Integrated Primary Care: Transitioning from Guest to Member of the Team
Cheyenne Hughes-Reid, PhD and Meghan McAuliffe Lines, PhD
There is no question that integrated care is a necessary mechanism for service delivery for pediatric populations. Changes with regards to health reform and movements to establish a medical home for children provide a foundation for ensuring that integrated care is part of standard practice in delivering family-centered care. Under the Patient Protection and Affordable Care Act, health care providers are encouraged to identify children in need of additional services and justify the need for additional treatment modalities. The pediatric primary care physician (PPCP) plays a critical role in navigating services for children throughout their development in terms of acute health problems, chronic health conditions, and behavioral and developmental health. Moreover, the integration of behavioral health into primary care practices theoretically increases access to psychological services for children in a timely and cost effective manner in order to ensure family-centered care.
Why pediatric primary care physicians are the first resource for parents
Pediatric primary care physicians have long been the first resource for parents who are concerned about their children's emotional or behavioral difficulties (Kelleher & Stevens, 2009), and over 50 percent of pediatric primary care visits address emotional, behavioral, psychosocial and/or educational concerns (Cooper et al., 2006). Traditionally, the role of the PPCP has been to provide advice and anticipatory guidance, and refer to a mental health professional in the case of complex problems (Hacker et al., 2006; Kelleher, 2000). However, treatment for mental health issues in children is increasingly being provided by primary care providers due to significant shortages in the availability of child mental health providers, and the literature suggests that 75 percent of children with psychiatric difficulties are treated in the primary care setting (Williams, Klinepeter, Palmes, et al., 2004). In 2000, it was noted that over the previous 20 years, the rate of psychosocial problems identified by primary care providers has more than doubled from 7 percent to 18 percent (Kelleher, McInerny, Gardner, Childs, & Wasserman, 2000). Moreover, when children are referred to a mental health provider, only 30 to 43 percent of parents have been found to follow through with obtaining services (Amone-P'Olak, Ormel, Oldehinkel, Reijneveld, Verhulst, & Burger, 2010; Bergman, 2004; Kelleher, Campo, & Gardner, 2006). This attendance rate is dramatically improved to 81% when families are referred to a mental health provider available on site in a rural setting ( Valleley, Kosse, Schemm, Foster, Polaha, & Evans, 2007). Integration of behavioral health services within primary care has been shown to increase both patient satisfaction and provider satisfaction (Rowan& Runyan, 2005).
Is psychology is a "guest" within primary care practice?
Integrated care is a relatively new frontier for psychologists, with various models of care emerging over the past 30 years. The level of integration in varying models is on a continuum, ranging from psychologists co-located in the same building as primary care physicians to psychologists as members of a fully integrated care team. As policy and health care reform continue to emphasize integrated care, it becomes important for psychologists to strive to establish themselves as team members rather than providing service in parallel. The March 2013 Report of the Interorganizational Work Group on Competencies for Primary Care Psychology clearly outlines the competencies needed for psychologists to work within primary care, specifically delineating competencies within science, systems, professionalism, relationships and application. These competencies underscore the multifaceted role that psychologists have within integrated care particularly that of an essential medical home team member. Despite this emphasis and need, there are some barriers to developing a fully integrated system of care including logistical challenges (e.g., space), reimbursement issues, meeting referral demands, identification of appropriate referrals and resistance to systems change. Psychology may be viewed as a separate, isolated service and may be viewed as a “guest” within a primary care practice rather than a team member of the medical home. As such, the process of creating a collaborative team providing integrated and coordinated care requires psychologists to have an understanding of the primary care system, flexibility and adaptability with practice, and strategies for strengthening communication with PPCPs.
Keys for becoming part of a team
Understand the System
The pediatric primary care medical home is a unique system. In order for psychologists to become effectively embedded, they must have an appreciation for the pace, roles of team members, and breadth of patients and presenting problems. The caseload and sheer volume of patients that PPCPs see in their practice lends itself to a fast-paced and dynamic workplace. There are also numerous demands with regard to screening, treatment, education, case management and provision of anticipatory guidance during well child checks on top of care during sick visits. Having an understanding of the multiple demands placed on the PPCP with regard to coordinating and managing care for children, sometimes across multiple providers or specialists, is critical in establishing yourself as a team member. The comprehensive role that the PPCP plays in primary and preventative health care provides ample opportunities for psychologists to develop a role to meet the needs by providing assessment, developing programs, providing education to other providers and providing treatment.
In addition to considering the clinical work of primary care, one must also consider primary care as a business and workplace. Efforts to integrate psychology into the existing infrastructure will aid in behavioral health being viewed as an integrated service and part of the practice. For example, it may be important for the nurses, medical assistants, office manager and support staff (i.e., patient service representative, schedulers, secretaries, etc.) to be familiar with psychology's role, schedule and procedures in order to answer any patient questions that may arise. Time is valuable in primary care and often there is little time for formal, scheduled meetings to discuss logistical and clinical issues; however, it is critical to build in time for communication and consultation with providers. If there are already regularly scheduled staff meetings, psychologists should attend and inquire about the appropriateness of bringing up logistical or clinical issues that need the team's attention. Much of the consultation and education happens informally — during lunch or in the hallway- and its key to be mindful of the PPCPs busy schedules.
Not only is it important to understand the primary care system, one should also understand how traditional psychology service delivery may differ from integrated care and how practice can be modified to be more accommodating to the primary care practice. Working in primary care requires flexibility and adaptability, and requires a paradigm shift from traditional psychological service delivery. Pomerantz, Corson and Detzer (2009) reference the need for primary care psychology to move away from lengthy course of treatment, 50-60 minute appointments, attendance policies and restrictions in breadth of patients. Psychology in primary care requires brief interventions, flexible schedule and often an open-door policy to treatment given the course of care provided in primary care that is delivered across a child's development. One must also be mindful of the population that their primary care practice services and match the services offered to that population.
In addition, being both aware and accommodating of PPCPs expectations of psychology is also key. PPCPs may have varying levels of comfort level in assessing and treating behavioral health issues (Pidano, Kimmelblatt and Neace, 2011) and also have different experiences in working with psychologists. These variations in experiences may lead to preconceived notions regarding expectations for the psychologists' role. Openness about these expectations and ongoing monitoring and evaluation of psychology services is key.
As primary care psychology continues to expand and define its role in the field of health care, it can be very easy to continue to provide treatment and care “as usual” in isolation from the care being provided by PPCPs. In order to be fully integrated, it is important for psychologists to be seen as available and open to consultation. Expectations in primary care are that the psychologist will be available on short notice for both informal consults and immediate intervention, and this flexibility is essential for increasing the value of the psychologists' role in primary care (Clay and Rowan, 2005a) The concept of the “warm handoff” is perhaps a hallmark feature of integrative care as this allows for the PPCP to refer a patient to psychology immediately at the time of visit for a “meet and greet” or brief assessment/treatment. Being available and readily seen allows for PCPPs to better access psychology and consult as needed given the busy and high-pace nature of primary care.
It is important to understand the needs of the population served by the primary care practice and the gaps of care that currently exist. It may be important to see your role as an ongoing educator, as well as a continuous consumer of the information and expertise that may be gained from working amongst professionals representing multiple disciplines. Moreover, it is essential to recognize that the behavioral health care provided is in the context of an enduring, long-term relationship of the entire care team with the patient and family (Clay & Stern, 2005b). So while the psychological intervention may be brief, it can be viewed by the family and PPCP as a valuable element of their long-term care plan.
As with any team, communication is a critical component. One complaint that PPCPs often have with referrals to community mental health services is the lack of continuity and communication between the PPCP and the mental health provider (Kelleher, 2000; Rushton, Bruckman & Kelleher, 2002). A real strength of integrated care is the mechanism for providing communication regarding initial assessment and conceptualization of the family, as well as the recommendations and treatment plan. Establishing opportunities for communication and collaboration with PPCPs is essential to truly collaborative care.
Psychology primary care is a vastly growing field that is gaining momentum from health care reform and the movement to the medical home model. Given the various levels of integration that psychology and primary care may have, special attention must be placed on the knowledge, competencies and skill set needed to ensure that psychology is seen as a valuable team member, rather than a guest in primary care.
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Cheyenne Hughes-Reid, PhD, is a pediatric psychologist at Nemours A.I. duPont Hospital for Children. Hughes-Reid received her doctorate in School Psychology with specialization in Pediatric School Psychology from Lehigh University. She completed her predoctoral internship at the University of Nebraska Medical Center's Munroe-Meyer Institute (Nebraska Internship Consortium in Professional Psychology) and postdoctoral fellowship in the Division of Behavioral Health at Nemours A.I. duPont Hospital for Children. Hughes-Reid's clinical and research interests focus upon integrated primary care, program development, quality improvement, collaborative care, psychosocial screening, school consultation, and assessment and intervention for children with gastrointestinal disorders.
Meghan McAuliffe Lines, PhD, is a pediatric psychologist at Nemours A.I. duPont Hospital for Children and Nemours Health and Prevention Services. Lines received her doctorate in Clinical Psychology from the University of Delaware. She completed her predoctoral internship and postdoctoral fellowship in the Division of Behavioral Health at Nemours A.I. duPont Hospital for Children. Lines' clinical and research interests center around integrated primary care, with a particular emphasis on trainee education, program development, quality improvement, evidence-based interventions and collaborative care. Lines is active in her state psychological association and is on the editorial board of Clinical Practice in Pediatric Psychology.