Earlier this year, a young patient came to physician Jim Duff, MD, at Jordan Valley Community Health Center with steadily worsening Type-I diabetes because he wouldn't regularly take his insulin. Without insulin, the patient risked kidney failure, losing his sight and the possible amputation of his legs within a few years.

"He was a bit of a puzzle," says Duff, medical director at Jordan Valley, located in Springfield, Mo. "He was bright, intelligent, so we said, 'Let's see what it is we're missing.'"

Duff called in a psychologist from the locally based Forest Institute of Professional Psychology, which has about 220 students pursuing PsyDs in clinical psychology.

The psychologist found the patient had depression and complications in his home life, and recommended a combination of therapy and medication that helped turn around the patient's outlook. He now regularly monitors his blood sugar levels and gives himself insulin shots.

The consultation with Duff's patient was part of an ongoing collaboration between the Forest Institute and Jordan Valley, a federally qualified health center, which last year handled about 19,000 visits from poor and underserved patients annually in its main clinic, with about 19,000 additional visits to its dental facility. The collaboration is a venture into integrated health care, in which psychologists match their behavioral health expertise with the medical needs of Jordan Valley's predominantly poor, mostly uninsured or underinsured patients, and it exemplifies the key role psychology has to play in community health centers, says Nina Levitt, EdD, APA's associate executive director for education policy.

Psychologists treat the behavioral health issues that often underlie patients' medical problems, "and, as a result, the physicians are freed up to spend more time with the medical issues," Levitt says.

"We are excited about collaborative programs such as this, as it has been a long-standing initiative of the APA Education Directorate to promote the interdisciplinary training of psychologists in community health centers," Levitt adds.

The Jordan Valley/Forest Institute agreement also opens up a practicum opportunity for Forest students, several of whom are learning how a primary-care clinic works by sitting in with the psychologists and shadowing doctors and nurses as they see patients.

In the future, Forest-which offers a concentration in integrated health care-hopes to bolster its hands-on training in integrated health care by rotating more students through the clinic, offering an internship and making a postdoctoral residency available.

A new approach

The venture started with discussions between Mark Skrade, PsyD, president of Forest, and Brooks Miller, executive director of Jordan Valley, which opened about three years ago. Last year, Skrade laid the groundwork for the venture by hiring husband-and-wife psychologists Scott Schinaman, PsyD, and Tina Runyan, PhD, as Forest faculty members. The two had previously helped integrate behavioral health into the Air Force's primary-care system.

Miller says the clinic was looking to address patients' behavioral health to bolster their overall medical treatment and quality of life. An earlier effort to bring in mental health professionals failed because the therapists fell back on offering treatment in weekly 50-minute sessions, constricting the number of patients they could serve and excluding "door-knock" consultations.

For effective behavioral health integration, says Miller, the clinic needed psychologists immediately available to physicians and patients in the same physical space, which is what Runyan and Schinaman do. They adjust to physicians' fast-paced practice, "sound biting" their analyses of the behavioral health factors behind a patient's physical problem, says Runyan.

"They're not interested in your full conceptualization of why this person is not exercising and they've got hypertension," she says.

In a departure from a typical practitioner's routine, Schinaman, Runyan and a third Forest psychologist, Stephanie Wood, PhD, schedule their days at Jordan Valley in about 16 half-hour blocks.

By coordinating with the 15-minute time blocks in which physicians see patients, the psychologists can be available when physicians send over patients for a consultation, says Runyan. Both physicians and psychologists also keep about four or five slots open to see patients together.

Duff estimates that 80 percent of the clinic's patients have "substantial" behavioral health needs.

Prescriptions for behavior

Jordan Valley psychologists create "behavioral health prescriptions" for most of their patients, explaining specific actions they want them to follow in their daily lives.

For example, Schinaman might have a patient with Type-II diabetes and a weight problem agree to eat only in one specific spot in the house-such as at the kitchen table-no matter the food.

Such a seemingly small adjustment helps a person lose weight, Schinaman says.

"They pay more attention to food, they're aware of satiety, and we generally see a drop in weight. You start small, and you get them invested," he says.

At Jordan Valley, patients are referred to psychologists in several ways. Some are flagged for a visit after being screened for symptoms of depression, anxiety or substance abuse when they check in for their appointment.

Physicians send over others with chronic medical conditions such as diabetes or hypertension to talk about taking better care of themselves or regularly taking their medicine.

Physicians and psychologists work together on psychotropic medication management, and psychologists consult with physicians about patients taking narcotic pain medication for chronic pain. They use the same electronic medical record system for each patient so they can make notes and communicate about behavioral health issues, Runyan says.

The psychologists are also expanding their efforts to the dental clinic, working with the parents of young children to encourage brushing, flossing and better nutrition, and trying to find ways to teach basic dental hygiene to parents who haven't taught their children any of those habits.

The venture is also opening up training opportunities in integrated health care for psychology graduate students like Samuel Preylo Jr., currently doing a six-month practicum. Preylo shadows both physicians and psychologists as they see patients.

Working with the physicians, Preylo helps determine if a patient might need a visit with a Forest psychologist. He then observes the psychologist meeting with the patient, and helps figure out the patient's behavioral health needs.

Preylo hopes to extend his practicum to nine months and wants to do his internship in a primary-care facility.

Looking to his early career, Preylo aims to work in integrated health care in a community health center, with potential loan repayment through the National Health Service Corps (see "A new route to the heartland").

"I really believe in working with people from a holistic standpoint to understand illness and disease, and to help prevent and treat it," Preylo says.