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Training the collaborative care practitioners of the future
Abstract
To prepare family medicine residents to function in the type of practices envisioned in the Future of Family Medicine Report, a residency needs to teach the skills of collaborative practice with behavioral health providers. This requires residents to have the experience of practicing with behavioral health providers who are peers, in addition to learning from behavioral science faculty. This article describes the development of a fellowship in primary care psychology within a department of family medicine and community health as an intervention on the training of residents for collaborative practice. It also sets out the structured routines of exchange between residents and fellows, as well as between behavioral science and medical faculty members, designed to maximize the experience of and learning from collaboration. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
... A summary of the program details can be found in Table 2. Twentyfive (62.5%) programs had a multi-disciplinary group of learners [29][30][31], with ten (25.0%) programs consisting of physician-MHP dyads [29][30][31]41,42,46,[52][53][54]56]. Three (7.5%) programs included other sectors [39,40,49] (e.g., education, fire, police) in addition to primary care staff. ...
... Less than half of the programs reported teaching measurementguided care (element 3) (n = 11; 27.5%) [33,34,37,[44][45][46]50,51,[57][58][59]64] and evidence-based care (element 4) (n = 17; 42.5%) [33,34,41,42,[44][45][46][48][49][50][51][56][57][58][60][61][62]64]. The counts for elements 3 and 4 are conservative estimates as some articles did not explicitly state whether their programs taught measurementguided (n = 5; 12.5%) [36,41,47,56,60] or evidence-based care (n = 13; 32.5%) [30,[36][37][38][39]43,47,54,55,59,63,65,66]. ...
... Interruptions in primary care is a commonly reported example of an unspoken cultural norm that required explanation [52,54,[58][59][60]. Practicing in a collaborative culture provides supervisors with the opportunity to mentor trainees [33,64] and model collaborative behaviours to shape the perceptions, beliefs, and behaviours of the learners [42,51,56,57,60,61,63,67]. ...
... this fragmentation (Blount & Bayona, 1994;Blount, DeGirolamo, & Mariani, 2006;Blount & Miller, 2009;Hall et al., 2015;Institute of Medicine, 2001). Differences in the traditional scheduling patterns for primary care clinician appointments (i.e., focused 15-min encounters) compared with behavioral health clinicians (i.e., 45-50 min, multiple sessions) further create cultural distinctions in how care is structured . ...
... For instance, most medical and behavioral health clinicians historically have been educated and trained in siloed environments without access to interprofessional team development (McDaniel, Belar, Schroeder, Hargrove, & Freeman, 2002). Although local and national training programs are emerging and competencies have been articulated for interprofessional practice (McDaniel et al., 2014), the majority of medical and behavioral health professionals are not trained to work in integrated settings (Beacham et al., 2017;Blount et al., 2006;Blount & Miller, 2009;Hall et al., 2015;McDaniel, 1995;McDaniel et al., 2002McDaniel et al., , 2014. Moreover, implementation of integrated care models requires robust leadership to change culture, redesigned clinical workflows This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. As defined by the Agency for Healthcare Research and Quality, the PCMH framework has 5 attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Evidence increasingly demonstrates that for the PCMH to best achieve the Triple Aim (improved outcomes, decreased cost, and enhanced patient experience), treatment for behavioral health (including mental health, substance use, and life stressors) must be integrated as a central tenet. However, challenges to implementing the PCMH framework are compounded for real-world practitioners because payment reform rarely happens concurrently. Nowhere is this more evident than in attempts to integrate behavioral health clinicians into primary care. As behavioral health clinicians find opportunities to work in integrated settings, a comprehensive understanding of payment models is integral to the dialogue. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy.
... There has been a growing recognition of such complex needs and the biological, psychological, social, and cultural aspects of medicine in the healthcare sciences curriculum (Quintero, 2014). There is also a greater appreciation for the collaborative care and practice model that brings together medical doctors, pharmacists, nurses, and other healthcare professionals together for patient care (Blount et al., 2006). The collaborative care model attempts to implement change in small and manageable cycles, appreciating the complexity involved. ...
The article highlights the urgent need to teach complexity science to health science students.
... Commonly referred to as dual interviewing (Blount, DeGirolamo, & Mariani, 2006), medical and mental health providers can provide treatment positioned towards positive behavioral change in tandem (e.g., smoking cessation). Systematic surveys of dual interviews have bolstered this notion by uncovering high rates of collaborative practice between the same clinic providers. ...
The integration of psychologists and other behavioral health providers in primary care practice continues to evolve and reshape approaches to patient care. This study is a replication and extension of a 2013 study describing dual interviewing encounters involving psychology trainees and family medicine residents within an integrated primary care clinic as it relates to behavioral health assessments and interventions. Psychology trainees provided descriptions of 400 collaborative patient encounters involving 337 single and 63 repeat encounters. Psychology trainees coded the frequency of behavioral health assessments and interventions by the psychology trainee, family medicine resident, or both. Seventy-eight percent of encounters contained an assessment, and 20% contained interventions. Compared to the 2013 study, there were significantly fewer behavioral health interventions offered and a significantly greater number of psychoeducation/supportive interventions offered collaboratively. It was discovered that discussions between psychology trainees and family medicine residents immediately after patient encounters occurred 50% of the time and involved issues of case conceptualization. These informal discussions may be an important source of behavioral health education for family medicine residents. This study adds to efforts to better understand what occurs during these encounters.
... Some graduate programs in psychology have included training for work in primary care through coursework and/or practicum (Beacham, Kinman, Harris, & Masters, 2012). Various organizations have intensive training programs, ranging from shadowing consultations with established BHCs, regular consultation groups, and ongoing supervision, such as those occurring at the Health Federation of Philadelphia (Daub, Levkovich, Serrano, & Gallagher, 2010;Levkovich & Daub, 2012), the U.S. Air Force (Dobmeyer, Rowan, Etherage, & Wilson, 2003), and predoctoral internships and postdoctoral training fellowships for psychologists (Blount, DeGirolamo, & Mariani, 2006;Hunter & Peterson, 2001). Likewise, professional conferences, including the Collaborative Family Healthcare Association and the Society of Behavioral Medicine, provide ongoing BHC training and information on current research initiatives (Robinson & Reiter, 2007). ...
The growing movement of integrating behavioral health services in medical settings aims to increase ease of access to behavioral health services. Behavioral health consultants (BHCs), who are embedded within primary care clinics, provide a variety of psychological services (screening, brief interventions, and referral to specialized treatment settings) in a novel manner relative to traditional outpatient behavioral health treatment. These alterations in service delivery present unique ethical challenges to effective patient care in primary care behavioral health (PCBH) practice. This article discusses potential ethical dilemmas and challenges that are faced in PCBH. Confidentiality, privacy and informed consent are discussed, given the complex level of communication within primary care clinics. The potential for having multiple relationships with coworkers is reviewed. The need for BHC’s to provide sufficient clinical intervention and assessment, and how these may be limited in scope in BHC practice, is discussed. Finally, the complexity of obtaining competence for practice in primary care is explored. We discuss how ethical guidelines apply to this work, and also aim to address where further clarity is needed and context-based ethical decision-making is warranted. Case studies are provided to help illustrate the novel challenges faced by BHCs in integrated medical settings.
... Access 1 We have not found any similar experiences in the literature. Joint physician/psychologist interviews with a patient have been used in the training of family physicians in some institutions in the USA (Blount, De Girolamo, & Mariani, 2006;Hepworth & Cushman, 2001;Holloway & David, 2005). Besides their episodic character, implementation of these interviews is dependent even in these cases on a request from the physician. ...
Evidence in the literature indicates that psychology is regarded favorably. The public, however, appears somewhat confused about the role and functions of psychologists. This may impact upon the capacity of professionals to assist the wider community. The aim of this study was to investigate whether the presence of a psychologist in the primary care setting together with the physician affects the image of psychologists among the public. An observational study was conducted on a group of 227 patients recruited in the waiting rooms of 4 primary care practices: the physician worked in a joint consultation with the psychologist in 2 of these practices, whereas the physician worked alone in the other 2. Propensity score-matching was used to minimize any bias arising from a nonexperimental design. An open-ended question was conceived to assess people’s perception of psychologists. Our findings show that almost 65% of the participants thought that the psychologist addresses daily life problems and 96% considered the psychologist useful. No significant differences between the 2 groups emerged regarding how useful psychologists are and the issues they address, while patients who attended a joint consultation were 4 times more likely to perceive the personal relevance of the psychologist than those who consulted the physician alone (odds ratio [OR] = 4.3, p < .02). In conclusion, this study reveals a positive public image of psychology, though a joint consultation setting appears to be required to induce patients to consider psychologists as relevant to themselves.
... It is therefore critical to also identify informal opportunities for psychology trainees given that any exposure to integrated behavioral health and primary care settings is incredibly valuable, even outside the context of formal practicums. A well-documented ''culture shock'' is experienced by many who transition from specialty mental health to primary care (Blount, 2003;Blount, DeGirolamo, & Mariani, 2006;Blount & Miller, 2009). Even lower intensity opportunities such as shadowing and participating in research projects and quality improvement initiatives can help acclimate trainees. ...
Health reform, post the passing of the Patient Protection and Affordable Care Act, has highlighted the need to better address critical issues such as primary care, behavioral health, and payment reform. Much of this need is subsequent to robust data showing the seemingly uncontrollable growth of healthcare costs, and the exacerbation of these costs for patients with comorbid behavioral health and medical conditions. There is increasing recognition that incorporating behavioral health in primary care leads to improved outcomes and better care. To address these problems, primary care will play critical roles across the healthcare system, especially in the delivery of behavioral health services. Psychologists are uniquely positioned to take advantage of this propitious moment and can help facilitate the integration of behavioral and primary care by developing competencies in integrated care, training a capable workforce, and advocating for integrated care as the status quo.
Collaborative approaches to healthcare that integrate behavioural and biomedical interventions are more likely to enhance patient outcomes as well as provider satisfaction with care delivery than siloed approaches to care. The recognition for specific and targeted training for these models is growing among all health professions, although many in the field have not received systematized, interprofessional, and competency-based training that adequately prepared them for the work of integration. This article reviews some of the fundamental principles of biopsychosocially-oriented, team-based approaches to care that integrate behavioural and biomedical perspectives and delineates the need for targeted training efforts. It describes which specific elements must be addressed within it in order to promote effective integration, and highlights the array of options for training currently in existence. This review provides an overview of current models of training offered in the US, and concludes with a discussion of the challenges and barriers that may render training either ineffective or difficult to achieve.
Primary care behavioral health (PCBH) is a model of integrated healthcare service delivery that has been well established in the field of psychology and continues to grow. PCBH has been associated with positive patient satisfaction and health outcomes, reduced healthcare expenditures, and improved population health. However, much of the education and training on PCBH has focused on developing behavioral health providers to practice in this medical setting. Less attention has been paid to physician team members to support and practice within an integrated environment. This is problematic as underdeveloped physician team members may contribute to low utilization and attrition of behavioral health consultants. A scoping review was conducted to examine the training of physicians in this domain since 2006. Twenty-one studies were identified, predominantly in Family Medicine training programs. Although PCBH training was generally well received, more program evaluation, formalized curriculum, and faculty development are needed to establish best practices.
The evidence for bringing behavioral health services into primary care can be confusing. Studies are quite varied in the types of programs assessed, what impacts are assessed, what kind of therapy is offered, for what populations, and on how broad a scale. By organizing the evidence into categories: whether the program is coordinated, co-located or integrated, whether for a targeted or non-targeted patient population, offering specified or unspecified behavioral health services, in a small scale or extensive implementation, programs can be compared more easily. By noting what sorts of impacts are reported-improved access to services, clinical outcome, maintained improvement, improved compliance, patient satisfaction, provider satisfaction, cost effectiveness or medical cost offset-the most comprehensive overall assessment of this important approach to patients’ needs can be encouraged.
Argues that the biopsychosocial model of health care will not replace the biomedical model until it is translated into an organization and a set of practices that will support and validate it. This situation is explained by considering the health care system as a self-maintaining system. One example of a setting in which an alternative model, organization, and practice have been attempted is described. This example is a health care center that provides services at the individual, family, and community level and serves primarily a Latino population. The organization and practice of this center are described, and the case of the treatment of a 38-yr-old woman with both medical and social problems is presented. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Discusses the importance of providing collaborative family healthcare, and questions the current state of training for collaboration in 1996. It is hoped that
Families, Systems & Health will provide an outlet to dispense information about training in Collaborative Family HealthCare. Three appendices are provided, covering (1) Generic Core Competencies for All Professionals Training in Collaboration, (2) Core Competencies for Training Healthcare Providers to Collaborate, and (3) Core Competencies for Training Mental Health Professionals to Collaborate. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Integrated primary care unifies medical and mental health care in a primary care setting. This book explains this practice as the most fully realized form of collaboration between medical and mental health providers and presents several different models for its practical application.
Contributions to this book describe best practices in integrated care and spend as much effort showing how to successfully develop and implement these programs in different settings as they do arguing for their usefulness.
It is intended as a comprehensive manual that will be welcomed by both mental health and medical providers and administrators. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
• After initial interviews with 20 291 adults in the National Institute of Mental Health Epidemiologic Catchment Area Program, we estimated prospective 1-year prevalence and service use rates of mental and addictive disorders in the US population. An annual prevalence rate of 28.1% was found for these disorders, composed of a 1-month point prevalence of 15.7% (at wave 1) and a 1-year incidence of new or recurrent disorders identified in 12.3% of the population at wave 2. During the 1-year follow-up period, 6.6% of the total sample developed one or more new disorders after being assessed as having no previous lifetime diagnosis at wave 1. An additional 5.7% of the population, with a history of some previous disorder at wave 1, had an acute relapse or suffered from a new disorder in 1 year. Irrespective of diagnosis, 14.7% of the US population in 1 year reported use of services in one or more component sectors of the de facto US mental and ad- dictive service system. With some overlap between sectors, specialists in mental and addictive disorders provided treatment to 5.9% of the US population, 6.4% sought such services from general medical physicians, 3.0% sought these services from other human service professionals, and 4.1% turned to the voluntary support sector for such care. Of those persons with any disorder, only 28.5% (8.0 per 100 population) sought mental health/addictive services. Persons with specific disorders varied in the proportion who used services, from a high of more than 60% for somatization, schizophrenia, and bipolar disorders to a low of less than 25% for addictive disorders and severe cognitive impairment. Applications of these descriptive data to US health care system reform options are considered in the context of other variables that will determine national health policy.
As health care undergoes rapid and momentous changes, health care providers must transform their practices and find new ways to treat patients and their families. How does a primary care physician treating chronic illness address the problem of family conflict? How does a psychotherapist bring an awareness of acute medical conditions into the treatment of mental health problems? Most important, how do health and mental health practitioners in diverse health care settings build bridges among themselves so that patients and families receive the best treatment possible?
As the authors of this volume illustrate . . . the answer lies in a collaborative approach. New models of collaboration are being developed to facilitate effective health care delivery. The road to implementing these models is not yet complete, but in this book the authors add a bold voice to the contemporary search for answers to our health care crisis.
"Models of Collaboration" places patients and their families front and center in the treatment of mind and body and shows us how to form effective practitioner–patient–family alliances where dialogue and understanding are paramount. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Describes the authors' involvement as family-therapy supervisors and trainees in a family medicine training program. This arrangement provided a collaborative context in which the 2 cultures of medicine and therapy convened for training. The primary goal for the family therapy intern was to participate in supervised family therapy; the student learned about physicians' training and participated in the joint care of families by physicians and therapists. The possibilities and difficulties of working within this framework are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We discover what we believe when we have to teach it. Late spring of 1997, Susan traveled to Germany to celebrate the German publication of
Medical Family Therapy and to continue a collaboration with internists in the medical schools in Aachen and Freiburg. Our Aachen colleagues asked her to speak about the training we believe to be important for Collaborative Family Healthcare. Building on the early discussions at Wingspread in 1994 about training (McDaniel & Campbell, 1996), the following editorial is based on her German talk. We publish it in this issue in conjunction with the white paper by the nursing Panel on Interdisciplinary/Transdisciplinary Education and accompanying commentaries. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Primary care psychology is a growing field that requires specific training opportunities for successful practice. The knowledge and skills that practitioners need for work in this setting are outlined here in detail. This curriculum integrates literature and experience in family psychology, health psychology, and pediatric psychology; considers multiple levels of education and training; and provides illustrative examples. It is a first attempt in an evolving process of integrating historical and cutting edge literature from many areas of psychology and other disciplines to contribute to comprehensive primary care psychology training. It can be used by programs and individual practitioners alike in designing education and training experiences. (PsycINFO Database Record (c) 2012 APA, all rights reserved)