State Leadership Conference
A medical resident training at LifePoint Hospitals in Las Cruces, N.M., was going through a list of diagnostic criteria with a patient with depression. The resident noted the patient's poor appetite and was ready to move on to the next item, when the psychology student training alongside him probed a little more. The result? A diagnosis of a serious eating disorder.
"That would have been missed," John Andazola, MD, program director of LifePoint Hospitals, told participants at the State Leadership Conference in March. "We have to look at the whole person."
That's just the kind of story that APA President Suzanne Bennett Johnson, PhD, had in mind when she chaired the session on integrated care. "Our current health-care system is a failed system," she said. "Integrated care is the exact opposite of our current system: It is patient-centered care, and it rejects mind/body dualism."
Integration of behavioral health and primary care plays a huge role in the Patient Protection and Affordable Care Act, said Robert McGrath, PhD, director of Fairleigh Dickinson University's certificate program in integrated primary care. Offering what he called "health-care reform 101," he explained several key terms, including patient-centered medical homes. Called patient-aligned care teams in the Veterans Affairs system—"because when you tell old soldiers about medical homes, they think it's a place to put you in your dotage," McGrath said—patient-centered medical homes mean providers working in conjunction with primary-care providers.
The health-care reform law also calls for the creation of accountable care organizations, which will be responsible for the complete care of Medicaid recipients. Unlike traditional managed care, in accountable care organizations "it's supposed to be providers driving the ship," McGrath said.
"Ideally, there will be less intrusion of third parties into decision-making, since providers will do the decision-making," he said. "If accountable care organizations succeed, they'll be seen as a model for revamping the entire health-care system."
State health exchanges are another key term to understand. In 2014, McGrath said, employers with at least 50 employees can pay a fine and shift employees from work-based insurance to the state exchanges. According to McGrath, fiscal analyses show that's a winning strategy for most large companies.
Psychologists must participate in shaping such changes, McGrath emphasized. They need to eliminate such barriers to integration as reimbursement obstacles and statutes that make it illegal in some states for psychologists to partner with physicians. They also need to share data showing that integrating psychological services into overall health care can reduce costs.
With 25 to 30 years' worth of research showing that integrated care is a good idea, why hasn't it happened yet? There are several reasons, according to Benjamin Miller, PsyD, director of the Office of Integrated Healthcare Research and Policy at the University of Colorado School of Medicine in Denver.
For one, fragmentation in the health-care system means that others often don't hear about successful integration initiatives and so can't come together to make a case that integration should be the standard of care. In addition, there's no standardization across models of integration, and people may use different terms to describe the same model. And while psychologists are good at collecting clinical outcomes data, other variables—such as financial outcomes—are crucial when it comes to making the case for integration.
Psychologists can help make that case, said Miller. To create more consistency across sites, for example, they could change the way they document patient care. "I can write a beautiful narrative note, which has a lot of clinical utility," said Miller. "However, what we have to do is think about the age of electronic health records." Drop-down menus and standardized forms make it much easier to pull data from records and show the benefits of integration, he said.
Andazola offered a physician's perspective. "I'm the physician you're going to integrate with," said Andazola, who trains psychology and medical students side by side and encourages them to consider not just psychological illness but the psychological aspects of physical illness.
Integration isn't the same as collaboration or co-location, Andazola emphasized. "We're not just working with psychologists," he said. "They're involved in everything we do across the board: We treat patients together." Psychologists and physicians see patients in the same setting, which helps break down the stigma often associated with seeking mental health services. And they use the same electronic records.
When medical residents graduate and move on to clinics that don't integrate behavioral health, added Andazola, they often feel they can't treat patients appropriately. "They feel they don't have a full armamentarium," he said.
Promoting integration more widely will require changing both psychological and medical education, Andazola concluded. Psychologists need to learn brief interventions, since 45-minute sessions are incompatible with integrated care. They also have to learn to talk to physicians. While psychologists are thorough, he said, physicians are to the point. And while psychologists don't make diagnoses until the data are definitive, physicians make diagnoses based on ambiguous data all the time.