Psychologists and Primary Care Physicians: A Training Model for Creating Collaborative Relationships Barbara A. Cubic, Ph.D. Associate Professor Eastern Virginia Medical School

Main Objective Psychologists and primary care physicians are well positioned for innovative, interdisciplinary collaborations. This presentation will review models of clinical care collaboration and interdisciplinary training of physicians and psychologists which result in an egalitarian process and produce better patient outcomes.

Learning Objectives §Following this presentation participants will be able to: l Describe the opportunities and challenges of integrated care l Consider ways to enhance the competencies of psychologists and primary care providers through innovative training models

TermSource, context, connotation Integrated Care Tightly integrated, on-site teamwork with unified care plan. Often connotes close organizational integration as well, perhaps involving social and other services Related to the concepts of Medical Home, a single- site, regular source of care for individuals seeking a broad range of biomedical and behavioral health care services and Patient-centered care Care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions (IOM, 2001).

Goal is an Integrated Care Model §Focus on biopsychosocial rather than just biomedical or just psychosocial aspects of care. §Fluid, egalitarian team process l Needs excellent communication l Needs respect & understanding of diverse backgrounds, philosophies, & viewpoints of team members. §Trade-off of provider autonomy for better patient outcomes. Pharmacist Psychologist Nurse- Practitioner Physician Patient & Family

Creating Collaborative Relationships with Primary Care Providers

Differing Perspectives §Primary Care Patients l Have Multiple Medical and Psychological Needs l Most Come in Only When Symptomatic l Expect a Brief Visit and that Pharmacological Treatment(s) will be Offered l Psychological Advice or Intervention is Unexpected and Often Unwanted l Referral to Mental Health Seen as Stigmatizing

Differing Perspectives §Primary Care Providers l Have Large Caseloads of Patients with Multiple Medical and Psychological Needs l Need to Prioritize What to Address at Each Visit l Ultimately Accountable for Care Provided by Extenders l View of My Patient Leads to Expectations Coordination of Care Exchange of Information with Consultants l Time Pressures

Differing Perspectives §Psychologists l Confidentiality Given Utmost Importance l Operate Largely in Context of Ongoing Relationships with Patients l Expect to Complete In-depth Assessments l Trained to Offer Interventions in Units of Time (e.g. generally 1 hour visits) l Generally Provide Solicited Psychological Advice or Intervention to Patient or Patients Advocate

Psychologists as Team Members Improve Dx & Rx of Mental Disorders Very Few Will See a Mental Health Specialist Patients often refuse mental health referrals 60-70% Will Be Underserved Inadequate medication dose/ duration Possible medication compliance and/or cost issues 80-85% Who Seek Help Go to PCP 50% of depressed primary care patients undiagnosed Most Who Need Help Wont Seek It

In an integrated care model Psychologists can become especially valued because…. §Highly trained in an area many physicians feel poorly equipped to treat §Easily adapt to multiple environments §Interpersonally skilled

Psychologists Contributions §Use empirically based treatment methods l Facilitate adaptation to chronic illness, disability, and life changes, l Facilitate behavioral change l Co-manage disorders with medical and psychosocial determinants. Understanding of motivational & learning theories Cognitive Behavioral Therapy Stress management

Psychologists also have a unique contribution to make regarding ACGME Competencies §The ACGME Website provides a toolbox of assessment methods and examples of use §Creativity is needed to determine specialty- specific and institutional-specific application §Were experts in the development and validation of assessment approaches l can offer institution-wide, cross-specialty assessment l especially in domains of communication and interpersonal skills

Psychologists will be especially valued because….. §A lack of time, educational expertise (especially regarding assessment) and funds mean meeting competencies are a challenge for program directors §ACGME often recommends nontraditional assessment methods, such as standardized patients (SPs) and our training prepares us well to objective evaluate interpersonal interactions

What We Learned at EVMS from a Collaborative Training Model Grant Title INTEGRATING PSYCHOLOGY INTERNSHIP TRAINING IN A PRIMARY CARE SETTING Grant Authors Barbara A. Cubic, Ph.D. Funding Source HRSA Other Funded Collaborators on the Grant Daniel Bluestein, M.D. Kathrin Hartmann, Ph.D.

The EVMS Clinical Psychology Internship Program §EVMS is a community based medical school founded in 1976 in Norfolk, VA § Norfolk is part of the Tidewater area of southeastern VA, consisting of 7 cities with a population exceeding 1.5 million § Internship Program is in the Department of Psychiatry which has a strong psychology division with 8 full time psychologists on faculty § Internship has existed since and has been APA accredited for 30 years § Accepts 6-8 interns from approximately 120 to 160 applications each year

The EVMS Ghent Family Medicine Residency Program §EVMS is a community based medical school founded in 1976 in Norfolk, VA § Norfolk is part of the Tidewater area of southeastern VA, consisting of 7 cities with a population exceeding 1.5 million § Ghent Family Medicine Residency is in the Department of Family and Community Medicine which has 12 full time faculty §Residency has existed since 1975 and it is an accredited three-year program which meets all the training requirements of the American Board of Family Medicine § Accepts approximately 5 residents per PGY year

Interdisciplinary Behavioral Medicine within the Internship §Internship had a behavioral medicine rotation in the Dept. of Family and Community Medicine (DFCM) in mid 1990's § Training was highly successful for both the interns and DFCM residents, but program lacked funding § Funding through a HRSA GPE grant allowed us to place 2 psychology interns on major rotations a year with family medicine residents (each for 6 months at a time) §Current HRSA grant is designed to allow us to move towards a complete model of integrated care with every intern rotating in primary care settings 1 day a week or more

Purpose/Rationale of Our Training § Model rests on reasons why mental health disorders are under diagnosed and under treated in primary care: l The stigma of mental illness l Primary care providers limited knowledge of psychiatric disorders l Confounds created when mental illness coincides with chronic physical illness l Time constraints for primary care providers

Purpose/Rationale of Our Training (continued) § Model also rests on the rationale for interdisciplinary training: l Historic separation of medical and psychological training leading to limited understanding of the different backgrounds, values, professional models, and ideologies l Often resulting in redundancy of effort, turf battles, and mixed, confusing, or negative messages to patients

EVMS Grant Objectives §Enhanced patient care §Immediate access to mental health consultation and treatment §Optimal patient-treatment matching §Special exposure to underserved populations §High accountability of services provided §Complete integration of mental health issues into overall primary care management §Creation of a workforce that is culturally competent and prepared to provide integrated care

Proposed Educational Model §Designed to teach psychology interns subtleties of working in primary care while concurrently fostering education of DFCM residents in core competences, e.g. basic doctoring skills, mental health, and behavioral health § Psychology interns placed in the role of educators, consultants, and service delivery agents in primary care settings and trained side- by-side with DFCM residents

EVMS Grant Methodology §Joint patient care delivery §Additional didactics added to DFCM seminar series §Joint intensive and collaborative supervision by Dr. Cubic and DFCM faculty for both psychology interns and DFCM residents §Specialized training in geriatrics §Specialized training in cultural diversity §Interns write a paper about a medical condition and psychology resources/interventions that can be of assistance to the patient and provider

Settings for the Training § Morning rounds in an inpatient setting § Consultation in an outpatient primary care practice § Carefully created opportunities for exposure to geriatric populations and children in a either a treatment program for attention deficit disorder or in a school program for at risk children

Number of Patient Contacts by Setting

Gender Distribution of Patient Population Across all Settings

Racial Distribution of Patient Population Across all Settings

SES Distribution of Patient Population Across all Settings

Age Distribution of Patient Population Across all Settings

Main Psychosocial Issues Addressed Across all Settings

Main Concepts Underscored with Interns

As a psychologist you are like a foreigner in a new country. It is your job to learn the language, not their job to adapt to you. Speaking a New Language: When in Rome do as the Romans Do

Skills need for a Psychologist to Thrive in Integrated Care Real World Knowledge of Primary Care and Confidence Practical View of Confidentiality Coordination Useful Documentation Efficiency Diversity of Skills Succinctness

Most Vital Skill Most Vital Skill Supervised Formal Supervised Formal or Informal Training Experiences in Primary Care Should be a Prerequisite Avoid Intimidation Avoid Intimidation Learn Medical Terminology Learn Medical Terminology Let the Unique Skills Psychology Offers Speak for Themselves/Provide Practical Advice Let the Unique Skills Psychology Offers Speak for Themselves/Provide Practical Advice Must Have a Good Sense of Humor Must Have a Good Sense of Humor

Understand Concept of a Treatment Team Understand Concept of a Treatment Team Full Disclosure to the Patient about What Will and Will Not be Shared Full Disclosure to the Patient about What Will and Will Not be Shared Understand the Dilemmas Created by Secrets Understand the Dilemmas Created by Secrets Differentiate Between What Needs to be Shared Versus What is Private Differentiate Between What Needs to be Shared Versus What is Private Use Written Consents in Specific Circumstances as a Safeguard Use Written Consents in Specific Circumstances as a Safeguard

Welcome Interruptions Welcome Interruptions As the Expert in Interpersonal Interactions You can Facilitate the Team Process Rely on Oral Communication Primarily esp. if Treating Patient in the PCP Office (with brief notes to document interactions with the patients or discussions with providers) Respect the Roles of Others

Forget What You Learned About Report Writing In School!!! PCPs are not Impressed with Theories, Lengthy Details or Specific Test Scores. Focus on Final Conclusions and Recommendations!!!

Succinct 1-2 Paragraph Descriptions If Documenting in Medical Record Use Different Color Paper or Designate a Section as the Mental Health Record Use Clear Headings SOAP Notes the Norm Word Issues Carefully (e.g. conversation about a marital affair could be worded as discussed interpersonal stressors) If Documenting in a Separate Chart Periodic Updates in the Form of a Letter to the PCP Should be Done (Brief Interactions or Therapy Sessions)

Reports in the Form of a Letter to the PCP Should be Done (1-2 Pages Max) Most Common Headers History of Present Illness (1-2 Paragraphs Max) Prior History (Only Most Relevant) Behavioral Observations (Quick MSE) Test Results (In Language PCP Can Understand) Diagnostic Impressions (Generally Axis I and II) Case Conceptualization (Main Findings Reviewed) Treatment Plan (Bulleted, Specific, Practical Recommendations) Offer to Discuss Impressions Further If Needed (Psychological Evaluations)

Primary Care Visits Are Usually 15 Minutes Primary Care Visits Are Usually 15 Minutes Describing Your Role to the Patient to Expedite Interaction (e.g. Im Dr. Cubic, a clinical psychology, and your physician, Dr. Bluestein, has asked me to discuss strategies with you for coping with your headaches) Describing Your Role to the Patient to Expedite Interaction (e.g. Im Dr. Cubic, a clinical psychology, and your physician, Dr. Bluestein, has asked me to discuss strategies with you for coping with your headaches) Stick to the Issue at Hand Stick to the Issue at Hand CBT and Interpersonal Approaches Work Well CBT and Interpersonal Approaches Work Well Have Patient Handouts on Key Issues Have Patient Handouts on Key Issues

Offer Broad Based Offer Broad Based Clinical Skills Clinical Skills Rule of Thumb is that Rule of Thumb is that 80-85% of Presenting Problems should be Managed in the Office Know Your Limitations but Recognize that You Likely Know More about Most Mental Health Issues than the Other Providers Know Your Limitations but Recognize that You Likely Know More about Most Mental Health Issues than the Other Providers Be Prepared to be Asked to Comment about Psychotropic Medications (general comments are within your scope of practice, but specific recommendations are not unless you meet APA Level III training) Be Prepared to be Asked to Comment about Psychotropic Medications (general comments are within your scope of practice, but specific recommendations are not unless you meet APA Level III training)

Carry a Tool Box Assessment Measures Assessment Measures (e.g. PRIME-MD Patient Health Questionnaire; Beck Depression, Anxiety, Hopelessness Scales; Geriatric Depression Scale; Cognistat; Conners; MMSE) Patient Handouts Patient Handouts (e.g. Coping with Depression, Relaxation Scripts, AA Meeting Directories, Pointers for Parents with Children with ADHD, Sleep Hygiene) (e.g. Coping with Depression, Relaxation Scripts, AA Meeting Directories, Pointers for Parents with Children with ADHD, Sleep Hygiene) Referral Information Referral Information (e.g. Keep an index of services, support groups, and internet resources for issues of bereavement, cancer, cardiovascular disease, diabetes, domestic violence, fibromyalgia, parenting, pregnancy, senior citizens, social services, substance abuse, STDs, transportation) (e.g. Keep an index of services, support groups, and internet resources for issues of bereavement, cancer, cardiovascular disease, diabetes, domestic violence, fibromyalgia, parenting, pregnancy, senior citizens, social services, substance abuse, STDs, transportation)

I think Sarah has anorexia nervosa, lets set up a family meeting VERSUS In the last 3 months Sarahs weight has dropped 18 lbs. She hasnt had a menstrual cycle and she is starving herself intentionally. My findings on the Eating Disorder Inventory-II suggest that she has a high degree of dietary restraint and poor interoceptive awareness. Her body image issues place her at risk for a negative prognosis if we dont involve her family immediately in her care. Are you comfortable with me setting up a meeting between you, me, the dietician, Sarah and her family?

Professional Development: Strategies for Overcoming Obstacles Coordination of Care Billing Billing Documentation Referrals

The House of Medicine Working as a Psychologist from the Inside OutUncompensatedActivities Consultations in PCP Setting Consultations in Your Office GenericReferrals SpecialtyReferrals

EVMS Evaluation Methods §Patient Contact Reports l # of patients seen, # of patients identified with mental health issue, other relevant tracking data §Pre and Post Physicians Belief Scales §Trainee Satisfaction Ratings §Patient Satisfaction Ratings §Pre and Post Tests on Knowledge of Primary Care Medicine, Attitudes about the Elderly and Issues in Treating Children

Pre-Grant Scores on the Physicians Belief Scale for the DFCM Residents (Higher Scores Reflect More Negative Beliefs about Identifying and Treating Psychosocial Issues) Minimum Score Maximum Score MeanStandard Deviation

Feedback Survey Scores from the DFCM Attendings at 6 months 1= Strongly Disagree to 4 = Strongly Agree Item # Item ContentMean 1.….lead to an increased emphasis on psychosocial issues overall ….enhanced my comfort in treating psychosocial pxs ….I am more likely to investigate psychosocial pxs with my patients 3.50

Feedback Survey (continued) 1= Strongly Disagree to 4 = Strongly Agree Item # Item ContentMean 4.….had no impact on the way I deal with psychosocial issues with patients *On Item #4 a Lower Score is More Positive 1.50* 5.….encouraged me to consider both organic and psychosocial pxs in patient care concurrently ….I am more likely to routinely investigate psychosocial issues myself 3.17

Feedback Survey Scores from the DFCM Attendings at 6 months 1= Strongly Disagree to 4 = Strongly Agree Item #Item ContentMean 7.….enhanced GFP residency training I would be less likely to consult with a psych intern about a patient…. If they were not in the GFP setting I view the psych intern as an important personal resource in maintaining my emotional well being ….enhanced the care received by patients at GFP 3.67

In Summary, the Training Expands the number of Psychology Interns and Family Medicine Residents that are prepared to work within an Integrated Interdisciplinary Model and Prepares both set of Trainees for a Number of Other Settings