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From Novice to Mastery:

Integrated Behavioral Health

Training across One’s Career

APAHC Conference

Friday, March 10, 2017

Mark E. Vogel, Ph.D., ABPP

Learning Objectives

Upon completion of the session, learners will:• Understand a model of skill acquisition applicable to

integrated care setting,• Name educational sequences and programs used to

train psychologists to work in integrated behavioral health environments,

• Identify competencies tools used to measure psychologists knowledge and skills when working in integrated primary care settings,

• Be able to assess their own need and readiness for integrated behavioral health practice.

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What is Integrated Behavioral Health

Care?• Behavioral Health

▫ broad term – mental health, substance misuse, health behaviors, ineffective health care utilization1

• Integrated Care

▫ Primary Care

integrated, accessible health care services, majority of health needs, sustained partnership with patients2

Integrated Primary Care (IPC)

1. Peek et al, 2013 2. IOM, 1994

Behavioral health and primary care

integration • “the care that results from a practice team of

primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population”

Peek et al., 2013

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What are we really talking about?

the knowledge, skills, and attitudes for high performance

McClelland (1973)

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Competencies Development

Health Service Psychology

Clinical Health

Psychology

Primary Care

Ongoing Iterative Process

Health Service Psychology

• Science

• Professionalism

• Relational

▫ Interpersonal Skills & Communication

• Applications

• Education

• SystemsHealth Service Psychology Education Collaborative (2013). Professional Psychology in Health Care Services: A Blueprint for Education and Training. American Psychologist, 68 (6), 411-426. doi: 10.1037/a0033265

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The Domain of HSPClinical Psychology

School Psychology Counseling Psychology

Health ServicePsychology

Belar, 2012

Clinical Health Competencies

6 Clusters (CCHPTP website –rating form)

• Cluster 1: Science

• Cluster 2: Professionalism

• Cluster 3: Relationships

▫ Interprofessionalism

• Cluster 4: Applications

• Cluster 5: Education

• Cluster 6: Systems

▫ Interdisciplinary/Interprofessional Systems

▫ Management/Administration/Leadership

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Competencies for Integrated Primary Care

•General knowledge of human anatomy, physiology, and pathophysiology, and pharmacology

Biological and cognitive components of health & illness

•Understanding how learning, memory, perception, and cognition can influence health and health behavior

Behavioral and developmental aspects of health & illness

•Understand how emotions and motivation can influence health and health behavior

Sociocultural components of health & illness

•Assessment of relevant components for common conditions seen in PCCommon primary care

problems

•Knowledge and skill in implementing empirically supported interventions for the prevention and treatment of the most common conditions in primary care

Assessment and intervention in PC

•knowledge of other disciplines, and expertise in collaboration with these professionals

Interprofessionalcollaboration in PC

•Identify the distinctive ethical issues encountered in primary care practiceEthical, legal & professional

issues in PC

McDaniel, Belar, Schroeder, Hargrove & Freeman, 2002

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Competencies for Psychology Practice in Primary Care

Systems

Leadership

&

Admin

Interdisci-plinary

Systems

Advocacy

Education

Teaching

Supervision

Relationship

Interpro-fessionalism

Building

& Sustaining

Science

Biopsycho

Social

Basis

Research

& Evaluation

Profession-alism

Value & Attitudes

Cultural Diversity

Ethics

Self Assessment

Self Care

Application

Practice Management

Assessment

Intervention

Clinical Consultation

APA, 2015http://www.apa.org/ed/competencies-practice.pdf

Interprofessional Competence• Every profession must meet its own

discipline’s core competencies

• Additionally, need to develop team-based competencies by engaging in interprofessional learning experiences

• Expands basic training model

▫ Acknowledges that interprofessionalpractice requires unique competencies

▫ Necessitates interprofessional experiences during training

Interprofessional Education Collaborative Expert Panel. (May, 2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

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Non-Clinical Roles

Research

Quality Improvement

Program Evaluation

Outcomes Research

Administration

Clinic policies and procedures

Hospital/school committees

Supervision

Trainees

Paraprofessionals

Community

Outreach/PopulationHealth

Networking

Ethics in IPC

• Multiple relationships & conflict of interest

▫ Teaching, Clinical, vsSupervisory roles

▫ Impaired colleagues

▫ Boundary transgressions

• Multiple disciplines

• Ambiguous situations

• Competences

• Informed consent

▫ Different expectations

▫ Hand-off protocol

• Confidentiality

Ethical Quandaries When Delivering Integrated Primary CareFamilies, Systems, & Health Christine Runyan, Patricia Robinson, and Debra Gould (Guest Editors) Vol. 31, No. 1, March 2013

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Unique Roles of Psychologists in

Primary Care Settings• Functional

▫ Assessment Screening in office

▫ Consultations▫ Program Evaluation▫ Management and Administration

• Foundational▫ Flexibility, Tolerance, and Resiliency▫ Effective Communication and Professional▫ Self-Assuredness and Assertiveness▫ Understanding and Appreciating Team-Based Care

and Interdisciplinary Systems

Nash, McKay, Vogel, & Masters, 2012

Milestones

• 1. a stone set up beside a road to mark the distance in miles to a particular place.

• 2. an action or event marking a significant change or stage in development.

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Bloom's Taxonomy (Anderson Rev)

Cognitive (Knowledge)

Affective (Attitude)

Psychomotor (Skills)

Bloom et al, 1956; Anderson, Lorin, Krathwohl, 2001

See also Miller’s Pyramid of Clinical Competencies

Novice to Expert

Dreyfus et al, 1980; Eraut, 1994; Cheetham, Graham, Chivers, & Geoff , 2005

Stage Characteristic

Novice Rigid adherence to taught rules or plansLittle situational perceptionNo discretionary judgment

Advanced Beginner

Guidelines for action based on attributes or aspectsSituational perception limitedAll attributes and aspects are given equal importance

Competent Coping with ‘crowdedness’See actions (at least partially) in terms of long-term goalConscious deliberate planningStandardized and routine procedures

Proficient See situations holisticallySee what is most important in a situationPerceives deviations from normal patterns

Expert No longer relied on rules, guidance, or maximumsIntuitive grasp of situations based on tacit understandingAnalytic approaches to novel situation

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How do we achieve this aim?

• Each stage of training (doctoral, practicum, internship, postdoctoral, and continuing education) should be tailored to the learner’s needs and their existing competencies.

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Knowledge-Based Competencies in IPC

Example: Professionalism

Doctoral Internship Post-Doc

Values and Attributes

Consolidates identify as a primary care psychologist

Values process of board certification

Diversity Knowledge of diversity via a Diversity course, modified to emphasize health disparities, illness beliefs, and the delivery of culturally competent health care

Ethics Knowledge of ethical issues in primary care via intern seminar and Family Medicine Grand Rounds

Knowledge of ethical and legal issues in primary care psychology as well as other health professions via Ethics Seminar

Larkin, Bridges, Fields & Vogel, 2015

Skill-Based Competencies in IPC

Example: Professionalism

Doctoral Internship Post-Doc

Values and Attributes

Builds professional identity as a member of the primary care team via Clerkship in FQHC

Prepares for attaining board certification by participating in mock orals

Diversity Experiences leadership role in Diversity Committee of the health care facility

Ethics Handles ethical and legal issues that arise in primary care settings through supervised clinical work

Formalizes a commitment to ethical principles unique to primary care and serves as a resource for questions of ethics that arise

Reflective self-assessment & care

Develops advanced reflective practice and self-assessment via group supervision.

Larkin, Bridges, Fields & Vogel, 2015

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Training in Integrated Primary Care

• Formal Training in Doctoral, Internship, Post-doc▫ See APA website for listing

• Sample curriculum▫ See McDaniel, Belar, Schroeder, Hargrove & Freeman

(2002) for ideas and reading and exercises Example: Cognitive components of health and illness

1. Interview an ill person to learn about his or her personal and family beliefs about the illness and their beliefs about the cause of illness and its most appropriate treatment. Compare this to the beliefs held by the medical profession regarding this illness.

2. In supervision, describe your own family illness history and how this affects your health beliefs.

3. List ten medical illnesses that can affect cognitive functioning.

Competency Tools• CHP Competencies Rating Form (Excerpt)

Benchmark CHP

1. Scientific Knowledge and Methods 1.Scientific Knowledge and Methods of Clinical Health Psychology

1A. Scientific Mindedness

Independently applies scientific methods to practice

1B. Scientific Foundation of Psychology

Demonstrates advanced level knowledge of core science (i.e., scientific bases of behavior)

Knowledge of pathophysiology of disease

Knowledge of the pathways and reciprocal interactions among psychosocial and biological phenomena

Knowledge of lifespan developmental and social-environmental factors associated with health behavior, illness, and disease

Knowledge of the interactions among populations and contextual variations and the impact on health behavior and health outcomes

Knowledge of the scientific foundations and research methods of other health disciplines (e.g., epidemiology, biostatistics)

CCHPTP 2014

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Measuring CompetenciesIPR1: Knowledge of strengths and potential pitfalls of role relationships that characterize

interdisciplinary collaborative activities (e.g., research, education, clinical care, administration)

Accurately assesses the knowledge and skills of other disciplines

Aware of skills and competencies of other health service professionals (e.g., physicians,

nurses, social workers) who (wish to) do research in health care settings

Able to identify successful collaborators for conducting interdisciplinary research

Has not Achieved

NOVICE ADVANCED BEGINNER

COMPETENT PROFICIENT EXPERT

Comments:

CCHPTP, 2015

APA and competency domains

• APA-CoA -> CoS

▫ Internship/Residency

Level 1: Profession wide

Level 2: Program specific

▫ Post-Doctoral

Level 3: Competencies that are specific to each recognized specialty

Deemed to be essential importance by the specialty

• Evaluate the attainment of these competencies by their residents/post-docs.

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Is Integrated Primary Care Right For you?

Do you like being part of a team?

Do you want to be a generalist?

How well do you tolerate uncertainty

and change?

Do you feel comfortable asking

questions?

Do you like going outside your

comfort zone?

Do you believe that brief interventions are meaningful and

effective?

Do you find the interplay of

biological and psychological

factors interesting?

How do you feel about medical

providers?

Do you like a fast pace?

Vogel & Ruddy, 2014

Summary

• Model of skill acquisition in integrated care

▫ Competency development

▫ Many skills are unique to integrated environments

• Training occurs in all educational sequences

▫ Each level with more specificity and granularity

• Work continues on competencies tools

• These tools also assist in self-assessment for readiness for integrated behavioral health practice

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Thank you

• Mark Vogel, Ph.D., ABPP

• vogel1@msu.edu