New APA Integrated Health Care Initiative

A very exciting new initiative was launched by the APA Education and Practice Directorates, with support from the Public Interest Directorate, on integrated health care and the utilization of psychologists and psychology trainees in our nation's federally qualified health centers (FQHCs). The FQHCs include community health centers, migrant health centers, low-income housing health centers and school-based health centers. With over 7,000 sites nationwide, this initiative promises to improve the quality of mental and behavioral health care for those in our county most in need of services.

Nearly two decades ago, the collaboration between the Education Government Relations Office (GRO) and the Practice Directorate Committee on Rural Health (CRH) under the auspices of the Committee for the Advancement of Professional Practice (CAPP) began as an effort to gain access for the first time for psychologists and psychology trainees in the National Health Service Corps (NHSC). In 1994, Nina Levitt, EdD, Associate Executive Director for Education GRO, launched that effort with a focus on the U.S. Congress, both authorizing and appropriations legislation and with the federal agency, the Bureau of Primary Health Care. The Practice CRH, then under the direction of Gil Hill, joined that initiative and primarily focused on national organizations involved with rural health issues. Mr. Hill had become a recognized leader in the field of rural mental health and his connections were critical to garnering support from those key players.

By 1995 psychologists began participating in the NHSC Loan Repayment Program and working at health care facilities that were designated in Health Professional Shortage Areas (HPSA). Later there was a great deal of interest on the part of psychologists but not a great deal of demand. There were more significant and positive gains in 2000 when Education GRO secured a $1 million appropriation to establish regional conferences to promote integrated care that included mental and behavioral health for underserved populations throughout the nation. Close on the heels of that success, in 2002 statutory language was accepted in the Safety Net Legislation that gave psychologists and psychology trainees access to all the NHSC financial aid programs. It also created a focus on mental and behavioral health in the FQHC program. As a result the number of psychologists participating in the NHSC recently doubled to almost 400.

Despite gains at the federal level through Congressional action and federal agency policies, it became clear that, although there has been significant progress with the NHSC, much more needed to be done to increase the number of psychologists working in FQHCs. Therefore, Education GRO determined that a push had to be made at the state level where the FQHCs were organized through state-based Primary Care Associations (PCA.)

In 2007 Dr. Levitt reached out to California Psychological Association (CPA), Gilbert Newman, PhD, Immediate Past President of CPA, and its Rural Health Coordinator, Marv Megibow, PhD, about a possible effort in California that could serve as a model for other states. Under Dr. Newman's leadership, the California PCA was approached and although the California PCA had been resistant in the past, its staff expressed a strong interest in working with him and the CPA to get more psychologists hired. They were especially interested in hiring psychologists with prescription drug privileges. In fact, the California PCA had already launched an effort to facilitate an integrated approach to health care that included spearheading an initiative to get the state legislature to remove the regulation that prohibited Medicaid reimbursement for medical and mental health services on the same day.

In parallel with the work of Dr. Levitt, the CRH had in recent years been focusing on increasing NHSC positions in Community Health Centers and Rural Health Clinics. Over time they set as a priority the need to increase psychology staff positions in these facilities. This confluence of interests led Dr. Levitt to approach Clark Campbell, PhD, Chair of the CRH, who enthusiastically agreed to make the state-based initiative on integrated health care a CRH priority. As a result, collaboration between Dr. Levitt and Practice Directorate staff, Dan Abrahamson, PhD, Assistant Executive Director for State Advocacy and Lauren Schussler, Governance Associate of the Practice Directorate was initiated.

Special Meeting to Advance the Integrated Health Care Initiative

 

On September 19th during the fall 2008 Consolidated Meetings in Washington, DC, the Education GRO and CRH hosted an all-day meeting on the role of psychologists and trainees in FQHCs. Attending were key APA members with interest and expertise in rural health, integrated health care, and those in underserved communities represented by the Public Interest Directorate Socioeconomic Status Committee. Other invited guests included Gina Capra, a representative for the US Bureau of Primary Health Care (BPHC) in the Health Resources and Services Administration, and Michael Lardiere of the National Association of Community Health Centers (NACHC). Both spoke about the FQHC program and the efforts to address the mental and behavioral health needs of the underserved.

Dr. Newman and representatives of the California Central Valley FQHCs reported on efforts by community health centers in that state to employ psychologists. Parinda Khatri, PhD of the Cherokee Health Systems in Talbot, Tennessee presented on their integrated health care model, which includes medical, dental and mental health services, and on their psychology internship program. Dr. Kahtri noted that research provided by the Cherokee Health Systems illustrates that one of the benefits of integrated health care services is a significant decrease in medical utilization of Medicaid patients, including pediatric patients. Ben Miller, PsyD of the University of Massachusetts’ School of Medicine, shared information about his program's focus on integrated health care and its interdisciplinary approach to training, which uses an "integrated household" model that includes psychology interns, fellows and residents.

It became apparent at the meeting that some of the attendees have Graduate Psychology Education (GPE) grants including Gilbert Newman, PhD, from The Wright Institute Berkeley, CA; Parinda Khatri, PhD from a FQHC in Talbot, Tennessee; and Michael Lardiere of NACHC who was associated with the Lutheran Medical Center in Brooklyn, New York when it had a GPE grant. Everyone noted that the interdisciplinary training required by the GPE grant is extremely worthwhile in preparing psychology students for work in integrated health care and the innumerable benefits that this approach provides for communities in need.

The goals of the meeting were to: 1) Learn what has worked to create positions for psychologists and psychology trainees in FQHCs; 2) create an action plan to translate lessons learned for use in CA and other states; and 3) build the foundation for a partnership among state, provincial and territorial psychological associations (SPTAs), state primary care associations, relevant federal agencies and national organizations, and the American Psychological Association to further the initiative.

The meeting concluded with a number of suggested recommendations, including:

  • Facilitating important data collection/analysis (e.g., tracking patients in a disease registry) by connecting graduate programs of psychology with FQHCs.

  • Learning more about the "medical home" model and work to get the term changed to "health care home".

  • Developing materials to educate FQHC administrators on the positive health outcomes of employing psychologists.

  • Sharing publications (e.g., APA Presidential Task Force's Blueprint for Change: Achieving Integrated health Care for an Aging Population) with key players in the FQHC program at the federal, state & local levels.

  • Training psychology students (future clinical leaders) on integrated health care and teach them how to deal with such barriers as reimbursement and licensing issues.

  • Drafting talking points for use by psychologists willing to reach out to their state PCA.

Finally, participants also agreed to focus on a couple of states recommended by the BPHC where there is interest on the part of the Rural Health Coordinator, SPTAs, and the state PCA to work collaboratively on integrated health care that includes the utilization of psychologists and psychology trainees. Some candidate states include: New Mexico, Maine, and Missouri. Dr. Newman noted that in building collaborations with SPTAs we are also educating the broader profession of psychology about the emerging discipline of primary care psychology and the need for psychology to take a more active role in the future of health care reform.

Thus, the PCA initiative is continuing to move forward. It is enabling APA and its members to demonstrate the positive impact of providing mental and behavioral health care services through a seamless and integrated service delivery to our nation's underserved populations. As our nation strives to achieve a "health care home", it is clear that psychologists and psychology interns will play an increasingly vital role.

For Further information, contact Nina Levitt (e-mail; 202/336-6023).