Integrated Primary Care Action Agenda

Attention to the Developing Lexicon

After C.J. Peek, PhD (American Psychological Association) started our meeting by alerting us to the importance of us developing a common understanding and common usage of language for the field, he mentioned several examples and others were mentioned during the course of our meeting. Two examples are listed below, and the fuller list kept by C.J. are in the Appendix at the back of this document. Please let C.J. know if you are interested in working on these lexical issues that are foundational for the field, and necessary for any comparison of clinical and research metrics and outcomes.

• The term behavioral health replaced mental health when a broader definition was desired (e.g., health behavior change, substance abuse). However, we need a term that connotes more than just behavior. Karen Weihs, MD (American Psychosomatic Society), raised this problem and volunteered to work with C.J. Peek, PhD (American Psychological Association) on a better term, suggesting perhaps "emotional" or "relational."
• Consider alternatives to the term "patient-centered medical home."

Proposed Principles/Conceptual Framework

• Integrated Primary Care (IPC) is a means to an end. We need to start with the "why." Our collective goal is to help people be healthy and improve well-being.
• We use an overarching biopsychosocial systems framework, with inter-professional team-based care as its application.
• Our framework takes into consideration the whole population, with varying applications depending on population needs and settings (e.g., urban or rural).
• We are committed to inculcate values of respect and knowledge of each discipline’s unique skill set as well as in all areas of "overlap."
• We are committed to developing learning systems that adapt and grow.
• We believe, and studies support, the need for focused education and training in Integrated Primary Care (beyond that of traditional professional training) for effective implementation of IPC.
• We believe it important to ask not only "what is important?", and "what works?", but also "under what conditions?", "for whom?" and "at what cost?"

• Develop templates to promote Maintenance of Certifications across disciplines (including, but not limited to, psychology, psychiatry, pediatrics, physician assistants and family medicine).
  W. Douglas Tynan, PhD and Mark Vogel, PhD (American Psychological Association), Laurel Leslie (Association of Behavioral Pediatrics), Wayne Riley (American College of Physicians), Jeffrey Katz, PA-C, DFAAPA (Association of Physician Assistants) and Cindy Cooke, DNP (American Association of Nurse Practitioners), Nate Blum, MD, (Society for Developmental and Behavioral Pediatrics), Terry Stancin, PhD (American Psychological Association).
• Integrate workforce data from health professions to inform population needs.

• Draft a letter to key members of Congress to urge the inclusion of behavioral health clinicians, including psychologists and social workers, to become eligible for the adoption and use of certified electronic health record technology.
  Ellen Garrison, PhD (American Psychological Association).
• Ask for help from the National Center for Vital and Health Statistics as a useful resource.
  Vicki Mays, PhD, MSPH (American Psychological Association).
• Share models and identify holes in approaches to IPC for rural populations.
  Jacqueline Gray, PhD (University of North Dakota Center for Rural Health).
• Convene guideline committees from different disciplines to review models of care, resources needed and other requirements for communities to be effective. Attempt to produce a common set.
• Consider various marketing approaches regarding integrated health care to develop a coherent, strategic marketing plan — whether from the perspective of consumers (especially 26-year-olds new to health insurance), researchers, educators, policymaker and payers. For example, use stories that are inclusive of many professions.
  Nancy Ruddy, PhD (American Psychological Association), Helen Coons, PhD (American Psychological Association).
• Explore interprofessional telehealth approaches.

• Consider what would be needed for dissemination beyond the field of psychology for the first four integrated health care training modules designed for psychology graduate education programs by the Society for Health Psychology (Division 38) of the American Psychological Association.
  Nancy Ruddy, PhD (American Psychological Association), Helen Coons, PhD (American Psychological Association), Ellen Rathfon (American Association of Physician Assistants).
• Develop a policy boot camp/toolkit for those involved with policy regarding integrated primary care.
  Ben Miller, PsyD (American Psychological Association and the Farley Center), Andrew Bazemore, MD, MPH (The Graham Center), Ellen Rathfon (American Association of Physician Assistants).
• Identify team competencies and increase awareness of effective approaches to teach them (e.g. Team Strategies and Tools to Enhance Performance and Patient Safety) to students and as part of faculty development.
  Eduardo Salas, PhD, Susan McDaniel, PhD, Tziporah Rosenberg, PhD (American Psychological Association), Madeline Schmitt, PhD, RN (American Academy of Nursing).
• Incorporate social determinants of health in interprofessional seminars.
• Learn together how to collaborate with patients and families. Ask patients and families what they believe to be important. Barry Jacobs, PsyD (American Psychological Association).
• Focus on cultural humility, across disciplines as well as demographics.
  Kevin Fiscella, MD, MPH (Society of Teachers of Family Medicine), Vicki Mays, PhD (American Psychological Association).
• Develop community based training for busy, under resourced settings. Models of community outreach are needed.
• "Coaching" Susan McDaniel, PhD, and Tziporah Rosenberg, PhD, (American Psychological Association) and "toolkit" are acceptable labels for education and training IPC.

• Reach out to the National Center for Vital and Health Statistics for help collecting health service data to advance work in integrated health care on a population scale.
  Vickie Mays, PhD (American Psychological Association).
• Draft and forward a letter to the Patient-Centered Outcomes Research Institute for possible Alliance member sign-on encouraging increased funding for comparative effectiveness research to evaluate integrated primary care models, as well as specific treatments for behavioral disorders related to physical conditions.
  Ellen Garrison, PhD and Nadine Kaslow, PhD (American Psychological Association).
• Focus on team science and examine why some teams succeed and others do not.
  Eduardo Salas, PhD, and Susan McDaniel, PhD (American Psychological Association); Deborah Cohen, PhD (North American Primary Care Research Group)
• Apply what is known about the science of teams to primary care. Study what works and what doesn’t.
  Eduardo Salas, PhD & Susan McDaniel PhD (American Psychological Association); Kevin Fiscella, MD, MPH (Society of Teachers of Family Medicine).
• Adopt multi-level approaches and mixed strategies for research and be clearer about a viable range of research methods. When impossible or inappropriate to use the gold standard of the randomized controlled trial, we must have an alternative approach that is impeccable and rigorous.
• Work together to measure what is being done; what elements are needed to impact which outcomes.
• Look to veteran associations' use of LEAN to be proactive about showing evidence of effectiveness of intervention.
  Donna Rasin-Waters, PhD and Toni Zeiss, PhD (Veteran’s Administration).
• Identify outcome measures that capture global health, function and whole person care. The objective is a patient who has a better quality of life and can achieve life goals. Also, identify outcomes that are important to patients.
• Since funders are particularly interested in implementation/translation research now, and the action is in integrated health, develop proposals from multiple organizations to study integrated primary care.
• Health care settings have a host of metrics they need to report, without evidence or alignment with what payers or NIH is interested in. This is an opportunity to work together to find simple metrics that are meaningful to all groups.

• Talk separately and together with regulators, accreditors and payors about IPC.
  Randy Phelps, PhD (American Psychological Association).
• Create financial incentives to support integrated services (ensure that adequate funds in carve outs go to behavioral care, tie in loan forgiveness for all students and professional graduates who work in IPC settings.
• Practitioners need to be armed with a toolkit for a global payment methodology.
  W. Douglas Tynan (American Psychological Association).
  It could include:
  • a repository of information that summarizes Colorado and other data. This would assist the move toward value based or global payment, when health care is not measured and paid for as units of service.
  • a protocol for value based care to makes it easier to move away from fee for service. 
  • address small and large systems. 
  • stratify for different sizes of practices/organizations.
• Associations together call on the Medicare Payment Advisory Commission to address payment that supports integration of behavioral health in primary care.
  W. Douglas Tynan (American Psychological Association), Tom Steiner (Deloitte Consulting).

• Connect with and share resources from the National Center for Interprofessional Education for IPC.
  Madeline Schmitt, PhD, RN (American Academy of Nurses).
• Reach out to the HRSA-funded North Dakota Center for Rural Health to contribute information about integrated primary care.
  Jacqueline Gray, PhD (American Psychological Association).
• Determine the health care to address rural and urban needs through use of big data.
  Donna Rasin-Waters PhD (American Psychological Association).
• Share a positive story/narrative about Integrated Primary Care to contribute to the positive primary care stories being collected by Glen Stream, MD, MBI, and Family Medicine for America’s Health. This is an ongoing project but he’s especially interested in our stories for Mental Health Awareness Month in May. Barry Jacobs, PsyD (American Psychological Association).

Note: Many disciplines talked of commitments focused on their discipline to educate their members about IPC so they are ready for interprofessional education and training (Cindy Cooke, American Association of Nurse Practitioners; Lucinda Maine, American Association of Colleges of Nursing.)

Clinical phenomena and models

• Name of subject matter
  • Behavioral health, mental health substance use, health behavior, behavioral medicine.
  • Psychosomatic, medically unexplained, stress-related, psychophysiological, emotional reactivity/disregulation.
  • Definition of health, e.g., World Health Organization or other.
  • Definition of primary care (PC)—not a building, set of disciplines but a set of functions.
• Population health
  • The several levels this term is used—geographic like county public health, practice panel like ‘our patients’, regional, or about sub-populations.
  • Population management (a practice activity) as distinguished population health as a goal vs. population health as some kind of strategy or activity.
• Distinctions among social determinants, health disparities, health equity, social disadvantaged, and patient complexity.
• Community engagement
  • Locus such as "inside clinic walls or outside the walls", outreach from clinic or building something within and with the community.
  • Methods all the way from surveys, focus groups, participation in designing services, patient advisory committees to being on the board with real responsibility. What counts?
• Operating models
  • Reverse integration, reverse colocation, bidirectional.
  • Models of integration—collaborative care model, primary care behavioral health integration, behavioral health consultant , etc.
  • Integrated care, collaborative care, shared care, co-located care, etc.
  • Referral, warm handoff, electronic medical record tasking.

Research and evaluation

• Distinction between research and evaluation and what questions and settings and purposes are most amenable to which.
• Evidence and "evidence-based."
  • An evidence strategy for outreach and advocacy.
  • Evidence for making management decisions in front of you (instead of nothing).
  • Evidence in the sense of scientific—new generalizable knowledge.

Workforce and competencies

• Interprofessional:
  • Differences between interprofessional education, integrated patient care, interprofessional education collaborative, etc.
  • Interdisciplinary, interprofessional, team-based, collaborative.
  • Updated concepts of teamwork such as from team science.
  • A broader concept of what constitutes the team and teamwork in PC.
• Competencies—generic vs granular (which altitude you are talking about—super general for a anyone vs. competencies for integrated behavioral health in particular).
• Difference between generic clinician sensibilities that any clinician can supervise any other vs. discipline-specific sensibilities for which it takes "one of your own kind.

Finance and business models

• Differences between payment system (how you get paid) and budgeting (how revenue streams are gathered together or not) The financing North Star has both combined budgets on the source side, and a population or bundled payment on the payment side.
• Differences or continuum of taking risk, accountability for results—basic understanding of these concepts and their inverse relationship.
• Carve-in, carve-out, bundled payment, global payment, gain sharing, risk sharing, P4P, etc.