by William G. Elder, Ph.D.
Integrated health care (IHC) creates new opportunities for psychologists willing to adapt themselves to the primary care environment (Freeman, 2007). According to Garcia-Shelton, this is the “frontier of psychology … a place where psychologists can make a real difference” (p.678). Psychologists are needed for two main reasons. First, the majority of patients with mental disorders are seen in primary care (Reiger et al 1993). Second, there is increasing recognition of the importance of psychosocial factors in the etiology and treatment of physical disease (Institute of Medicine, 2001). Among American Psychological Association (APA) members, 25% now work in medical settings; primary care settings represent one source of this expansion (Kohut, Li & Wicherski, 2007). Just as work in the medical setting requires special skills (Stone, 1991, Rozensky, Sweet and Tobin 1991), primary care psychology has a unique scope and style of practice (Bray, 2006). In this article, I describe my work in a primary care setting and identify the competencies necessary.
TYPES OF IHC
In IHC, the psychologist is part of the treatment team and may facilitate sessions or see the patient with the physician. A major aspect is to increase efficiency and effectiveness of service by understanding how the system works and how mental and behavioral problems impact patients and care. Problems addressed include responses to illness, developmental or situational issues, acute or chronic physical illness management, self management, compliance and adherence and relationships between primary care providers (PCPs) and patient, and among members of the team. These problems and needs are clearly within the scope of psychology practice (Garcia-Shelton, 2006).
IHC is one of three main models used in the primary care settings (Berg-Cross, Mwendwa, Crump & Griffith, 2007). The Co-Location Model is essentially a private practice model with the psychologist and medical providers sharing the same location, which facilitates referrals and communication. In the Consultant Model, the psychologist evaluates patients so that each patient’s medical treatment plan is more bio-psychosocially oriented. Psychologists provide information to the medical providers to enhance their treatment decisions, perform brief psychological interventions and deliver typically brief interventions with patients. The psychologist in this model is often seen as the expert on mental health in the clinic (Rowan and Runyon 2005).
In my work, I move in and among these models flexibly depending on the needs of the patient and demands of the situation. It should be noted that most of my cases involve mental health diagnoses; referrals for health behavior problems are increasing but represent a relatively small part of my practice.
MODIFIED CO-LOCATION MODEL
Practice of this model might start with an urgent call from one of our PCPs asking me to see a patient. For example, the PCP might have learned from a family member that a patient is suicidal. The PCP might contact the patient directly and, based on existing confidence in the PCP, the patient may comply with a suggestion to see me. I try to see the patient the same day. My goal would be to do crisis intervention and to start the best treatment for this patient. Benefiting from positive transference brought by the relationship with the referring physician, a patient with very depressed mood and even psychomotor retardation will typically be able to open up to me. If I decide the patient will benefit from hospitalization, our nurse escorts the patient to our emergency department to be evaluated for possible admission by a psychiatrist whom I have called. After treatment, the patient may be discharged into my outpatient care with medication management by the PCP. I would see the patient fairly frequently early in the course of treatment, titrating frequency based on need for support. As the patient is able we would uncover and process issues and typically apply a cognitive-behavioral approach to treat depression and hopelessness. In some sessions, I take advantage of positive transference held towards the PCP (and thus vary from the co-location model) by having the physician see the patient with me. Early in the course of therapy these sessions give encouragement and enhance self-esteem. Later in care, such sessions inform the PCP about patient emotional issues and how these have been resolved, and facilitate transfer of the patient back to follow-up exclusively by the PCP. The patient will be open to return to me for consults if the need arises and if medication changes are considered.
INTEGRATED HEALTH CARE MODEL
From my perspective, application of the IHC model is marked by the degree to which I work with the patient and the team to improve medical visit outcomes and to facilitate patient adherence to plans and interventions. Often a case will begin as a consult, where the PCP is seeking to improve patient outcome with an existing treatment plan. After meeting with the patient I may discover that the patient is not adhering to the current treatment plan. I will analyze the situation to determine what patient, provider and system factors may be contributory. Sometimes the issue is trust in their PCP or the patient may be exhibiting dependency. If the latter, I advise the physician on how to recognize and work with patients who are over-dependent, as well as work with this patient directly. An example of a physician factor is the number of residents seeing patients; patients need an opportunity to express how they may feel about this and assistance determining if they are receiving appropriate help. Systems issues, especially with patients who are compromised in functioning, are numerous and patients require assistance navigating the system. Problems such as these may manifest when patients do not keep their scheduled appointments. If already involved in care I will call the patient myself to understand what happened. Sometimes the patient will have forgotten, and we will reschedule. Sometimes it is apparent that the mental or physical difficulties are interfering with ability to adhere. These may be addressed by enlisting a family member’s instrumental support, with the patient’s permission.
Application of the IHC model sometimes involves brief behavioral interventions. As an example, I may provide mind-body interventions such as relaxation training in the exam room to help patients manage anxiety associated with blood draws or procedures such as pelvic exams. I also see patients for brief advice to modify health risk behaviors and conditions like smoking and overeating.
I get frequent referrals for consults. Some are for health behavior disorders asking for advice about “what do to differently with this patient?” Many are for mental disorders, seeking guidance on diagnosis or medication recommendations. Referrals of patients for whom potentially addictive medications are prescribed are increasing. These referrals are motivated by increasing recognition that some medications are harmful for patients in the long term. These referrals involve several different questions, “What’s the patient’s diagnosis? Are they abusing their medications? What’s the best treatment? And, how should I manage their care?” These types of evaluations often will involve psychological testing. Like others I am using psychological tools less but find them particularly useful when I am trying to form a reasonably quick opinion of diagnosis and determine treatment options. Recommendations often include behavioral interventions by our mental health team.
COMPETENCIES FOR IHC PRACTICE
As noted earlier, the practice of IHC constitutes a unique scope and style of practice. Primary care presents a multitude of demands, therefore flexibility in approach is essential (Hass & deGruy, 2005). Many IHC activities and requisite psychological skills are related to creating a coordinated response to PCPs’ philosophies and styles of practices. According to Bray (2006), primary care practice is driven by biomedical research and technological solutions. There are hierarchical relationships, with physicians at the top. Physicians have been trained to take personal responsibility for patient outcomes and therefore are reluctant to share decision making. They seek to quickly answer and fix patients’ problems. From psychologists, they want to obtain concise information and recommendations and or competent care for their patients. They want to be informed about patient progress and may not appreciate or understand psychologists’ confidentiality issues.
COMPETENCIES FOR IHC PRACTICE
William G. Elder, PhD, is a clinical psychologist at the University of Kentucky Department of Family and Community Medicine, where he is an Associate Professor and Director of Behavioral Science. From 2003 to 2007, he represented psychology on a federal advisory committee on training programs for healthcare professions and was a chair for reviews of the psychology training grants awarded by the Health Resources and Services Administration. He has been credentialed by the National Register since 1993.
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