Heather Kirkpatrick, PhD, Mark E. Vogel, PhD,
and Scott Nyman, PhD
Psychologists are experts at negotiating changes within their clients/patients. A challenge for psychologists who have not been trained in integrated primary care (IPC) is to modify the way they relate to other healthcare providers in the service of their patients. We believe that there are increased opportunities for working in IPC, as we have outlined previously (Vogel et al, 2008). However, in a decision to become more integrated, psychologists must confront the change process itself, with all its attendant discomforts. These discomforts may be conceived of as either external or internal barriers to change. While external factors are important in this change process, this article focuses primarily on key internal changes that psychologists must wrestle with in shifting to a more IPC focus of service delivery.
There are five key changes that we have observed in our own transformation into higher levels of integration within our primary care settings: transitioning from solo provider to health care team member; simultaneously meeting the needs of both the patient and the physician; adjusting to the fast pace and triage focus of integrated primary care; being flexible; and learning or developing brief interventions to provide effective care.
1. Working in Teams
The Institute of Medicine’s Health Professions Education: A Bridge to Quality examined the health care delivery system and identified five competencies essential for all providers in redesigned systems (IOM 2003). Proficiency in working as part of interdisciplinary teams was one of these skills. Likewise, the Patient-Centered Medical Home (PCMH) strongly emphasizes the importance of collaborative care and recognizes that development of these teams involve a fundamental shift in how care is delivered (Nutting et al, 2009). Primary care depends on team-based care to coordinate services, access resources and provide health promotion and illness prevention (Lerner et al, 2009). Where traditional care has emphasized a strong doctor-patient relationship, integrative care is based upon a team-patient relationship (Taplin et al, 1998; Grumbach & Bodenheimer, 2004).
IPC psychologists can take several steps to become assimilated with the team:
Physically work in the same environment. Co-location in the primary care office is a good first step to greater integration, but insufficient. Becoming more integrated with the team means being visible and active in the same clinic space. This physical presence not only establishes the intention to be a part of the team, it facilitates the necessary communication and interaction. Much can be learned about the day-to-day functioning of the team by sharing more than just the lunch room. When psychologists segregate themselves and wait for the “good referral” to come down the hall they are usually disappointed to find that they are considered ancillary care.
Engage in Group Medical Visits. Group medical visits (GMV), or shared medical appointments, are a model in which multiple patients are seen as a group for follow-up or routine care with their PCP and other members of the team (Noffsinger, 2009). The group visit is conceptualized as an extended doctor’s office visit where not only physical and medical needs are met, but educational, social and psychological concerns are dealt with effectively (Improving Chronic Illness Care, 2002). These visits focus on a disease entity (hypertension, diabetes) or specific populations (hearing impaired, orthopedic).
Collaborate with the whole team. The psychologist’s position may be more strongly established if they reach out to all team members. Sites that utilize physician assistants and advanced nurse practitioners as physician extenders are becoming the norm. These professionals are often very aware of patients’ needs and attuned to the ways in which a psychologist might contribute. Nurses and medical assistants know patients well and are effective in guiding other team members around road blocks as they understand operational issues in the clinical site – both what works and what is dysfunctional. Another trend is for care managers to join the medical team. These individuals help the patient navigate the medical system, activate their care, and track their progress in illness prevention and disease management. Collaboration between the psychologist and care manager may help a chronically depressed individual become more active or a diabetic patient adhere to a regimen. Pharmacists, as part of larger practices, provide valuable psychopharmacological information that may impact the overall care of a patient (compliance, interactions, and side effects). If available, dieticians and physical therapists complement the psychologist’s efforts in working with some patients.
Accept transdisciplinary care. We have seen the progression from multidisciplinary care (where a group of professionals work to provide a task – “I do my thing, you do yours”) to interdisciplinary care (where these professionals coordinate their work – “I saw your patient and helped him/her with X”). Transdisciplinary care moves this one step further by teams sharing not only information, but roles. Transdisciplinary teamwork involves a certain amount of boundary blurring between disciplines and cross-training (within limits of professional scope of practice) in accomplishing tasks (Garner 1995; Hoeman 2002). Here the psychologist understands the roles of others and steps out of the traditional roles in service of needed patient care. Proactively scheduling a follow-up physician appointment is not the exclusive role of the physician and likewise, behavioral activation of patients is not limited the behavioral health specialist. All team members contribute toward these goals.
Act more like a consultant: Psychologists have much to offer the medical environment in addition to psychotherapy. Approaching the primary care environment with a consultant’s perspective (e.g., a provider who listens first to the needs and concerns of constituents and then helps them solve problems) can lead to acceptance as a valued team member. Skills such as understanding how human factors affect health care quality, data analysis and statistical interpretation, and system design are among the assets that psychologists bring to the primary care medical team.
2. You have two consumers: Meeting the needs of both patient and provider
The IPC psychologist changes from the traditional focus of addressing the patient’s needs to addressing the concerns of the referring medical provider. Successfully adapting to this model enhances the quality of the patient’s continuity of care as well as increases referrals to our service, but requires a philosophical change similar to consultation-liaison work.
Meeting the Needs of Medical Providers: A typical clinic day involves 15-20 patients seen by a physician, with multiple physicians in practice at each office. In our setting, we also welcome new resident physicians every summer. In order to maintain an effective collaborative relationship, it becomes necessary to explain to physicians our abilities and limitations, establish a clear method of referral, and continually emphasize the importance of how we are presented to the patient. A smooth and efficient referral process is incredibly important as is why a physician is requesting services from the psychologist (Belar & Deardorff, 1995). Our newer physicians tend to present with looks of concern on their faces and struggle with the referral question. The “warm handoff”, or the more recently accepted term “hallway handoff,” is key (Laygo et al, 2003). Hallway handoffs involve a brief consultation with the physician to determine the referral question and encourage the physician to directly transfer the care by introducing the psychologist to the patient. Those physicians who possess skill in explaining their referral requests and identifying specific requests of the psychologist increase the medical team’s efficiency and efficacy.
IPC can be likened to a form of consultation, which is an indelible part of the medical culture. Physicians appreciate just in time information that will enhance their care for the patient. Once IPC psychologists evaluate and/or provide immediate interventions, they complete the consultation with feedback to the PCP. Frequently, physicians wait for our evaluation before considering whether to prescribe medication for the patient’s symptoms as well as to determine if a referral is needed. Successful IPC psychologists extend the work of the PCP. This might occur through assessment of a patient’s substance abuse concerns while the physician goes on to see the next patient, or helping a physician to quickly identify a treatment plan to improve a diabetic patient’s diet. An important dimension of our work is to provide support and assistance to both PCPs and their patients – not to assume management of these cases. At all times, care is coordinated by the PCP, who is still responsible for monitoring the results of interventions. This may be challenging for psychologists who are used to their independent licensure status, but in this team oriented environment collaboration is the guiding principle.
Physicians naturally turn to psychologists around issues related to depression and anxiety. However the scope of our practice can be so much wider. Communication with the physician and other team members experiencing behavioral issues with patients leads to fertile areas of consultation. You may learn that patient “non-compliance,” drug seeking behavior, or displayed strong emotion are the hot button issues for your colleagues.
Meeting the Needs of Patients: Patient needs are at the forefront of our work in the IPC model. The hallway handoff allows the physician to introduce the psychologist and begin the assessment, intervention, and triage process. Without the opportunity for same day evaluation, a referral to an appointment on another day and time could require 1-2 weeks, wasting valuable time that could otherwise be used to begin treatment. The hallway handoff saves a great deal of time for patients as well as offering the IPC provider an opportunity to conduct brief intervention, such as guided imagery relaxation training, during the initial appointment. The ability of the IPC provider to meet the needs of both patient and medical provider can prove challenging at times, yet those who can effectively manage this process will be able to offer services that truly integrates psychology into the medical setting and offers patients immediate services that might be otherwise unavailable.
In the following section we will spend time discussing processes for effective hallway handoffs, assessing patient needs, and providing effective brief interventions within the fast-paced primary care setting.
3. Running late, working fast
Another challenge that IPC psychologists face is confronting changes in workflow. Traditionally, outpatient mental health services provided by psychologists are structured with the 50-minute psychotherapy hour. In our practices, the goal is to meet the need of the physician and the patient in the time span of about 45 minutes. Practically, this means a 3-5 minute hallway handoff, 25-30 minutes of interviewing the patient, and 5-10 minutes to track down the physician and present our findings and recommendations. Our experiences of doing initial sessions with patients are that time moves quickly. This also means that psychologists do a more rapid assessment keyed around the identified problem, keeping in mind that the problem the physician identified may not be the cause of the patient’s distress. Over time, we have relied less upon the clinical interview to identify symptoms, and use interview time to get a sense of the situation and the relevant history. This feels quite disturbing at first considering past practices in which psychologists used an initial appointment to gather information about social developmental history, vocation, living situation, and cognitions/values that contribute to the individual’s perception of the problem. In any given IPC interview, we may choose to gather those details, but seldom do we collect data about all of them. Symptom information is frequently collected with brief screens that the patient completes prior to or after the psychologist interview, while time spent in the initial clinical interview is focused on developing a good enough foundation of the presenting problem. In terms of brief symptom assessment, we have found the PHQ-9 (Kroenke et al, 2001) and the GAD-7 (Löwe et al., 2008; Spitzer et al, 2006) to be ideal short-form symptom screening measures to assist with the initial evaluation process as well as providing ongoing comparison data for future clinic visits. They are available at no cost.
Not surprisingly, the main goal of the initial patient interview is triage. Identifying the problem and determining if progress can be made in 4-6 follow-up sessions is the main task of the psychologist. If the patient presents with severe or persistent mental illness, we recommend referral for specialty mental health care including consultation with a psychiatrist. Patients presenting with psychotic symptoms, treatment resistant depression, severe substance abuse, or poorly functioning patients with personality disorders are examples of those likely to be sent out for referral. In some of these cases, we may meet for a few sessions to increase likeliness that the patient connects specialty mental health care, or to help stabilize the patient in the short-term until such care is provided. In our geographic area, it is common for patients with relatively severe problems to wait 4-6 weeks for a specialty mental health care intake, and then another 2-3 weeks until evaluated by a psychiatrist for psychotropic medication. In cases where it is unclear whether the patient would benefit from specialty mental health care, we collaborate with the patients in deciding what they would prefer. We find that many patients choose to work with us initially, and defer the decision about longer term interventions until the end of our 4-6 sessions.
Another key difference in the IPC setting is to focus rapidly on the distressing symptoms and identify a concrete treatment goal. This begins in the initial interview. Toward that end, emphasis is placed on providing intervention within the first session as well. Follow-up sessions are typically scheduled for 30 minutes. We have all found that it is easy to slip back into traditional psychotherapy during follow-up sessions. It is as if our training ingrained a set point to which our practice seeks homeostasis. Frequent concrete goal setting on the part of the psychologist helps to maintain the focus necessary. On a positive side, similar to existential theories of change, often acknowledging that we have limited sessions from the outset seems motivating to both the psychologist and the patient.
A consequence of adopting this model of service delivery is the internal sense of the psychologist that one is working fast. This sometimes leads to the perception that one is providing incomplete service delivery. Given the unpredictable nature of requests for consults, psychologist’s schedules also begin to look more like physicians—working in acute hallway handoffs means that one will likely run late for one’s established appointments. We have found that patients seeing a psychologist in a physician’s office cope well with this, and understand when the psychologist explains “the doctor needed me to see someone in the office quickly.”
4. The definition of flexible: Capable of withstanding stress without injury
Part of meeting the needs of the provider entails being available to receive the hallway handoff. Gone are the days in which we could review the day’s schedule in the morning and prepare for the day. An IPC psychologist often has to juggle competing interests. It is part of the primary care culture that “providers get interrupted and everyone multitasks” (O’Donohue et al, 2006). In our experience, demands for one’s services can vary widely. Inevitably, the request for handoffs does not come during time we have set aside to respond to them. They appear to present during times where we already have clinical follow-ups scheduled. Frequently when we are engaged in other activities, such as supervision, medical education, or administrative work, we are asked to see a patient. We try to meet this need as much as possible. However, we do not typically interrupt a therapy or follow-up session, other than to briefly return a phone call to let the provider know that “we are with a patient right now, but will be available in 30 minutes.” By scheduling our follow-up sessions in thirty minute blocks, we are available for a quick handoff in a relatively short period of time.
Having an unpredictable schedule means being more flexible. There are times where we might not begin the initial interview at the time of handoff, if the patient seems agreeable and is not in immediate crisis. Instead, we might meet and greet the patient and establish a time for them to come in for the initial interview. There are other times where the situation is complex enough that we cannot meet our goal of a 30-45 minute episode, and the initial interview stretches to 60 or even 90 minutes.
Flexibility is also required around team participation. Psychologists may help a patient advocate for services or complete paperwork for a physician, because that is what the patient requires from the team, and the psychologist is able to fulfill this need. In complement, there are other times where we use physicians and ancillary staff to help us meet the patient’s needs. We may ask the physician or a care manager to meet with a patient in two weeks because we are unavailable and the patient ideally needs to be seen weekly during crisis stabilization. We may also ask the referral department to help in securing a specialty mental health appointment for a patient.
5. Learn to Be Focused – Do More with Less
With the emphasis on a shorter time interval, IPC calls for a different set of psychotherapeutic tools and techniques applied in a more efficient and focused manner. Information from the patient is gathered over consecutive sessions, each time refining the understanding as more information becomes understood. PCPs characteristically have a strong doctor-relationship with their patients, earned through the continuity of their visits. Therefore, psychologists in this setting conduct an initial baseline assessment – with the understanding that more information will be gathered in subsequent visits. In addition, the assessment includes brief screening and tracking instruments to help identify and monitor the problem. The psychologist has ready access to common assessment measures needed in the patient encounter, while having a digital (or printed) reserve of less common tools also available.
When it comes to interventions, a problem focused approach is essential. “While the patient may have many social, behavioral, or physical complicating factors the “first line” emphasis is to resolve problems. Through the handoff and assessment process, key behavioral or cognitive factors are identified (e.g. lack of sleep, limited exercise, anxious thoughts, etc.) and these become the targets of the focused interventions. Tools (educational handouts, recording logs, and exercises in cognitive, motivational, and behavioral interventions) are easily accessible for printout and review with the patient (see Hunter et al, 2010 and Robinson and Reiter, 2007).
All encounters result in an IPC evaluation or progress note placed in the patient’s medical chart. The psychologist visit needs to be conveyed to the primary care team in a concise and efficient manner. The rule of thumb is that nothing longer than one printed page will be read and shorter is better. In those cases where longer documentation is required, a summary statement of key recommendations is listed first. Since primary care is more action oriented, theoretical discussions, speculative musing, or complicated case conceptualizations are not valued. While such understanding may still be important for treatment planning, communication of this in the medical record does not add value. Specific recommendations for the primary team to follow-up in their interactions with the patient create the consistent message.
External Factors in Making Change to IPC
Although our article has focused primarily on five identified changes psychologists make in moving from a structured, traditional, outpatient psychotherapy model to an IPC model, it is also worth noting various external forces and factors that can influence the ultimate effectiveness of an IPC clinic. For example, external factors such as financial reimbursement, training effective health care psychologists to meet increasing market demand, clinic constraints such as size of patient population and number of referring physicians, all appear to play a crucial role in success (Gunn & Blount, 2009). With respect to reimbursement, we recommend Robinson and Reiter (2007) regarding the Health and Behavior codes as well as working with third party payer administrations to increase IPC reimbursement. We have also noted that our increased availability for hallway handoffs provides a potential referral to our own billable psychotherapy slots.
Many training models have been discussed (Garcia-Shelton & Vogel, 2002; Vogel et al, 2008; Blount & Miller, 2009), with debate on the baseline requirements for a psychologist to step into the IPC role. Accommodating the demand for increasing numbers of skilled IPC psychologists may require training of psychologists at multiple levels (McDaniel et al, 2002).
In conclusion, traditionally trained psychologists can become effective integrative providers within the IPC setting. The journey is both stimulating, provocative, and at times, disturbing. However, we are finding ways that work better and accommodate the changing realities of helping patients and physicians in the primary care setting.
Heather Kirkpatrick, PhD, received a PhD in Counseling Psychology from the University of Illinois at Urbana-Champaign. After completing a two-year postdoctoral fellowship with CAPT in Primary Care Health Psychology, she joined the Internal Medicine faculty at Genesys Regional Medical Center. She has been credentialed by National Register since 1999.
Mark E. Vogel, PhD, is Director of Behavioral Science and Psychology at Genesys Regional Medical Center in Grand Blanc, Michigan. He is chief psychologist for the Consortium for Advanced Psychology Training, a post-doctoral fellowship for clinical psychologists. Dr. Vogel has been credentialed by the National Register since 1990.
Scott Nyman, PhD, is the Associate Director of Behavioral Science for the Family Medicine Residency Program at Genesys Regional Medical Center in Grand Blanc, MI. He received his doctoral degree in counseling psychology from Purdue University, West Lafayette, IN. Dr. Nyman completed a two-year clinical health psychology fellowship with the Consortium for Advanced Psychology Training at Genesys Regional Medical Center.
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