In 2014, after two decades of treating patients at his group practice, the Center for Cognitive & Behavioral Therapy in Columbus, Ohio, psychologist Kevin Arnold, PhD, decided it was time to revolutionize his practice model. During the previous several months, he’d heard speakers at three conferences describe how behavioral health integration into primary care was the future of health-service psychology. Arnold suspected a co-located care model, where he treated patients alongside primary-care physicians, would increase access to his mental health services and improve patient outcomes by providing immediate feedback to physicians about patients’ behavioral health problems and coordinating care.
But first he had to sell the idea to physician practices.
Arnold pitched the concept to Central Ohio Primary Care (COPC)—a group of more than 400 providers. “We made a strong case based on improved care for patients and financial incentives from health insurance providers as a result of health-care reform,” Arnold says. A psychologist in the clinic, he told them, could improve patient outcomes, and insurance companies are increasingly rewarding practices with monetary bonuses for providing a higher quality of care.
One of their pediatric practices agreed to run a pilot project to see if having Arnold in their office improved patient care. With the co-location system, pediatricians referred children and adolescents with such diagnoses as anxiety, depression and gastrointestinal problems. Arnold saw those patients weekly on a half day he spent at the practice. The physicians were impressed when Arnold was able to resolve difficult cases after six to eight visits, and his referrals increased. It quickly became clear that there were far too many patients to see in just four hours a week, so the physicians asked Arnold to come to the pediatric practice three half days a week and invited another provider from Arnold’s team to work there an additional half day.
A successful partnership
The physicians he works with are grateful for the support. “We see a lot of pediatric patients who have mental health issues that arise while they are growing, and I can only offer them general guidance,” says Bonnie Pugh, MD, a pediatrician at COPC. “Some of them need more sustained support from a mental health professional, and the beauty of having a psychologist in the office is that there is a lot more collaboration.”
Word spread about the pediatric group’s success with this new model of care, and now Arnold is co-located with four COPC practices and two other medical groups in the area. Working alongside physicians has been highly rewarding for the psychologists, the physicians and the patients, says Arnold, who encourages other psychologists to consider such collaborations.
“I think our vitality as a profession will depend on tackling mental health issues that are co-morbid with physical issues, and we need to educate physicians about the benefits of this model,” he says.
One of those benefits is that patients seem to get better faster, Arnold says. “When people see a psychologist in a primary-care setting, they have a different mindset than when they see me in my private practice office. The medical environment seems to set a different tone, and they are more motivated and less likely to cancel.”
Network early
How can other psychologists replicate Arnold’s success? The first hurdle is finding physicians and other health-care providers who are willing to invite psychologists into their offices. Earning that opportunity starts long before meeting with physicians and their administrative staff.
Before approaching medical practices about the idea of co- location, Denver practitioner Helen L. Coons, PhD, developed strong, collaborative relationships with physicians, nurse practitioners, physician assistants, genetic counselors and physical therapists who already referred patients to her. “That means sending consult notes with the patient’s status and treatment goals, and following up with phone calls when appropriate,” says Coons, who specializes in women’s health and mental health and has been working with physician groups for almost 20 years.
That type of communication between psychologists and physicians is surprisingly uncommon, says Arnold Holzman, PhD, managing partner of Behavioral Health Consultants, LLC, in Hamden, Connecticut. “I’ve been accepting referrals from medical groups for 30 years, and when I send a clinical follow-up note, I still get responses from physicians saying I was the first mental health professional who gave them any feedback about a patient.”
He urges psychologists to view themselves as health-care providers who respect the confidential nature of their relationships with patients yet also communicate with physicians about patient needs. “Doctors want to know about the symptoms, treatment plan and progress, but not really the details about the patient’s history of abuse or other private information.”
Build contacts
Another way to increase patient referrals is to offer to give “lunch and learns,” staff in-service training or continuing education to health-care providers beyond your referral networks, says Coons. She formed connections by speaking to nursing and medical groups about such topics as coping with cancer, delivering difficult medical news and pregnancy loss.
Psychologist Jennifer Harned Adams, PhD, expanded her network by attending the annual meeting of the Childbirth and Parenting Association of Colorado, where she met lactation consultants, doulas and labor and delivery nurses. “I was surprised to learn that I was the only mental health professional who attended,” says Adams, who runs a private practice in Denver. “The people there were excited to have a therapist who wanted to connect with the same patient population.”
Adams started giving talks at the organization’s conferences on such topics as recognizing the symptoms of postpartum depression. Soon after, she met a lactation consultant who worked at Presbyterian/St. Luke’s Hospital in Denver, which specializes in treating women with complicated pregnancies. Five years later, the hospital offered her a contract position for two days a week in the Center for Maternal Fetal Health, where she works with mothers who are on long-term bedrest and families with babies in the neonatal intensive care unit.
“Many of these families are far from home, and I help them deal with the difficult dynamics that arise,” Adams says. “There may be older children at home, fear about a baby’s health, stress on a couple’s relationship and relatives who have opinions about how care should be managed.” By supporting families, Adams not only frees providers to focus their attention on the medical needs of the mothers and babies but also helps staff understand how to communicate effectively with parents and other family members.
New opportunities
While improving patient care is an invaluable selling point for psychologists who want to co-locate with physicians, psychologists should also be aware of new ways they can add revenue to medical practices thanks to provisions of the Affordable Care Act (ACA), says Doug Tynan, PhD, director of APA’s Office of Integrated Health Care.
Under the law, medical groups can receive bonuses from insurers for meeting patient outcome goals related to lower hospital readmissions, reduced emergency room use, diabetes control and a variety of other measures. Psychologists can play an important role in helping physicians reach these goals, Tynan says.
“People with diabetes, for example, are much more likely to be depressed, and this increases the risk of poorly controlled diabetes,” he says. “Psychologists can help these patients with setting goals, identifying negative thoughts and other behavioral interventions, which could lead to significant financial bonuses for the practice if these patients can better manage the disease.”
Eugene, Oregon–based psychologist Teri Strong, PhD, had been practicing as a psychologist for 20 years when she decided to tap into the incentives of the ACA to improve patient care and expand her reach. Strong collaborated with a large medical group that had received federal and state grant money to establish integrated behavioral health services in their primary-care clinics. “I knew many of the physicians in the medical group, so collaborating with them was a natural outgrowth of these relationships,” she says.
Strong quickly realized that she alone could not meet the needs of all the patients in the Oregon Medical Group, which included 100 medical providers. So, she offered to create a team of mental health professionals with varying specialties who could consult in the medical offices and provide care for patients.
“I knew it was a financial risk because I would be spending some of my time forming and managing this new group, and also taking on administrative overhead and staffing costs that were not directly reimbursed by the grants or by billing,” says Strong.
But her risk paid off. She started with three employees at Strong Integrated Behavioral Health in 2014 and had doubled in size by 2016. Now, she has a staff of 42 psychologists, professional counselors, social workers and postdoctoral psychology trainees who treat patients in adult medicine, pediatric primary care and pain management settings.
“We contract with all payers, including Medicare, Medicaid and all commercial insurance, so we can serve the entire population of patients who need our services,” says Strong, “And this fits with the social justice mission of our practice.”
She also hired a training director who teaches new employees how to consult in an integrated-care setting because most don’t have experience working in a physician-run practice. Employees learn about the medical terminology and medications related to their patient population and how they can leverage short-term treatments, including cognitive-behavioral therapy, for 30-minute appointments.
Strong’s group practice has attracted early career psychologists, practitioners who have returned from retirement and other seasoned psychologists interested in shifting to integrated care.
“Providing opportunities for mental health professionals to learn new ways of practicing has been the most gratifying thing I’ve done in my career,” Strong says. “And many of the patients we see in the medical clinic would not have necessarily come across town to see someone in private practice.”
