From the halls of Congress to overflowing emergency rooms across the country, integrated health care has become one of the latest catchphrases in the health-care reform debate, and with good reason, many psychologists say. Often referred to as interdisciplinary or collaborative care, integrated care brings together health-care professionals who work in teams to treat the whole person. Physicians, psychologists, nurses and other providers work in tandem to diagnose physical and psychological health problems, plan and provide treatment, and evaluate whether that treatment is effective.
And when that treatment includes psychological interventions, patient outcomes improve right along with their satisfaction, research finds. For example, a 2005 Journal of the American Medical Association (Vol. 293, No. 13) study shows that combining stress management, medical treatment and exercise reduces depression and distress and improves heart function in cardiology patients.
But even more important in light of the health-care reform debate, new studies are demonstrating the ways integrated care improves care at a lower cost. A study in the January 2009 Psychiatric Services (Vol. 60, No. 1), for example, found that collaborative care in which patients receive mental health services onsite led to reduced treatment time, fewer appointments and, consequently, lower costs than traditional patient referral to offsite mental health centers.
That's no surprise to Katherine Nordal, PhD, APA's executive director for professional practice, who emphasizes that common medical disorders often co-exist with behavioral health problems, and that unless they are treated, these conditions only worsen. “Psychologists are the leading experts in changing unhealthy behaviors of individuals,” she says. “We have the skills to improve quality of life, reduce the level of disability associated with illness and at the same time dramatically reduce costs in our health-care system.”
The ways psychologists are working in integrated care continue to grow. Here are some of the settings they're working in, and the paths that got them there.
Geisinger Health System, Danville, Pa.
Thanks to President Barack Obama's praise of Geisinger during a September speech to a joint session of Congress, the system is recognized nationwide as a model of low-cost, quality health care.
Geisinger serves 2.6 million mostly rural Pennsylvanians, providing health-care services ranging from primary care to complex subspecialty medical expertise, such as pediatric endocrinology and urogynecology. Psychologists are involved in nearly every aspect of Geisinger's operation, from patient care to staff training and self-care promotion to medical student education, says Charlotte Collins, PhD, one of Geisinger's two adult behavioral medicine psychologists. The leadership at Geisinger, she says, often looks to psychologists to help the organization improve care and maximize outcomes.
“We're respected, valued, and asked to weigh in on many important issues hospital-wide,” Collins says.
Before joining Geisinger, she studied health psychology at the University of Kansas and later worked on many different integrated-care teams in various settings, including an integrated burn unit rehabilitation care team at Seattle's Harborview Medical Center. She joined Geisinger in 2007 to help expand integrated care in the health system. Integrated teams at Geisinger work with many different medical populations, including those in bariatric surgery, oncology, cardiology, primary care, pain and sleep medicine. For example, Collins says, Gesinger is a national center of excellence in bariatric surgery and psychologists help to evaluate, prepare and support patients before and after such surgery. Psychologists are also integral members of the system's cancer clinic teams, which see patients with breast, lung and bone cancers. In each of the weekly cancer clinics, a team made up of a psychologist, medical oncologist, radiation oncologist and surgeon gathers before and after meeting with patients individually to discuss diagnoses, treatment options and emotional health. It's all in an effort to streamline and improve patient care.
“It's reassuring to patients that providers are all working together and communicating about their care,” Collins says.
Psychologists also work to help Geisinger staff cope with stressful situations inherent in current medical practice. For example, Collins and her colleagues are developing an intervention to help staff facing possible litigation. The goal is to help health providers continue to provide excellent patient care despite any stress the potential suit may cause them.
In pediatrics, psychologists provide services in Geisinger's enuresis clinic and pediatric obesity treatment program, says Paul Kettlewell, PhD, another of the system's psychologists. Psychologists also collaborate with pediatricians to treat children with attention-deficit hyperactivity disorder. The group has had success using a shortened version of an evidence-based ADHD treatment intervention developed by Caroline Webster-Stratton, PhD, founding director of the University of Washington Parenting Center. After eight weeks of 75-minute group behavioral management and social skills training for parents and children, two-thirds of the children showed significant behavioral improvement, according to an article in Cognitive and Behavioral Practice (Vol. 11, No. 1).
“There's a very serious gap between researchers in university settings and clinicians in the real world,” Kettlewell says, adding that through the use of ongoing effectiveness studies such as this one, Geisinger is hoping to change that, and also prove that psychologists' involvement in medical care makes sense.
U.S. Department of Veterans Affairs, Washington, D.C.
Integrated health care is nothing new at the VA, says Antonette Zeiss, PhD, deputy chief consultant for mental health services at the VA's Central Office in Washington, D.C. The organization began incorporating interdisciplinary care into geriatric health services in the early 1980s, then expanded the teams to address spinal injury treatment, primary and hospice care. In 2009, the VA mandated the integration of mental health services as the de facto standard of care at all primary-care clinics, says Zeiss, who spent 23 years as a trainer of psychology interns and postdocs at the Palo Alto VA and also served as a co-chair on APA's 2007 Presidential Task Force on Integrated Health Care for an Aging Population.
VA psychologists work as part of the primary-care team, directly delivering mental and behavioral health care in clinics. Indirectly, they guide, coach and consult with primary-care physicians, physician assistants and nurses to treat common mental health issues. As experts in interpersonal relationships and group dynamics, these psychologists also help teams function well together and manage contradictory opinions, Zeiss says.
“We all get trained as individual health-care providers and are spoken of as licensed independent practitioners, but it's also important to be able to say — especially when working with patients with more complex health problems — that we're part of a collaborative team,” Zeiss says.
The VA also offers care virtually to patients in rural locations. Psychologists provide therapy to patients and meet with onsite health-care providers via video conferencing. VA's integrated care teams also make house calls to homebound veterans with significant physical injuries or traumatic brain injuries. In 2007, the group added psychologists to these home-visit teams, and preliminary longitudinal data show that overall health-care costs per patient went down in the year after mental health professionals started making home visits.
“We don't know for sure yet that the addition of psychologists was the primary change that led to this outcome, but it's a very intriguing finding,” Zeiss says.
Wheaton Franciscan Healthcare, Racine, Wis.
On a typical day at one of Wheaton's nonprofit long-term care facilities, clinical health psychologist Shamin Ladhani, PsyD, might consult with a physician about which antidepressant would work best for an older depressed patient, talk to a speech therapist about the decline of another patient's cognitive function, and speak with a nurse about how to deal with compliance problems arising from a patient with dementia.
Ladhani also meets individually with patients and uses cognitive behavioral therapy techniques or mindfulness meditation to help them deal with the emotional anguish of losing their independence and adjusting to living in the facility. And several hours a week she talks with patients' families to discuss progress, and meets with others on the health provider team to discuss each patient's physical and psychological barriers to improvement.
“Psychologists have the ability to pull different perspectives together and show how every person on the team can contribute and help move the patient along,” says Ladhani, who as part of her training worked at an in-patient rehab center and provided psychological support to heart transplant patients.
The 2008 chair of APA's Committee on Early Career Psychologists, Ladhani also notes that in the midst of the nation's health-care reform, integrated care is a flourishing career move for early career psychologists.
“Mental health is a critical component to managing almost all health problems and by providing psychological services to medical patients, we can improve outcomes, and hopefully also reduce costs and utilization of services,” she says. Ladhani has firsthand knowledge of how much collaborative mental-health care can help struggling patients: For two years she also served as a mental health provider for Wheaton's interdisciplinary pain management program.
Over four weeks, four to six patients received intensive care and consultation from a team of occupational therapists, nurses, physicians, pharmacists, dieticians and psychologists to help them cope with chronic pain. Program expenses were too high to justify the initiative's continuation once the recession hit, however, despite a three-month-long waiting list and cost savings relative to further health-care needs, Ladhani says. The patients who participated in the program didn't need as much medication or as many surgeries or injections, and stopped requesting psychological care because they'd learned how to manage their pain, she says.
She's still pursuing work in pain management, however, providing chronic pain consults to physicians throughout the hospital system and running twice-weekly, two-hour intensive pain management groups.
“I'm doing more cross-discipline care,” says Ladhani, who adds that her referrals have tripled since building partnerships with other physicians that treat pain. “It's not like we're all together, but I'm still talking to everyone to help provide the best care that's needed for that patient. It's the only way I know how to work, because I don't believe you can treat pain in isolation.”
Women's Healthcare Partnership, St. Louis
A 2009 survey by APA's Center for Workforce Studies shows that 46 percent of all clinical psychologists work in independent practice. But even private practitioners can provide integrated care, says St. Louis psychologist Diane Sanford, PhD. Since 1995, as president and co-developer of the Women's Healthcare Partnership, Sanford has collaborated with more than 150 St. Louis-area obstetricians/gynecologists to provide mental and emotional health support during pregnancy and after birth.
“Postpartum depression is the most frequent complication of childbirth; one in eight women is affected by it,” Sanford says. “But emotional health is still not regarded as integral to physical health in medical practice.”
To increase awareness of the condition among physicians, Sanford has written two books about and presented on the topic at physician conferences. She began by building her professional relationship with labor and delivery nurses, childbirth educators and OB-GYN groups when she first opened her practice. As it grew and more referrals came in, she recognized the importance of frequent communication with physicians, nurses and office receptionists to ensure prompt, effective care for patients.
“In women's health, OB-GYNs are the gatekeepers,” Sanford says. “You have to work with them if you're really going to help women.”
Her practice is a five-minute drive from two of St. Louis' major maternity hospitals, and Sanford says she does often see patients — for example, those who are on restricted bed rest — in the hospital. She also speaks to consumers at local hospitals and school districts about pregnancy and postpartum emotions and the adjustment to the physical, psychological and relationship changes women experience throughout these life changes.
“I just love helping create healthy families from the start,” Sanford says.
University of Rochester Medical Center, Rochester, N.Y.
Susan McDaniel, PhD, is considered one of the pioneers of psychologists' involvement in integrated care. She pushed for their inclusion on the health care team starting in 1982 when she first came to the University of Rochester Medical Center to collaborate with physicians to develop a behavioral science curriculum with a focus on families. These days, as associate chair of the university's department of family medicine and director of the Institute for the Family in psychiatry, McDaniel spends her time leading interdisciplinary case consultation, teaching a professional writing seminar for psychology fellows and family medicine faculty and working with insurance companies to advocate for including behavioral health in primary care, all while still collaborating on patient care.
She says she's been encouraged by the health-care sector's shift toward patient-centered medical homes as a model for putting primary care back at the center of health care, but adds that psychologists need to play a bigger role in making sure that mental and behavioral health are integrated into that model.
“Psychologists are uniquely suited to help [integrated-care teams] figure out how to do team-building, how to grow with the team, how to work out roles and how to be complementary,” McDaniel says.
This won't happen if clinicians sit in their offices waiting for referrals, she adds.
“I had to learn that just because someone isn't asking me what I think about a patient doesn't mean I don't have something very valuable to offer,” McDaniel says. “We are the answer to some of what's wrong in health care.”
For more information on APA's involvement in integrated-care efforts, visit APA's Integrated Care Health-Care Reform Web site at www.apa.org/health-reform/integrated-care.html.Amy Novotney is a writer in Chicago.