Barbara Ann Cubic, PhD
The Wave of the Future is Integrated Care
The majority of individuals receive their behavioral health services in primary care settings, as family physicians are viewed by patients as providers of community based comprehensive healthcare. However, a legacy of segregation of mental health and physical health services has resulted in poor healthcare coordination. Absent an integration of care (i.e. the inclusion of behavioral health providers in primary care settings) individuals and their families are not adequately equipped to deal with chronic medical conditions resulting in poor health and early mortality. More importantly, mental illnesses are often undetected or undertreated.
However, now integrated care is a key concept in healthcare reform and is foundational to the Patient-Centered Medical Home (PCMH) (Rosenthal, 2008). In PCMHs patients serve as collaborative participants in their own health and well-being through receipt of evidence-based services from a physician led team of medical and behavioral providers optimally coordinated to meet the preventive, acute and chronic needs of patients throughout their lifetimes (American Academy of Family Physicians, 2009).
Psychologists are uniquely qualified to be integrated into the primary care settings and PCMHs, especially in regards to the mental health needs of the elderly (Abeles & Victor, 2003) and at nursing home sites (Molinari, 2003). This is likely due to the fact that healthcare psychologists seek to understand the whole patient through a formal conceptualization process that allows an integrated understanding of current stressors and coping strategies, as well as an appreciation for the patient’s history of formative experiences. This conceptualization process leads to a depth of understanding that can then be used to target care most effectively. Furthermore, mental health professionals from other disciplines often cannot offer the wide range of interventions typically rendered by healthcare psychologists. For example, psychologists interested in integrated care can provide psychological assessment (brief and in-depth), empirically validated treatment approaches (e.g. cognitive-behavioral therapy and interpersonal therapy), motivational interviewing and a variety of treatments aimed at skills building (e.g. pain management, assertiveness training, relaxation skills, behavioral contracting to improve treatment adherence). These behavioral interventions are a good fit for primary care as they represent a treatment style acceptable to both primary care providers and patients (that is, pragmatic, here-and-now oriented, focused, finite) and are often the most effective non-pharmacological interventions for the typical mental health problems seen in primary care (e.g. depression, anxiety disorders) (Leahy & Holland, 2000).
Unfortunately, although psychologists may be uniquely positioned to be part of the PCMH team, without having specific training experiences in primary care the psychologists fail to understand the perspectives of primary care patients and the needs of the primary care environment (Bluestein & Cubic, 2009). Thus, they lose the opportunity to make significant contributions to the prevention and treatment of medical and mental health diseases.
Interprofessional Training Models in Integrated Care
To accelerate the integration of behavioral health services in PCMHs interprofessional training is necessary. Unfortunately, on-site interdisciplinary training in primary care for psychology interns or primary care residents occurs too infrequently despite the fact that the main areas of healthcare reform relate to quality care access, behavioral change, mental health, and substance abuse. Thus, mechanisms for addressing barriers in integrated training at the doctoral and postdoctoral level (i.e. practica, internship, residency) need to be created so that each discipline develops an understanding of the other discipline’s backgrounds, values, professional models, and ideologies.
Training models related to integrated care should build on the clinical service delivery models of interdisciplinary medical and behavioral collaboration described in the literature (Miller et al., 2009). Existing interdisciplinary models can be placed on a continuum from coordinated services to integrated care. Coordinated care refers to the exchange of information between a behavioral and primary care provider regarding mutual patients. Similar to a traditional mental health model, coordinated care reflects a separation of service delivery; however, after obtaining patient consent an exchange of information is offered to enhance the patient’s overall health care. On the other end of the continuum, integrated care emphasizes team-based treatment, merging of the psychosocial and medical aspects of assessment and intervention, culturally and contextually competent relationship-centered interactions, and a focus on family and community as a determinant of individual health. In integrated care it is understood that parties invested in the patient health care, including the patients and their families, work collaboratively together and share information fluidly. Between these two extremes are co-located practices and collaborative care. In co-located practices psychologists and primary care providers are housed in the same setting but referrals to the psychologist often result in traditional psychological services (e.g. 1-hour individual therapy sessions and traditional psychological assessments). Location serves as an advantage to facilitate the referral, but integrated care is not provided. Collaborative care, whether through co-location or separate offices, focuses on fostering an ongoing communicative relationship between a psychologist and primary care provider to allow for shared decision making longitudinally while treatment is offered autonomously by both providers.
An Example of Interprofessional Training: The Eastern Virginia Medical School Model
Integrated care is not a novel concept but implementation of the concept has been difficult primarily due to difficulties in obtaining reliable funding mechanisms that reimburses two or more providers for simultaneous or same day clinical care delivery. Despite these financial challenges, as models of integrated care are further refined the role of psychology evolves and becomes increasingly apparent. To prepare psychologists for these opportunities the Eastern Virginia Medical School (EVMS) Clinical Psychology Internship Program has developed creative educational models funded in part through the departments/settings served and in part through training grants. This has occurred because of EVMS longstanding history of offering innovative training opportunities to psychology interns and family medicine residents simultaneously. Some of these EVMS training opportunities reflect the ideal of integrated care while others are more of a hybrid such as described by Miller and colleagues (2009). Nonetheless, in each training experience the ultimate goal for trainees is to teach them to work in collaborative relationships with other healthcare providers in as integrated a fashion as feasible.
The Training Programs at EVMS
The EVMS pre-doctoral internship in psychology was founded in 1976. It has been accredited by the American Psychological Association since 1983, and provides training for six to eight interns each academic year. The internship subscribes to an apprenticeship model which encourages the growth of individual strengths, provides a variety of teaching styles and professional models, and emphasizes the development of the scientist-practitioner. Specific training goals include further development of assessment and psychotherapy skills with a wide range of client populations through involvement in diversified inpatient and outpatient activities. Interns develop leadership and consultative skills within a medical center setting, and function as part of a multi-disciplinary treatment team. Professional development through lectures, seminars, and workshops, and opportunities for clinical research are provided. Clinical settings also provide for an opportunity to integrate ethical and administrative issues into an appreciation of treatment issues.
In the current EVMS training model interns typically complete two major rotations (24 hours a week), each lasting six months, in inpatient psychiatry with chronically mentally ill patients, child or adolescent psychiatry, and inpatient behavioral medicine (i.e. rehabilitation medicine, consultation-liaison). The major rotations provide opportunities for conducting personality, intellectual, and neuropsychological assessments, participating in multi-disciplinary treatment teams, and providing group, family, and/or individual psychotherapy. Each intern completes a minor rotation (eight hours a week throughout the training year) dedicated specifically to a focus on integrated care in primary care practices. Interns complete inpatient rounds with primary care teams, provide services in nursing homes with primary care physicians or provide specialized services with health care teams (e.g. bariatric surgery evaluations, pediatric rehabilitation medicine). Clinical training is supplemented by didactics with a series of speakers who focus specifically on integrated care supplementing a curriculum that covers multicultural issues, behavioral medicine, child and adolescent assessment and psychotherapy, cognitive-behavioral psychotherapy, forensics, sleep disorders, neuropsychology, ethics, professional development, and advanced personality assessment.
The Department of Family and Community Medicine (DFCM) at EVMS offers three accredited residency programs leading to eligibility for certification by the American Board of Family Practice. One of these training programs is university-based, one is community- based, and one is co-sponsored as a joint Internal Medicine- Family Medicine residency program with the Department of Internal Medicine. In addition to residency education, the DFCM is actively involved in the undergraduate medical education of medical students and physician assistants. The DFCM administratively oversees two clinics in which the faculty, residents, medical students, and other trainees provide clinical services. These clinics are the Ghent Family Practice (GFP), and the Portsmouth Family Practice (PFP) both of which serve as training sites for the integrated care training model.
This residency welcomed its first class in 1974. It currently offers six positions in each of the three years of family practice residency training and is located in Norfolk, Virginia, within the EVMS complex. The residency program focuses primarily on patient care at the GFP, where residents are supervised by faculty with a wide variety of interests, including geriatrics, academic medicine, obstetrics, behavioral medicine, and medical informatics. A special feature of the GFP is weekly, focused clinics for flexible sigmoidoscopy, colonoscopy, family-centered obstetrics, dermatology, and geriatric assessment. Residents who wish to pursue a career in academic medicine have opportunities to teach medical students both in the family practice center and as small group facilitators. A large cohort of GFP patients come from a Norfolk community designated as a primary care health professional shortage area (i.e. a HPSA in South Norfolk).
The EVMS Combined Family Medicine/Internal Medicine Residency Program began in July of 1995. This residency incorporates the strengths of family and internal medicine training and prepares trainees to manage the medically complex patient and treat a wide spectrum of ambulatory and hospitalized patients. The program is four years in duration and approved to offer four positions in each training year. As of July 1, 2009, 43 residents have completed this training. Successful completion of the training program confers board eligibility in both disciplines. More than 50 percent of the training in the combined residency takes place in an ambulatory setting. Longitudinal continuity ambulatory experience makes up over 30 percent of the training experience, is supervised by Family Practice and Internal Medicine faculty, and takes place in the offices of GFP on the EVMS main campus. The DFCM GFP residency and the Department of Internal Medicine’s Categorical Internal Medicine residency are both fully accredited and in existence for 30 years, provide support for the Combined residency.
The philosophy of the PFP residency is to support residents in an environment that promotes expert, compassionate, and comprehensive care. The focus is on treating the entire family and caring for the whole person - body, mind, and spirit. This is the only residency program at Maryview Hospital in Portsmouth, Virginia, and is located in a HPSA for primary care that allows residents an unparalleled experience in caring for a wide range of patients. The program’s commitment to improving the health care of Portsmouth’s citizens is evident in numerous outreach activities.
The integrated care training models used over the last decade at EVMS began through financial support of psychology intern stipends from the DFCM and more recently through two Graduate Psychology Education (GPE) grants awarded this author. The training has evolved across the continuum of interdisciplinary collaboration models defined by Miller et al. (2009). In the original years of training coordinated care and collocated practices were utilized. At present, many elements of the training truly approximate integrated care with some incorporation of collocated practicing. The most recent GPE grant was obtained in 2007 and provides three years of funding to allow the interns the opportunity to complete minor rotations in primary care (i.e. one day a week experiences in integrated care working with residents in pediatrics, internal medicine, and family medicine). These experiences are aimed at teaching psychology interns the subtleties of working in a primary care environment and educating primary care residents on behavioral and mental health issues.
Unique aspects of this training model are the degree of interprofessional collaboration and education that occurs, thus enhancing the ability of the internship and the primary care residencies to create a competency based educational program. The psychologists are trained in congruence with the recommendations of the American Psychological Association’s Primary Care Psychology Curriculum Interdivisional Task Force (McDaniel, Belar, Schroeder, Hargrove & Freeman, 2002) on competencies for primary-care psychologists. The primary goals for psychology interns are to be able to show an understanding the biological components of health, illness and disease and the interaction between biology and behavior; namely, how learning, memory, perception and cognition influence health; ways emotions and motivation influence health; how social and cultural factors affect health problems, access to health care and adherence to treatment regimens; and how to assess cognitive, affective, behavior, social and psychological reactions for common conditions seen in primary care. The primary goals for the family medicine residents are to show enhanced general ACGME competencies (esp. related to Patient Care, Interpersonal Communication Skills, Cultural Competence and Systems Based Practices) and skill specific competencies related to behavioral topics.
To successfully implement the type of training at EVMS the psychology interns must unlearn aspects of what they have learned about provision of psychology services during graduate school. Interns are shown how services provided by the psychologist must be altered to allow for integrated care (see Table 1 from Bluestein and Cubic (2009)). Emphasis is on building confidence, practical confidentiality, efficiency, interprofessional coordination, brief documentation, application of a diversity of assessment and intervention skills, and learning the health care culture (Bluestein and Cubic, 2009).
Shifting to a training paradigm with increased focus on integrated care requires leadership willingness to try new paradigms. This necessitates strong working relationships among key players (i.e. training directors) and respect amongst faculty, nurses, staff and trainees. Primary care training sites must be identified. Supervisors with experiences in integrated care must be located. Financial support must be obtained for trainee stipends and benefits as well as for resources needed (e.g. assessment measures, psycho-education materials and treatment resources) and space. The final ingredient is a patient population that is open to new models of clinical service delivery. A couple of steps taken to address these challenges are described below.
To obtain an initial financial buy-in from the DFCM a convincing argument was made that the residency programs would not only benefit from the integrated care training, but that the presence of psychology interns, and that of their supervisors, would meet the residency requirement to have behavioral scientists involved in residency education. Also, the psychology internship’s willingness to share in the costs of the program through the internship budget and grant funding has allowed training to remain viable. However, realistically more longstanding sustainable models of internship funding are necessary for a true paradigm shift to be maintained.
Clinical residency training directors at EVMS based primary care training sites in medically underserved areas were approached diplomatically and encouraged to participate in the new training model on a trial basis (i.e. inpatient settings at a local hospital for adults and a children’s hospital, two outpatient family medicine practices in an academic health setting and one that is community based, and local nursing homes where EVMS primary care physicians serve as consultants). Empirical data were provided to create a convincing argument that patients and providers both benefitted from the shift.
Key advocates for the integrated care training (Drs. Cubic and Bluestein) from both disciplines (psychology and primary care) created another unique aspect of training early on that was vital to the success of the training model. This unique aspect was dyadic supervision/ precepting. When trainees saw faculty supervising trainees simultaneously on integrated care the model had more credibility. This joint supervision insures psychology trainees receive supervision from both psychologists (to meet accreditation guidelines) and attending physician preceptors (to underscore the commitment to integrated care) so they can sharpen their psychological skills while also seeing the complexities of integrated care from the view of physicians and offers co-precepting to primary care residents as they address the complex biopsychosocial needs of their patients. As this joint supervision became more commonplace it was easier to transition to the current model where co-supervision/co-precepting occurs. Supervising psychology faculty are available at pre-designated times to jointly precept with the attending family medicine physician in the outpatient clinic or during morning rounds with various attending physicians in family medicine available for consultation. Each intern is assigned a primary care physician mentor. Thus, opportunities exist for trainees to see licensed professionals interacting onsite in the primary care setting as well as part of a treatment team. Trainee-to-trainee consulting is also strongly encouraged.
Across all of the primary care training settings, 66% of patients are female, 43% are from lower socioeconomic backgrounds, and 42% are African-American. Over the course of a year psychology interns make approximately 200 individual patient contacts on their minor rotations in addition to numerous hours each week in interdisciplinary treatment team or dyadic contacts (psychology interns paired with primary care residents). Data suggest that the majority of patient contacts made by our psychology intern trainees in primary care settings are with underserved populations.
- At Sentara Norfolk General Hospital, the population consists of 81% African American and 2% Asian or Hispanic patients
- The population treated at GFP is 62% African American
- Across our geriatric facilities psychology interns treated elderly patients who are in a middle (6 84%) or low (15-36%) socioeconomic status.
An important component of EVMS is the careful evaluation of the effects of training alterations. Our evaluative methods include:
- Performance reports: Psychology interns compile data on the number of patients seen, those needing mental health services, and other relevant tracking data.
- Pre and Post tests: Psychology interns complete pre and post tests measuring their knowledge base and attitudes about primary care, geriatrics, and at-risk children.
- Physician’s Belief Scale scores: Scores on the Physician Belief Scale (Ashworth, Williamson, & Montanco, 1984) empirically evaluate the effects of primary care residents participation in the integrated care training program.
- Trainee satisfaction: Psychology interns, family medicine residents, and faculty complete a questionnaire designed to assess their view of the overall training program. Below are the average scores obtained on this questionnaire in a recent training year (1 = strongly disagree to 4 = strongly agree).
|Item #||Item Content||
|1.||…lead to an increased emphasis on psychosocial issues overall||
|2.||…enhanced my comfort in treating psychosocial problems||
|3.||…I am more likely to investigate psychosocial problems with my patients||
|4.||…had no impact on the way I deal with psychosocial issues with patients||
|5.||…encouraged me to consider both organic and psychosocial problems in patient care concurrently||
|6.||…I am more likely to routinely investigate psychosocial issues myself||
|7.||…enhanced GFP residency training||
|8.||I would be less likely to consult with a psychology intern about a patient…..If they were not in the GFP setting||
|9.||I view the psychology intern as an important personal resource in maintaining my emotional well being||
|10.||…enhanced the care received by patients at GFP||
Periodically and at random intervals, patients are asked by psychology interns or family medicine residents to complete a questionnaire designed to assess their view of the care they received.
When new training models are implemented, the existing culture for the trainees and their patients must also change. Within the primary care practices it was necessary to devote time addressing the stigma associated with seeking or receiving mental health services. The main barriers to shifting towards an integrated care training model are:
The departmental program and the GPE training grants provides funding. Long term stability of interprofessional training programs requires more creative allocation of funds dedicated towards Graduate Medical Education in hospitals and modifications in the mechanisms for reimbursement for integrated care services by physicians and psychologists.
Resistance from patients and trainees.
To address this psychology interns must be taught how to introduce themselves as behavioral specialists and focus on treatments that are present oriented and provide practical ways to cope with stress, distress, and medical issues (for more specifics regarding areas of training to create this change please refer to Bluestein and Cubic, 2009). Family medicine residents have to be educated on how psychology interns can be of value to them and their patients, and also educated about a variety of mental health topics. Psychology interns have to be educated about the importance of being part of health care and ways that participating in integrated care experiences will benefit them.
Resistance to a new model.
Being treated by a dyad of providers is a novel concept to most patients as well as to most providers. Patients and providers both can display resistance initially due to misconceptions about the intent and benefits of integrated care. Therefore, a gradual introduction of the model into the primary care settings was used.
Resistance to completing evaluation measures.
Collecting empirical data from the providers and patients, especially the family medicine residents involved in the project is challenging due to the competing demands for their time. However, as the presence of psychology increases in the primary care settings, trainees and patients are more responsive to requests for feedback and faculty have been more supportive.
Table 1. Converging Perspectives of Primary Care Patients, Primary Care Providers and Psychologists Completing Training As Usual (TAU) and Suggested Perspective for Psychologists to Provide Integrated Care (IC)
|Primary Care Patients||Primary Care Providers||Psychologists (TAUl)||Psychologists (IC)|
|Reflect a Diverse Population with Diverse Needs
Present with Multiple Medical and Psychological Concerns
Present When Symptomatic
Expect a Brief Visit
Favor Pharmacological Interventions
Struggle to Make Lifestyle Changes and to Adhere to Medical Regiments
Are Not Expecting Psychological Advice and Interventions Unless Specifically Requesting It
View Referral to Mental Health as Stigmatizing
|Have Large Caseloads with Diverse Concerns
Treat Complicated Cases
Need to Prioritize What to Address at Each Visit
Are Ultimately Accountable for Care Provided by Extenders
Endure Intense Time Pressures
Assume Ownership of Patient’s Care
Need Coordination of Care
Assume an Exchange of Information
Feel Underequipped to Handle Mental Health Issues and Behavioral Aspects of Health Care
Welcome Practical Support from Mental Health Professionals
|Treat a Small Number of Patients (usually in a specialized area)
Often Prioritizes Confidentiality Above Coordination of Care
Operate Largely in Context of Ongoing Relationships with Patients
Expect to Complete In-Dept Assessments
Offer Interventions in Hourly Units
Expect Patients to Engage in Extensive Courses of Treatment
Provide Solicited Mental Health Services to Patient or Patient’s Advocate
|Treat Diverse Patients with Diverse Issues
View Treatment as a Team Process
Share Information with PCPs
Conduct Brief Assessments
Use Brief, Empirically Based Interventions )
Integrate Services Seamlessly into Health Care Visit to Avoid Stigmatization Issues
Table adapted from Bluestein, D., & Cubic, B. A. (2009). Psychologists and primary care physicians: Creating collaborative relationships. Journal of Clinical Psychology in Medical Settings, 16, 101-112.
The combining of primary care and mental health resources leads to better efficiency in patient care due to increased coordination, ease of communication, and improved outcomes stemming from improved patient adherence and avoidance of duplicated effort. Integration fosters continuity, comprehensiveness, coordination and better understanding of the patient. Such understanding is at the heart of empathy, which in turn promotes a strong provider-patient relationship, and is instrumental in getting patients to internalize behavioral and attitudinal change that can facilitate better coping with stress and chronic illness, increased compliance, and greater practice of health protective lifestyles (Satterfield, 2003).
Nationally, there are insufficient opportunities for psychologists to train in primary care settings, and rarely can primary care physicians gain immediate access to mental health consultants. This increases the burden on psychology internship training programs to develop ways to place trainees in settings through the development of integrated care models which prepare them for the future needs of the population.
The EVMS Clinical Psychology Internship Program through its linkages with EVMS primary care residencies has attempted to approximate the ideal of interprofessional education and prepare a psychology workforce to provide integrated care. While only a percentage of the primary care environments at EVMS has benefitted from the inclusion of psychology interns this program has a track record of providing training in integrated care and that helps eliminate barriers to care by substantially increasing the number of trainees serving medically underserved communities. The model also addresses the issue of health disparities, as trainees receive specialized training on cultural competence. Lastly, the training model coincides with the goals of health care reform to address key 21st century health issues because the training is predicated on the interrelatedness of mental and physical health and how to address these issues in the most efficacious manner.
More opportunities for psychology trainees to complete practicum, internships, and postdoctoral fellowships in primary care settings need to be developed in order to create a psychology workforce that can address behavioral aspects of health care while recognizing that most patients seek their mental health treatment in primary care settings. To allow these opportunities to emerge the profession of psychology needs to continue to advocate for funding of training (e.g. Graduate Psychology Education grants; reimbursement under GME monies) and fair reimbursement for clinical service delivery in medical environments. Without expanding integrated care educational opportunities it will be difficult for future psychologists and primary care physicians to have experiences that create shared values and common goals needed for the internalization of integrated care precepts.
Barbara Ann Cubic, PhD, is an Associate Professor at Eastern Virginia Medical School (EVMS) with joint appointments in the Department of Psychiatry and Behavioral Sciences and the Department of Family and Community Medicine. She serves as the Co-Director of the EVMS Clinical Psychology Internship Program, Director of the EVMS Student Mental Health Program and Director of the EVMS Center for Cognitive Therapy. She also serves as the editor of the Journal of Clinical Psychology in Medical Settings.
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