Diomaris E. Jurecska and Misti Tuerck
Hospital emergency departments (ED) tend to be fastpaced work environments with patients who have behavioral and emotional problems that have escalated to a potential for harm to self or others (Campbell, Campbell, O’Friel, & Kennedy, 2009). The co-occurring diagnoses of pain and either depression or anxiety are the most common behavioral healthcare problems presented by patients admitted to EDs of general medical hospitals (Fleming, Davis, & Passik, 2008; Grant, 2006; McInstosh & Leffler, 2004). At the same time, ED physicians have limited behavioral health training and insufficient time to address those concerns.
Today there is increasing interest in the provision of behavioral health services in medical environments and a concomitant need for behavioral health care providers qualified to provide those services (Dobmeye, Rowan, Etherage, & Wilson, 2003; Robinson & Reiter, 2007). Current literature reflects a growing trend in time-effective, integrated care to treat the behavioral aspects of physical health concerns (James & O’Donohue, 2009). Thus, this presents an opportunity for graduate students to develop skills in this domain of psychological service delivery (James & Folen, 2005). This article describes the role of psychologists as consultants in an ED, a unique opportunity for training graduate students in a setting that allows for the development of multiple clinical competencies.
Emergency Department Services: Consultation Practicum
George Fox University (GFU) is a small university located in a rural area of Oregon with approximately 3,500 students. The Graduate Department of Clinical Psychology (GDCP) at GFU offers a doctoral degree in clinical psychology (PsyD) in a program that is accredited by the American Psychological Association. The doctoral program is organized by cohorts, with 20 students per cohort. During the first year of the clinical training program the students participate in coursework and simulated psychotherapy designed to prepare them for subsequent practica. The students then participate in three years of supervised clinical training and a fifth year in a full-time internship. The typical practicum requires approximately 20 hours per week and includes both internal and external sites. Due to the unpredictability of the demand for ED services, the Behavioral Health Consultation (BHC) team described below is a supplemental practicum.
The Practicum Setting
The medical center is located in a semi-rural region and serves people in a catchment area of approximately 75 miles. The hospital’s services include medical-surgical, intensive care, primary care, and obstetrics; additionally, it has 40 inpatient beds and a 24-hour ED. A GDCP practicum program trains students to provide BHC services for patients in the ED and in Medical-Surgical and Intensive Care Units. Seven clinical psychology doctoral students who have completed a Master’s degree program and have more than two years of practica are chosen by faculty to perform 24-7, on-call coverage as Behavioral Health Interns (BHI). Four licensed clinical psychologists, who have previous professional experience in hospital settings, provide intensive training and supervise by phone before and after each BHI assessment. A team of supervisors, comprised of licensed psychologists and GDCP faculty, accompany students to confirm competency and co-sign on student documentation. BHIs also receive weekly group supervision. The clinical supervisors developed the assessment protocol used by the students, which includes the use of standardized assessment measures tailored to the ED services.
The ED BHC team demonstrates a multidisciplinary approach, providing holistic treatment for patients in crisis. ED staff pages the student; the student contacts the on-call supervisor to review the reason for referral and to develop the plan for assessment. The student then consults with the nurse or physician at the hospital to determine specific issues or questions (e.g., discharge plans, level of safety in the home environment, etc.). Through these consultation meetings, the student determines what information is required and performs a risk assessment. Following the assessment, the student consults the on-call supervisor to determine probable diagnoses and the appropriate level of treatment. Clinical impressions, diagnostic information, and recommendations are developed and communicated to the medical staff under the supervision of a licensed clinical psychologist. To ensure that the students are providing quality services, their knowledge and abilities are assessed within the competence- based training model.
Competence-Based Training Model
The past two decades have yielded a major paradigm shift toward competency-based education, training, and credentialing in the field of professional psychology (Sumerall, Lopez, & Ochlert, 2000). Epstein and Hundert (2002) define professional competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served” (p. 226). Competence is evidenced by the interaction of knowledge, skills, and attitudes while reflecting a professional’s capability and proficiency for practice in a professional domain. In accordance with this recent shift, the BHC team is assessed on the following competencies: applied research, assessment, consultation and the appropriate use of supervision.
In order to show competency in applied research, the student effectively demonstrates research-based knowledge of harm to self or others. The student identifies both risk and protective factors as they relate to safety, while paying particular attention to the relative importance of specific high risk factors of intent, plan, means, and previous history. The Suicidal Adult Assessment Protocol (SAAP) is one of the evidence-based tools used in the ED by the BHI. This measure evaluates suicidality from static and dynamic perspectives. Static factors are demographic and historical variables that do not change such as prior suicide attempts, recent, planned, or serious attempts in the last three months, childhood trauma, family suicide attempts or completions. Dynamic factors include clinical factors such as stability level (axis I, II, and III) and are often more acute but can change. Contextual and protective variables that may be modified can be positive or negative: positive contextual or protective factors relate to the individual’s family responsibility, religious belief, coping or problem solving strategies, and social support; negative contextual factors refer to firearm access, recent loss, stressors, social isolation, and incarceration. (See Fremouw, Tyner, Strunk, & Mustek, 2005 for more information.)
After completing the protocol, the student tallies the number of items rated as low, medium, high, or extreme risk for suicidal behavior. Other unique factors are considered and then the interviewer assigns the individual to one of the four overall risk categories. Following training, students’ competence in applied research is assessed by completing a post-test to demonstrate knowledge of these specific risk factors. Junior Behavioral Health Interns (students newly selected to the team) learn to rate the level of risk after observing clinical interviews performed by supervising psychologists or senior BHI (students with at least one year of BHC team experience).
The assessment competency emphasizes the student’s ability to complete a clinical interview and assess risk of harm to self or others in patients from different demographic and cultural backgrounds. The student builds rapport by showing respect and interest in the patients’ perception, experiences, and fears and, at the same time, gathers relevant information related to potential risk, completes a mental status exam, and articulates ways in which ethnicity may influence symptom presentation and response to intervention during medical emergencies.
There are several ways to measure the BHI’s assessment competence. First, the junior BHI observes the senior interns engage in assessments and identifies strengths and weaknesses in interviewing and clinical assessment skills. The junior BHI conducts a risk assessment or pain consult under the supervision of a senior BHI and under the supervision of the licensed psychologist. Supervisors then provide feedback to the BHIs regarding their strengths and weaknesses in interviewing and assessment skills.
Demonstrating consultation skills and interdisciplinary collaboration is essential to the delivery of services in the medical setting. This set of skills includes development of appropriate interventions and administrative management skills. The student demonstrates an ability to frame the consultation question as well as knowledge of HIPAA regulations relevant to the consultation relationship. Demonstrating accurate and appropriate use of the electronic medical record and standardized documentation of risk is important. Finally, the student prepares useful consultation reports and communicates recommendations in a clear and precise manner to medical staff under the supervision of the on-call GDCP supervisor.
Use of Supervision
Case reviews by supervising psychologists or by peers on the BHC team under the direction of supervising psychologists provide evidence of how well the interns use supervision. Additionally, random auditing is conducted by ED medical staff of medical records for patients evaluated by the BHI. The timeliness of the student’s response to consultation calls and ability to cover assigned shifts is also monitored.
Finally, students demonstrate knowledge of limits and an awareness of when to consult with staff, and the appropriate use of supervision, including the ability to accept and integrate supervisory feedback from hospital staff, clinical supervisors, and peers. Students portray an active approach to learning, including review and professional presentation of cases. This competency is assessed when the student presents cases during weekly supervision. The students collaborate on an annual evaluation of the practicum and respond to the supervisor’s evaluation with a willingness to develop skills in identified areas. Rating scales are utilized by hospital staff to assess service delivery satisfaction.
Assessing Hospital Satisfaction
A 9-item pencil-and-paper questionnaire was distributed to hospital employees to assess satisfaction with the GFBHC. Questionnaire items assessed team members’ skills, level of expertise, effectiveness, and usefulness. Seven items utilized a 7-point scale ranging from “Strongly Disagree” to “Strongly Agree.” Respondents rated the services provided by the BHC team on a scale of 1 – 7, with 1 indicating weakness, 4 indicating neutrality, and 7 indicating strength. Resultant scores ranged from 6.5-7, indicating strong strengths across all domains.
Results indicate that the BHC team provides useful documentation of consultations. Medical staff noted an improvement in the quality of care for patients with mental health concerns since the beginning of the consultation program 5 years ago. Respondents agree that the BHC team provides unique skills in evaluating the mental health needs of patients. Finally, medical staff commented on the necessity of the services provided by the team and acknowledged the compassion with which services are delivered.
Of the domains assessed, results suggested areas for growth including building credibility for doctoral interns as future professionals so that recommendations are followed up on by the medical staff. In order to demonstrate competency and build positive working relationships with physicians, the BHC team now provides educational training opportunities for medical staff. Respondents also expressed a desire for BHI to spend time with patients and their families in the Medical-Surgical Unit. As a result, the BHC team set a target goal of spending 50 minutes with a patient in the Medical- Surgical unit. This time is used to address fears associated with patient safety and long-term adjustment in addition to mental health issues related to level of risk (Burkhart, Cocoli, Frise & Tuerck, 2008).
Caring for Patients with Chronic Pain
In addition to risk assessment and crisis intervention, the BHC team implemented guidelines for ED providers, nurses, and BHC to follow when assessing, treating, and discharging/referring chronic pain patients. These guidelines include a multi-disciplinary response to patients who present to the ED with a primary complaint of chronic pain.
In order to better serve these patients, they are classified into the following three categories: Low Concern (patients who have never utilized the ED or have utilized the ED two or fewer times in the past three months); Moderate Concern (patients who have utilized the ED at least three times in the past three months); and High Concern (patients who have utilized the ED at least six times in the past six months). The High Concern group is offered, free of charge, outpatient therapy that focuses on non-pharmacologic interventions for pain management. At the time of consultation, patients with chronic pain are assessed and, after a brief psycho-education intervention, are offered a pain management brochure and are encouraged to access the free services provided by the GFU doctoral student. Services include cognitive behavioral treatment to manage pain, progressive muscle relaxation, and other evidence-based coping strategies to develop the patient’s repertoire of coping strategies for chronic pain that will supplement pharmacologic treatment of symptoms and increase level of functioning. If a patient requires more intensive pain management services or long-term psychotherapy, the patient is referred to other providers in the community.
The data for January 2007 - May 2008 show that receiving a narcotic in the ED may influence recidivism. Specifically, the group of patients who received a narcotic had significantly more visits over a six-month period than did the patients who didn’t receive narcotics (4.38 vs. 1.72). Furthermore, the number of days between visits was different for patients who received narcotic vs. those who did not. Patients who received a narcotic averaged 31 days between their first and subsequent visit; patients not receiving a narcotic averaged 45 days between visits.
Expansion on Behavioral Health Consultation
BHC services were initially designed to provide assessments for at risk patients who presented to the ED or the medical units. As awareness of the need for additional resources emerged, additional services were added. In spring of 2008 the GFU Behavioral Health Clinic, a partnership between GFU and the medical center opened. The clinic is grant funded which allows minimal-cost mental health services for the uninsured and underinsured citizens of Yamhill County and the surrounding area. The goal of the clinic is to provide behavioral health care to those who are otherwise unable to access these services. Therapy is offered to those with chronic and acute issues as long as there is a specific, identified, therapy goal. This service is frequently utilized upon discharge and is an excellent option for low-income patients.
Additionally, patients are often referred for behavioral health services within the hospital’s primary care clinics. GDCP faculty selects three graduate students for practicum placements at the primary care clinics. The university training program and practicum supervisor provide training in competencies relative to a BHC role. To facilitate students’ training, the GDCP’s Director of Clinical Training developed a manual of evidence-based practices. Following the initial student training, students are introduced to the Primary Care Providers and support staff of the medical clinics. Each clinic has a licensed psychologist/ supervisor one-half day per week and a senior BHI for 2 days a week.
Patients are referred to the BHC team by their Primary Care Providers and, depending upon the severity of the presenting problem, the patient has between 1 to 6 sessions with a BHC team member. Each session is approximately 20 minutes in length with a focus on brief evidence-based interventions. Ideally, the warm hand-off technique is utilized, allowing the patient to be introduced to the BHI by the attending physician (Robinson & Reiter, 2007). This technique often allows patients same day access and increases the rate of patient follow-up. Due to the collaborative nature of the BHC-physician relationship, the practicum students’ consultation is an integral aspect of services. Additional services include: diagnostic assessment, short-term solution, focused therapeutic interventions, psychological assessment, and group therapy.
Patients seen in the Behavioral Health Clinic represent a broad range of demographic and diagnostic categories. Anxiety (37%), depression (38%), pain (8%) and co-occurring anxiety and depression (17%) have been the most common reasons for referral to date. The total number of consultations from October 15, 2008 – February 15, 2009 was 420, and a total of 124 patients received consultation services. The average number of visits per patient was 3.39. Patients ranged in age from 4 to 93, with 72% of patients being female and 28% male.
The BHC program within a medical setting offers an opportunity to integrate practice and research. As awareness of the biopsychosocial model continues to increase, multi-disciplinary treatment teams should become the norm for patient care in the medical setting. Thus, it is important to build training opportunities for students in this environment. Acquiring expertise as an ED consultant is a complex and multifaceted task, including understanding the patients’ emotional needs while recognizing the hospital as the primary client. It is pivotal that BHC learn to manage multiple tasks in the ED environment, including evidence based assessment, clear communication about the patients’ needs, knowledge of available treatment options, and detailed problem-focused documentation. Provider satisfaction surveys do indicate that the BHC services provide helpful care for their patients.
Advancement in the delivery of psychological services in traditional medical environments has occurred over the last decade. Simultaneously, the last decade has yielded a major paradigm shift toward competency-based education, training, and credentialing in the field of professional psychology (Sumerall, Lopez, & Ochlert, 2000). In accordance with these trends, practicum training positions on the BHC team offer students the opportunity to gain experience in integrated medical care while specifically building clinical competency.
Diomaris E. Jurecska received a Master’s degree in Clinical Psychology in 2009 and is a third year doctoral student in Clinical Psychology at George Fox University in Newberg, Oregon.
Misti Tuerck earned a Master’s degree in Clinical Psychology in 2008 from George Fox University in Newberg, Oregon and is currently a fourth year Clinical Psychology doctoral student. Misti is a behavioral health intern at a Primary Care clinic in Sherwood, Oregon as well as a member of the Behavioral Health On-Call Consultation Team at a medical center in Newberg, OR.
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