Psychologists and Primary Care Physicians: A Training
Model for Creating Collaborative Relationships
Barbara A. Cubic, Ph.D.Barbara A. Cubic, Ph.D.Associate ProfessorAssociate Professor
Eastern Virginia Medical SchoolEastern Virginia Medical School
Main ObjectivePsychologists 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 ObjectivesLearning ObjectivesFollowing this presentation participants will
be able to: Describe the opportunities and challenges of
integrated care Consider ways to enhance the competencies of
psychologists and primary care providers through innovative training models
Term Source, 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
Needs excellent communication 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 PerspectivesPrimary Care Patients
Have Multiple Medical and Psychological Needs Most Come in Only When Symptomatic Expect a Brief Visit and that Pharmacological
Treatment(s) will be Offered Psychological Advice or Intervention is
Unexpected and Often Unwanted Referral to Mental Health Seen as Stigmatizing
Differing PerspectivesPrimary Care Providers
Have Large Caseloads of Patients with Multiple Medical and Psychological Needs
Need to Prioritize What to Address at Each Visit Ultimately Accountable for Care Provided by Extenders View of “My Patient” Leads to Expectations
• Coordination of Care• Exchange of Information with Consultants
Time Pressures
Differing PerspectivesPsychologists
Confidentiality Given Utmost Importance Operate Largely in Context of Ongoing
Relationships with Patients Expect to Complete In-depth Assessments Trained to Offer Interventions in Units of Time
(e.g. generally 1 hour visits) Generally Provide Solicited Psychological Advice
or Intervention to Patient or Patient’s Advocate
Psychologists as Team Members Improve Dx & Rx of Mental Disorders
Most Who Need Help Won’t Seek It
80-85% Who Seek Help Go to PCP50% of depressed primary care patients undiagnosed
60-70% Will Be UnderservedInadequate medication dose/ duration
Possible medication compliance and/or cost issues
Very Few Will See a Mental Health Specialist
Patients often refuse mental health referrals
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 environmentsInterpersonally skilled
Psychologist’s ContributionsUse empirically based treatment
methods Facilitate adaptation to chronic illness, disability, and
life changes, Facilitate behavioral change 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
We’re experts in the development and validation of assessment approaches
can offer institution-wide, cross-specialty assessment 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 aCollaborative Training Model
Grant TitleINTEGRATING PSYCHOLOGY INTERNSHIP
TRAINING IN A PRIMARY CARE SETTINGGrant AuthorsBarbara A. Cubic, Ph.D.Funding SourceHRSAOther Funded Collaborators on the GrantDaniel 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 1976-77 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 2002-2004 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 TrainingModel rests on reasons why mental health disorders are
under diagnosed and under treated in primary care: The stigma of mental illness Primary care providers’ limited
knowledge of psychiatric disorders Confounds created when mental illness
coincides with chronic physical illness Time constraints for primary care
providers
Purpose/Rationale of Our Training (continued)Model also rests on the rationale for
interdisciplinary training: Historic separation of medical and psychological
training leading to limited understanding of the different backgrounds, values, professional models, and ideologies
Often resulting in redundancy of effort, turf battles, and mixed, confusing, or negative messages to patients
EVMS Grant ObjectivesEnhanced patient careImmediate access to mental health consultation
and treatmentOptimal patient-treatment matchingSpecial exposure to underserved populationsHigh accountability of services providedComplete integration of mental health issues into
overall primary care managementCreation of a workforce that is culturally
competent and prepared to provide integrated care
Proposed Educational ModelDesigned 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 MethodologyJoint patient care deliveryAdditional didactics added to DFCM seminar
seriesJoint intensive and collaborative supervision by
Dr. Cubic and DFCM faculty for both psychology interns and DFCM residents
Specialized training in geriatricsSpecialized training in cultural diversityInterns 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
0
20
40
60
80
100
120
140
160
Outpatient Inpatient Nursing HomeNeurofeedback Assisted Living
Males36%
Fem ales64%
Gender Distribution of Patient Population Across all Settings
Caucasian51%
African American
48%
Other1%
Racial Distribution of Patient Population Across all Settings
Low48%Middle
51%
High1%
SES Distribution of Patient Population Across all Settings
<1916%
19-3511%
36-5016%51-65
18%
>6539%
Age Distribution of Patient Population Across all Settings
Mood D/O51%
Anx4%
Sub Use4%
ADHD14%
Cog Px11%
Other16%
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
Practical View of Confidentiality
Coordination
UsefulDocumentation
Efficiency
Diversity of Skills
Succinctness
Real World Knowledge of Primary Care and Confidence
Most Vital SkillMost Vital Skill Supervised Formal Supervised Formal
or Informal Training Experiences in or Informal Training Experiences in Primary Care Should be a Primary Care Should be a PrerequisitePrerequisite
Avoid IntimidationAvoid IntimidationLearn Medical TerminologyLearn Medical TerminologyLet the Unique Skills Psychology Let the Unique Skills Psychology Offers Speak Offers Speak for for Themselves/Provide Practical AdviceThemselves/Provide Practical AdviceMust Have a Good Sense of HumorMust Have a Good Sense of Humor
Understand Concept of a Treatment Understand Concept of a Treatment TeamTeam Full Disclosure to the Patient about Full Disclosure to the Patient about What Will What Will and Will Not be Sharedand Will Not be Shared Understand the Dilemmas Created Understand the Dilemmas Created by Secretsby Secrets Differentiate Between What Needs Differentiate Between What Needs to be Shared to be Shared Versus What is Versus What is PrivatePrivate Use Written Consents in Specific Use Written Consents in Specific Circumstances Circumstances as a Safeguardas a Safeguard
Welcome InterruptionsWelcome Interruptions As the Expert in Interpersonal Interactions You
can Facilitate the Team ProcessRely 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 Respect the Roles of Othersof Others
Forget What You Learned About Forget What You Learned About Report Writing In School!!! Report Writing In School!!! PCPs are not Impressed with PCPs are not Impressed with Theories, Lengthy Details or Theories, Lengthy Details or Specific Test Scores. Focus on Specific Test Scores. Focus on Final Conclusions and Final Conclusions and Recommendations!!!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 Primary Care Visits Are Usually 15 MinutesMinutesDescribing Your Role to the Patient Describing Your Role to the Patient to Expedite to Expedite InteractionInteraction (e.g. “I’m Dr. Cubic, a clinical (e.g. “I’m Dr. Cubic, a clinical
psychology, and your psychology, and your physician, Dr. Bluestein, has asked me to physician, Dr. Bluestein, has asked me to discuss discuss strategies strategies with you for coping with your with you for coping with your headaches”)headaches”)
Stick to the Issue at HandStick to the Issue at HandCBT and Interpersonal Approaches CBT and Interpersonal Approaches Work WellWork WellHave Patient Handouts on Key Have Patient Handouts on Key IssuesIssues
Offer Broad Based Offer Broad Based Clinical SkillsClinical Skills
Rule of Thumb is thatRule of Thumb is that80-85% of Presenting 80-85% of Presenting Problems should be Managed in the OfficeProblems should be Managed in the Office
Know Your Limitations but Recognize that You Know Your Limitations but Recognize that You Likely Know More about Most Mental Likely Know More about Most Mental
Health Issues than the Other ProvidersHealth Issues than the Other ProvidersBe Prepared to be Asked to Comment about Be Prepared to be Asked to Comment about
Psychotropic Medications Psychotropic Medications (general comments are within (general comments are within
your scope of practice, but specific recommendations are not unless you meet your scope of practice, but specific recommendations are not unless you meet APA Level III training)APA Level III training)
Carry a Tool BoxCarry a Tool BoxAssessment MeasuresAssessment Measures
(e.g. PRIME-MD Patient Health Questionnaire;(e.g. PRIME-MD Patient Health Questionnaire;Beck Depression, Anxiety, Hopelessness Scales;Beck Depression, Anxiety, Hopelessness Scales;Geriatric Depression Scale; Cognistat; Conner’s;Geriatric Depression Scale; Cognistat; Conner’s;MMSE) MMSE)
Patient HandoutsPatient Handouts (e.g. Coping with Depression, Relaxation Scripts, AA Meeting Directories, Pointers (e.g. Coping with Depression, Relaxation Scripts, AA Meeting Directories, Pointers
for Parents with Children with ADHD, Sleep Hygiene)for Parents with Children with ADHD, Sleep Hygiene)
Referral InformationReferral Information (e.g. Keep an index of services, support groups, and internet resources for issues of (e.g. Keep an index of services, support groups, and internet resources for issues of
bereavement, cancer, cardiovascular disease, diabetes, domestic violence, bereavement, cancer, cardiovascular disease, diabetes, domestic violence, fibromyalgia, parenting, pregnancy, senior citizens, social services, substance fibromyalgia, parenting, pregnancy, senior citizens, social services, substance abuse, STDs, transportation) abuse, STDs, transportation)
“I think Sarah has anorexia nervosa, let’s set up a family meeting”
VERSUS“In the last 3 months Sarah’s weight has dropped 18 lbs. She hasn’t 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 don’t 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 Coordination of CareCare
BillingBillingDocumentationDocumentation
ReferralsReferrals
The House of MedicineWorking as a Psychologist from the Inside Out
Specialty Specialty ReferralsReferralsSpecialty Specialty ReferralsReferrals
Generic Generic ReferralsReferralsGeneric Generic ReferralsReferrals
Consultations Consultations in Your Officein Your OfficeConsultations Consultations in Your Officein Your Office
Consultations Consultations in PCP Settingin PCP SettingConsultations Consultations in PCP Settingin PCP Setting
Uncompensated Uncompensated ActivitiesActivitiesUncompensated Uncompensated ActivitiesActivities
EVMS Evaluation Methods
Patient Contact Reports # of patients seen, # of patients identified with
mental health issue, other relevant tracking dataPre and Post Physician’s Belief ScalesTrainee Satisfaction RatingsPatient Satisfaction RatingsPre and Post Tests on Knowledge of Primary
Care Medicine, Attitudes about the Elderly and Issues in Treating Children
Pre-Grant Scores on the Physician’s Belief Scalefor the DFCM Residents
(Higher Scores Reflect More Negative Beliefs about Identifying and Treating Psychosocial Issues)
Minimum Score
Maximum Score
Mean Standard Deviation
57 83 69.89 9.85
Feedback Survey Scores from the DFCM Attendings at 6 months1= Strongly Disagree to 4 = Strongly Agree
Item #
Item Content Mean
1. ….lead to an increased emphasis on psychosocial issues overall
3.50
2. ….enhanced my comfort in treating psychosocial pxs
3.17
3. ….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 Content Mean
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
3.50
6. ….I am more likely to routinely investigate psychosocial issues myself
3.17
Feedback Survey Scores from the DFCM Attendings at 6 months1= Strongly Disagree to 4 = Strongly Agree
Item # Item Content Mean
7. ….enhanced GFP residency training 3.508. I would be less likely to consult with a psych
intern about a patient…. If they were not in the GFP setting
3.30
9. I view the psych intern as an important personal resource in maintaining my emotional well being
2.50
10. ….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
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