In 2001, as a pediatric psychologist, W. Douglas Tynan, PhD, noticed some troubling trends: More than half of patients' visits to their primary-care physicians were driven by psychological problems, such as anxiety, panic, depression and stress. In addition, while many patients were referred to a mental health provider for treatment, few patients followed up.
"Even though some of our primary-care clinics were less than three miles away from the hospital where the outpatient behavioral health office was, we'd get referrals and the patients wouldn't come," remembers Tynan, who at the time worked at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.
To help make mental and behavioral health services more accessible, Tynan developed a federally funded program that trains pediatric and psychology residents to work together to assess and treat child behavior problems in primary-care settings.
"Among low-income, difficult-to-reach populations, this is the most effective way for people to get their mental health services," says Tynan, who in May joined APA staff as director of integrated health care.
The program Tynan developed proved revolutionary for the Nemours system. By educating physicians and patients about the benefits of psychological treatment and co-locating psychologists in primary-care offices, the program sharply reduced the number of patient no-shows for outpatient mental health care, decreased the stigma associated with seeing a psychologist and improved access to care for behavioral issues, such as attention-deficit hyperactivity disorder, says Hal Byck, MD, a pediatrician at Nemours's Jessup Street Clinic.
"The fact that they're part of our office makes seeing a psychologist more palatable for a lot of patients," Byck says. Plus, the psychologists have been able to help primary-care providers and other staff handle the psychological stress that comes with their jobs. "It's been a win-win for everyone working here."
Today, as one of the nation's largest integrated pediatric health systems, Nemours treats 250,000 children a year — many of whom are minorities or located in health-provider shortage areas — through its children's hospitals in Wilmington and Orlando and its pediatric specialty clinics in Delaware, Florida, New Jersey and Pennsylvania.
Six of the system's 10 primary-care clinics are pursuing NCQA recognition as a patient-centered medical home (see Psychology’s roles in patient-centered medical homes article), and Nemours continues to see improvements in patient care and outcomes as a result of the integration of psychologists into primary care, says Cheyenne Hughes-Reid, PhD, a pediatric psychologist with Nemours.
"It's about increasing communication across providers, making sure we're following up on referrals and making sure we're addressing barriers many families face," Hughes-Reid says.
The system is also working to develop customized care plans for every patient seen by a Nemours primary-care physician. Those plans would include several treatment or wellness goals that the patient develops with help from his or her care team.
It's a way to make sure all of the health-care professionals a patient sees are on the same page and following the same treatment protocol, and it helps the patient feel more in control of his or her health, Hughes-Reid says. "That's particularly important for the population that we work with because of all the needs they have and the challenges they face," she says.
In addition to providing therapy and brief interventions with patients in primary-care practices, Nemours primary-care psychologists provide specialty services as needed.
For example, a psychologist often sees patients with a primary-care provider to help develop a patient's care plan or to assess any behavioral concerns. In addition, Nemours psychologists train physicians in motivational interviewing, a method that can help pediatricians take a more focused, goal-directed and patient-centered approach in their conversations with patients to help motivate them to change unhealthy behaviors.
Psychologists also educate their pediatrician colleagues — often in one-on-one, lunchtime conversations about a patient — about some of the most effective behavioral interventions parents can use with their kids, and how to help patients stay on track with medication management, says Jennifer Schroff Pendley, PhD, chief psychologist and co-director of the division of behavioral health at Nemours/Alfred I. duPont Hospital for Children.
"Rather than leading more formal seminars, our psychologists are more focused on shadowing and on-the-spot training opportunities with their colleagues," Pendley says. "It's much more effective at that level because it's not just hypothetical."
Psychologists are also instrumental in Nemours's new policy to screen every child to make sure he or she meets key developmental milestones.
"So much of primary care is about prevention, and this is an opportunity for us to catch kids who are at risk for developmental or behavioral issues early and get them over to see psychology or other resources," says Nemours pediatric psychologist Meghan Lines, PhD.
Now nearly 90 percent of all Nemours children are screened, thanks to psychologists' work to standardize such assessments. Just a few years ago, only a handful of providers used the screenings, Lines says.
Nemours is also working to help psychology trainees prepare for the health-care changes ahead. In September, for example, the organization welcomed two psychology interns into its new Integrated Behavioral Health Track, which will train them in interventions, assessments and consultation.
The training fills a critical need in the field, experts say.
"Right now, the demand is so strong and we don't have enough psychologists trained in this area," says health-care expert Kristi Van Sickle, PsyD, assistant professor of psychology at Florida Institute of Technology. "We need to recognize that the future of psychology is going to include psychologists in these settings and to make room for that training."
Amy Novotney is a journalist in Chicago.