Primary Care Psychology Lisa K. Kearney, Ph.D. Primary Care Psychologist South Texas Veterans Health Care System

Models of Primary Care Psychology Co-located Clinics Model: psychology services and medical in same building Co-located Clinics Model: psychology services and medical in same building Psychologist in Primary Care: provide traditional mental health services, but housed within primary care Psychologist in Primary Care: provide traditional mental health services, but housed within primary care Behavioral Health Consultant Model: fully integrated services for variety of mental and behavioral health problems Behavioral Health Consultant Model: fully integrated services for variety of mental and behavioral health problems Staff Adviser Model: psychologist serves as consultant to PCPs alone Staff Adviser Model: psychologist serves as consultant to PCPs alone (Gatchel & Oordt, 2003) (Gatchel & Oordt, 2003)

Behavioral Health Consultant Model Provides services to broad range of patients, with and without official MH diagnoses Provides services to broad range of patients, with and without official MH diagnoses Primarily brief therapy model (1-4 sessions) Primarily brief therapy model (1-4 sessions) Provide services to targeted disorders (e.g., depression, diabetes, chronic pain) who are high-utilizers of clinic services Provide services to targeted disorders (e.g., depression, diabetes, chronic pain) who are high-utilizers of clinic services Advantages: serve more patients, greater access to psychologist, assists with psychiatry back log Advantages: serve more patients, greater access to psychologist, assists with psychiatry back log (Gatchel & Oordt, 2003; Rowan & Runyan, 2005)

Behavioral Health Consultant vs. Specialty Mental Health Clinic Models Differences fall in the following areas: Primary goals Primary goals Appointment structure Appointment structure Intervention structure Intervention structure Intervention methods Intervention methods Termination and follow-up Termination and follow-up Referral structure Referral structure Primary information products Primary information products (Runyan et al., 2003) (Runyan et al., 2003)

Behavioral Health Consultant Skills Focused assessment Focused assessment Time efficiency: minute appts Time efficiency: minute appts Use of cognitive behavioral techniques Use of cognitive behavioral techniques A stages of change model (Prochaska, DiClemente, & Norcross, 1992) A stages of change model (Prochaska, DiClemente, & Norcross, 1992) Appreciation for population health focus Appreciation for population health focus Good communication with physicians and other staff members of the clinic Good communication with physicians and other staff members of the clinic (Gatchel & Oordt, 2003; Rowan & Runyan, 2005)

Behavioral Health Consultant Skills Function as a team member Function as a team member Respect for hierarchy of the system Respect for hierarchy of the system Flexibility in scheduling Flexibility in scheduling Understand medical conditions, procedures, medications Understand medical conditions, procedures, medications Help PCPs become comfortable treating pts with MH diagnoses; provide education Help PCPs become comfortable treating pts with MH diagnoses; provide education (Bray et al., 2004; Gatchel & Oordt, 2003)

The Referral Process Language in referral process (e.g., behavioral health vs. psychology) Language in referral process (e.g., behavioral health vs. psychology) Help pts understand behavioral health is part of primary care treatment Help pts understand behavioral health is part of primary care treatment Explain connection between behavioral and physical health (e.g., diabetes and depression/stress, HTN and stress levels Explain connection between behavioral and physical health (e.g., diabetes and depression/stress, HTN and stress levels Be first line referral for variety of problems Be first line referral for variety of problems Allow opportunity for PCP to introduce you Allow opportunity for PCP to introduce you (Gatchel & Oordt, 2003; Haley et al., 2004)

Setting Up Shop Build rapport with staff; reveal how BH can meet needs in primary care Build rapport with staff; reveal how BH can meet needs in primary care “Psychotherapy ain’t enough” “Psychotherapy ain’t enough” Find specific need and help address it Find specific need and help address it Work as a team member Work as a team member Market your services and be available Market your services and be available Learn primary care culture (e.g., clinic pace, how providers refer, feedback) Learn primary care culture (e.g., clinic pace, how providers refer, feedback) (Gatchel & Oordt, 2003; Haley et al., 20054

Common Key Concerns Diabetes Diabetes HTN and cardiovascular disease HTN and cardiovascular disease Chronic pain Chronic pain Sleep disturbance Sleep disturbance Non-compliance Non-compliance Depression, anxiety, and PTSD Depression, anxiety, and PTSD Coping with MMP Coping with MMP Substance abuse and dependence Substance abuse and dependence

VA Setting Examples Behavioral health orientation for initial intakes Behavioral health orientation for initial intakes –Pts initially referred to orientation for overview of BH services and referral options –Pts complete 1 page intake form and brief depression screening –Follow-up individual phone calls made to set up plan of care

VA Setting Examples Group therapy model Group therapy model –5-6 groups run per week in primary care –Example groups: Diabetes Support, Mood Management Group, Chronic Pain, Healthy Living, Medical Problems Support, Trauma Connections with psychiatry through a PharmD Connections with psychiatry through a PharmD –Goal is to manage pts in primary care, assisted by Pharm D when necessary –Appropriate referrals to psychiatry: Bipolar, Schizophrenia, Psychotic Disorders, and non- responsive Depression after 2-3 initial trials of antidepressant in the clinic

VA Setting Examples Interdisciplinary team approaches Interdisciplinary team approaches –Talk to PCPs about perception of large needs in clinic (e.g., non-compliance) –Collaborate with other professionals Dietitian and nurses in the MOVE! Program Dietitian and nurses in the MOVE! Program Creating healthy living programs (e.g., hypertension, diabetes, vascular risk reduction) which incorporate a team including a dietitian, PharmD, psychologist, and a nurse Creating healthy living programs (e.g., hypertension, diabetes, vascular risk reduction) which incorporate a team including a dietitian, PharmD, psychologist, and a nurse

VA Setting Examples Assist with management of pts newly diagnosed with depression and placed on anti-depressant medication Assist with management of pts newly diagnosed with depression and placed on anti-depressant medication –Group co-led by physician and behavioral health consultant with 3 visits scheduled in 3 months after onset Use of patient workshops Use of patient workshops Create educational handouts Create educational handouts Education of staff on key areas Education of staff on key areas

Initial Data Evaluation of all cases seen by BH in 9/05 Evaluation of all cases seen by BH in 9/ pts with only 26 referred to psychiatry (21.1%); referrals for Bipolar, Psychotic Disorder, or Dementia or failed 2 or more meds 123 pts with only 26 referred to psychiatry (21.1%); referrals for Bipolar, Psychotic Disorder, or Dementia or failed 2 or more meds Workload comparison to traditional MH psychologist: Workload comparison to traditional MH psychologist: –967 vs. 275 uniques –7736 vs encounters

Primary Care Psychology Lisa K. Kearney, Ph.D. Primary Care Psychologist South Texas Veterans Health Care System