The psychologists also observe the residents with their patients via a one-way mirror or video in order to provide feedback regarding residents’ communication skills and interaction patterns. Although residents often report this experience as nerve-wracking, the vast majority report that the input that they receive from the psychologist has been invaluable for them in building their communication skills with patients. Additionally, when given the opportunity to observe themselves via video-recording, residents gain very useful insights into their communication skills and style. Residents tend to come away from the experience feeling both validated and challenged to grow.
Personnel and Departmental Role
Finally, the psychologist team participates in a number of departmental meetings on topics including the curriculum, faculty business, resident well-being, and resident disciplinary/progress. The psychologist offers psychological insight into personnel conflicts, possible changes to the training program, factors related to work stress and well-being, and findings that may improve education and remediation plans for residents. Residents with performance issues have been identified as having issues such as attention deficit/hyperactivity disorder or a depressive disorder or substance abuse issues and have been referred for appropriate treatment. Additionally, the psychologists help the faculty and residents understand the interplay of one’s personal life and one’s professional identity.
As this article demonstrates, the role of the psychologist in the department is multifaceted and requires a great deal of flexibility and creativity on the psychologist’s part. It is necessary for the psychologist to have some knowledge of basic medical conditions, medical procedures and medical terminology. Additionally, it is critical that the psychologist is aware of the milieu and social structure of hospitals and medical environments. Primary care physicians, particularly medical residents and interns, are chronically stressed by their workload, educational requirements and emotional demands of dealing with illness and death. Many tend to see dealing with psychological issues as time intensive distractions from addressing a patient’s medical condition. Additionally, some physicians are concerned that asking about psychological issues will open a can of worms and they will be left with a patient with psychological needs that they cannot address.
It is the psychologist’s ongoing task to educate the primary care physician on how psychological factors impact health status. It is important to make the physician aware of the value and usefulness of the information that the psychologist is sharing; specifically how knowing about and working on psychological issues can make medical care more effective and efficient. Psychological information and behavioral techniques are best learned and utilized when they are combined with other educational opportunities. When they see first-hand how effective these techniques are, primary care physicians tend to be more interested in gaining more knowledge and incorporating the techniques into their practice. In addition, it is just as critical to educate primary care physicians on knowing when mental health conditions are beyond the parameters that they can effectively treat and how to access resources in their community. Education about psychological and behavioral principals seems to work best when it is woven in with the rest of the curricula for family medicine residents. For this to happen, the role of the psychologist must be integrated into all aspects of the department.
Harriet Boxer, PhD, is in private practice in Los Angeles, California and consults to the Los Angeles County Department of Mental Health. She holds adjunct appointments at the University of California Los Angeles and Pepperdine University. She has been credentialed by the National Register since 2003.
Jed Grodin, PhD, is currently the behavioral medicine consultant to the Department of Family Medicine at Harbor-UCLA Medical Center. Dr. Grodin received his doctoral degree from the University of Southern California where he conducted research on Motivational Interviewing and previously served as a Postdoctoral fellow in Behavioral Medicine at Harbor-UCLA after completing internship at the Long Beach VA Medical Center.