Imagine a diabetes patient going to her primary-care physician with health concerns related to her condition. Instead of getting an initial assessment and being referred out, an interdisciplinary team immediately starts working on her case, involving her throughout the process. As part of that team, a psychologist assesses her level of depression, knowing that it often goes hand in hand with diabetes. The psychologist might also devise behavioral strategies to control her blood glucose levels.
That dream scenario would be commonplace in a patient-centered medical home, also referred to as a “health home.” First conceived in 1967 by pediatricians as a way to coordinate care for children with developmental disabilities, the concept is regaining steam as a way to make primary care more robust, comprehensive and cost-effective. Versions of the concept — which is a central part of the 2010 health-care reform law — are already being adopted at the Mayo Clinic, the Department of Veterans Affairs (see A health home champion) and in pilot projects nationwide.
“The patient-centered health home is what primary care will be revitalized into,” predicts James H. Bray, PhD, 2009 APA president and a primary-care psychologist at Baylor College of Medicine in Houston.
Psychologists could be key players in both shaping and implementing this concept, but experts inside and outside the field say they aren’t moving fast enough.
“Psychology has an unprecedented opportunity in the medical home movement to integrate ourselves into the redesign of primary care,” says Benjamin Miller, PsyD, assistant professor of family medicine at the University of Colorado School of Medicine in Aurora and co-founder of the Collaborative Care Research Network or CCRN. “But if we don’t decide which direction to go as a profession, other mental health professionals will step up and fill the roles we are not filling.”
One reason psychologists will be attracted to the patient-centered home model is its ability to increase access to mental health care for all patients. Research shows that up to two-thirds of people who need mental health or substance abuse treatment are first seen in general medical settings, yet only 12.7 percent receive even minimally adequate treatment there, according to data compiled by the independent actuarial firm Milliman Inc.
Moreover, between 30 percent and 50 percent of people referred to mental health services don’t make their first appointment, according to studies in the Archives of Internal Medicine (Vol. 6, No. 4) and the Journal of the American Medical Association (Vol. 295, No. 9).
“There’s a huge set of patients who, if they got a referral from their physicians into the community, would never show up,” says Rodger Kessler, PhD, a clinical and primary-care psychologist at the University of Vermont College of Medicine in Burlington who has helped get behavioral health integrated into primary-care practices and in patient-centered health home pilot projects throughout Vermont.
Because care is better coordinated in a health home than in traditional medical settings, psychologists on these teams can improve the quality of both medical and mental health care, adds Katherine Nordal, PhD, APA’s executive director for professional practice. And by normalizing what psychologists do, psychologists’ integration into teams is likely to reduce stigma, as well, she says.
“Psychologists in this model are seen as just another doctor on the team — they’re not necessarily even identified explicitly as a psychologist or health-care provider,” she says.
At the same time, primary-care physicians are finally understanding the importance of incorporating a behavioral and psychological perspective in medical care, says Paul Grundy, MD, president of the Patient Centered Primary Care Collaborative, a consortium of Fortune 500 companies that played a key role in incorporating the health home concept in health-care reform legislation and that embraces behavioral health as part of its model.
“Many of us are beginning to grasp that the kinds of services and training and leadership that [psychologists] have been talking about for years is what is needed to address people’s presenting complaints,” Grundy says. “If you just peel back the onion a little bit, you’ll find that for many people, multiple mental health and behavioral issues are the norm.”
But to become permanent members of patient-centered teams, psychologists might benefit from more evidence demonstrating that their interventions make a positive difference in primary care. The research that does exist suggests definite benefits: A meta-analysis published online in BMC Medicine on June 25 indicates that brief psychotherapy in primary-care settings to treat anxiety and depression helps to reduce both mental and physical health problems. Meanwhile, studies show that one of the largest evidence-based treatment trials for depression to date, IMPACT shows that the model — which provides collaborative, integrated and supportive care using a team of health and mental health providers — significantly reduces depression, improves functioning and quality of life, and reduces health-care costs. The program, run out of the University of Washington and funded by the John A. Hartford Foundation and others, randomized 1,801 depressed, older adults to IMPACT or treatment as usual at 18 diverse primary-care sites across the country.
Further research now under way could bolster the evidence that integrating psychology can improve care in patient-centered health homes. With a grant from the Agency for Healthcare Research and Quality, for instance, Miller will be able to combine his CCRN network with another large national federated network called the Distributed Ambulatory Research and Therapeutics Network (DARTNet) to examine the aggregated electronic health records of thousands of patients. Analyses will allow him to compare outcomes of practices that integrate treatment for co-morbid mental and physical health conditions with those that do not.
“The data will let us go to policymakers and talk about the importance of addressing the whole person — not just mental health, not just physical health, but the two intertwined,” he says.
The health home on the ground
While researchers are gathering evidence, other psychologists are already working on health home teams. Miller’s network has enrolled 60 practices throughout the country that integrate mental health providers either in primary care or in patient-centered health homes.
Among such settings are the Salud Family Health Centers, nine clinics that serve low-income and immigrant patients in north-central Colorado. Salud is developing a health home model that involves a strong behavioral and mental health component, says clinical psychologist Andrea Auxier, PhD, Salud’s director of integrated services and clinical training.
“Many of our patients have immigration-related stressors and limited financial resources, and they don’t speak English or know how to navigate life in the United States,” she says. “It was important for us to find a way to address their needs in a comprehensive way.” As a result, patients receive both a full medical evaluation and a mental health screening by a psychology team made up of three postdoctoral fellows and seven practicum students. If psychological problems surface, the psychology team conducts further tests, working in tandem with the medical providers to ascertain how those issues might affect physical health issues, for example.
“All of our providers consider medical and mental health issues at the same time, using the same records and notes,” she says.
Treatment looks different at Salud than it would in a traditional setting, too, Auxier adds. Patients with mental health issues have the option of seeing an in-house professional for treatment, rather than being referred out — and many take that option. Another feature: Patients, no matter what their condition, aren’t kept waiting.
“Once someone comes in for help, we pretty much see them right away,” she says.
Salud Medical Services Director Tillman Farley, MD, says he can’t imagine good care being delivered without mental health professionals fully on board. “Not only do physicians not have a magical ability to spot mental health problems, but it is well-studied that they actually have a very poor ability to know who should be seen,” says Farley, who spoke about Salud’s version of integrated care at the APA 2009 Summit on the Future of Psychology Practice. “We rely on psychologists and other behavioral health professionals to provide that expertise.”
Another setting that is adopting the medical home model is New York’s University of Rochester Medical Center, where psychologist Susan McDaniel, PhD, has spent 28 years building a fully integrated care system. There, psychologists work on teams of medical professionals to provide comprehensive care that taps the wisdom of patients and their family members, McDaniel says.
“Because families are such an integral part of people’s lives and health, the family systems approach has particular salience for primary care and the patient-centered medical home,” says McDaniel, who also directs the medical school’s Institute for the Family in Psychiatry.
To ensure that the model extends beyond the confines of her clinic, McDaniel also heads a two-year psychology fellowship program at the medical school that brings together psychology postdocs with medical residents. These budding professionals learn a family systems approach to care and how to work effectively with one another.
“It demystifies who we are for them, and it demystifies them for us, too,” says Ann Cornell, PsyD, a second-year fellow in the program. Besides learning how physicians think, she has been able to share her perspective on the biopsychosocial challenges faced by older adults with medical residents doing geriatrics rotations, for example.
Psychologists have a wealth of other roles to play in health homes, as well. They’re well-equipped to design and lead patient-centered care programs, evaluate systems, and measure quality-improvement outcomes, says APA’s Nordal. “These are areas where psychology can shine,” she says.
In addition, psychologists can serve as team facilitators, a skill that will be increasingly necessary as team-based care becomes more common, McDaniel says.
“Research shows it takes people at the top of their scope of practice and who are part of a cohesive, well-functioning team for the medical home concept to actually provide better care,” she says.
Students who want to get involved in this movement can seek internships, postdocs or fellowships in settings that are adopting patient-centered health home models, including at the VA (see article on page 45), at federally qualified health centers such as Salud and at other leading-edge primary-care settings, such as the Mayo Clinic and the medical centers at the University of Rochester, University of Vermont and University of Colorado. In addition, the Graduate Psychology Education Program, a federally funded grant program initiated by APA, supports the development of and training in integrated-care teams at a number of sites across the country.
Practicing psychologists who are interested in the area should consider taking continuing-education courses in primary-care psychology, behavioral medicine and family systems psychology, says Bray. They can also consider gaining practical experience in primary-care settings, for example through programs such as the Certificate Program in Primary Care Behavioral Health at the University of Massachusetts.
Practicing psychologists can strengthen existing relationships with physicians and hospitals by keeping in contact with them and attending team meetings at hospitals to discuss shared patients, if possible, McDaniel adds. It also helps to highlight your ability to address problems that may be eluding physicians, such as lurking depression that is inhibiting a person’s ability to heal, she says.
If psychologists become full players in the health home movement, they’re likely to achieve an incredibly satisfying result: helping to develop a system that provides the kind of health care we’d all like to receive, McDaniel adds.
“Ninety-nine percent of the time, patients who receive this kind of care can’t believe how lucky they are,” says McDaniel. “To be able to come to the same place and get all of your care, and for people to work together on your behalf, is a great feeling.”
Tori DeAngelis is a writer in Syracuse, N.Y.
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APA’s Blueprint for Change: Integrated Health Care for an Aging Population. This report addresses the hallmarks of medical home and patient-centered integrated care models for older adults, as well as related fact sheets for consumers and policymakers.