When Shanda Wells, PsyD, started graduate school, she couldn't have predicted she would be working as part of a health-care team in a pediatric medical clinic. "I definitely did not go into grad school thinking I'd do integrated care — because I didn't know what it was," says Wells, now a behavioral health psychologist at the University of Wisconsin Medical Foundation.
Wells was hardly alone. The concept of integrated care is still relatively new, and not widely taught in graduate schools. Integrated care brings physical and behavioral health-care providers together into coordinated teams. And experts say it is more than just a trend.
Mental and behavioral health disorders often go hand-in-hand with chronic illnesses such as diabetes, obesity and cardiovascular disease, and people with mental health disorders are at an increased risk of premature death. But the traditional primary health-care system in the United States has not done a good job of addressing those co-morbidities, says Barbara Ward-Zimmerman, PhD, a child psychologist who worked in integrated pediatric primary care in Bristol, Connecticut, and now consults with pediatricians across the state. Integrated care has emerged as a solution.
"Health-care reform is catapulting this, and I think it's the future of health care," she says.
There is no single model for integrating care. In some cases, it simply means bringing mental health and primary health-care providers and services under a single roof. In other setups, mental health-care providers, physicians, nurses and other professionals work closely in teams to treat and monitor a patient's care. These teams are increasingly housed in so-called patient-centered medical homes, or health homes (see "Patient homes" in the November 2014 Monitor).
And demand for psychologists in integrated-care systems is growing rapidly, Ward-Zimmerman says. "Integrated care is really becoming ingrained, and I don't think there's any turning back."
Is integrated care for you?
Clinical psychology is often focused on treatment. But integrated primary care, says Ward-Zimmerman, is primarily about prevention and early intervention. "We work on health behaviors and promoting health in a way many psychologists don't do," she says.
Psychologists on an integrated-care team need to think and act a bit like a primary-care physician, says Ward-Zimmerman. "We replicate the pace of primary care. The pace is fast. The work is brief." Despite the fast pace, behavioral health-care providers in integrated settings have to be committed to working with others. "Integrated care is a team sport," she adds.
And like a general practitioner, a psychologist practicing in a team setting needs to be a Jack-of-all-trades. "You have to be willing to not always know the answer, and to know what to do with that," Wells says. "There are a lot of unknowns, but the field of health care in general isn't stagnant. The whole point is that integrated care has to be nimble."
And for people who like to be on their toes, solving problems, she says, that ever-shifting climate provides a welcome challenge. "I always want to be learning and figuring things out."
Gaining skills
While more health-care settings are moving toward an integrated model, many psychology graduate programs haven't caught up. Though some doctoral programs offer training in primary-care psychology (a list is available), few clinical and counseling psychology programs are affiliated with hospitals, and practica aren't often based in medical settings, notes W. Douglas Tynan, PhD, director of integrated health care with APA's Center for Psychology and Health. "Most training programs focus on ‘psychology,' not on ‘psychology as part of the American health-care system,'" he says. "That needs to change."
To help more graduate programs begin moving toward that goal, Ward-Zimmerman, Wells and a committee of other psychologists are working within APA's Div. 38 (Society for Health Psychology) to create a freely accessible curriculum that graduate instructors can use to help students develop the skill sets necessary for working in primary-care settings. The modules are being piloted this fall, and the complete curriculum is targeted to be available in early 2016, Ward-Zimmerman says.
If integrated care is appealing to you, consider asking your faculty to check out the new curriculum modules, which can be adapted for a variety of uses, from a single colloquium to a full-semester course. (Email for more information.) "The point is to jump-start training in integrated primary care," says Ward-Zimmerman.
But whether or not your institution offers this or other courses specific to primary care, there are steps you can take to gain the skills you need to succeed in a health-care team:
Get connected.
Network with psychologists doing work in the areas that interest you, both in person and digitally. Several APA divisions have email Listservs specific to integrated health care, says Ward-Zimmerman, including Div. 38, Div. 17 (Society of Counseling Psychology) and Div. 54 (Society of Pediatric Psychology). Following those lists can help you connect with possible mentors and identify fellowship opportunities in integrated care.
Learn the system.
Understanding the U.S. health-care system is daunting, but it's necessary for students going into applied health psychology, says Tynan. For example, students should understand how the modern health-care system arose, how it historically handled mental and physical health separately, and how mental health parity laws and the Affordable Care Act affect mental health benefits. If your school doesn't offer courses on U.S. health-care policy, consider an online course to get up to speed.
Seek out experiences.
To identify internship opportunities in primary care, visit Education and Training for Psychology Practice in Primary Care. Ask faculty for help in identifying both practica and internship placements in health-care settings, and don't forget adjunct clinical faculty, who may have useful connections. When choosing a practicum, "look for the places in health care where there's an obvious point of entry for psychology — programs that deal with chronic illness, diabetes, pain or diseases where there's a lot of self management," says Anne Kazak, PhD, co-director of the Nemours Center for Healthcare Delivery Science and the new editor-in-chief of American Psychologist.
Consider a health-care angle in your research, too.
"There's a whole culture around working in a health-care system," Tynan says, and doing research in that setting helps familiarize you with its protocols, systems, hierarchies and terminology. He also suggests tweaking dissertation topics to make them more relevant to health-care careers. If you're planning a dissertation on clinical outcomes, for instance, consider gathering data on cost-effectiveness and the value of psychological services, he suggests. "That will make you much more attractive on the health-care market."
Career openings for psychologists interested in integrated care will only grow, Ward-Zimmerman predicts. "There will be more and more opportunities. I think we've reached the tipping point."
Models for integrating physical and behavioral health care are likely to shift and change as providers figure out what works best. But it's an exciting time to be involved, says Kazak. "We're at a time of transition, and it's a period of some uncertainty — but also a lot of opportunity," she says. "It's exciting to be working at the interface of the mind and the body."