Psychologists and Primary Care Physicians: A Training

Model for Creating Collaborative Relationships

Barbara A. Cubic, Ph.D.Barbara A. Cubic, Ph.D.Associate ProfessorAssociate Professor

Eastern Virginia Medical SchoolEastern Virginia Medical School

Main ObjectivePsychologists and primary care physicians

are well positioned for innovative, interdisciplinary collaborations. This presentation will review models of clinical care collaboration and interdisciplinary training of physicians and psychologists which result in an egalitarian process and produce better patient outcomes.

Learning ObjectivesLearning ObjectivesFollowing this presentation participants will

be able to: Describe the opportunities and challenges of

integrated care Consider ways to enhance the competencies of

psychologists and primary care providers through innovative training models

Term Source, context, connotation

Integrated Care

Tightly integrated, on-site teamwork with unified care plan. Often connotes close organizational integration as well, perhaps involving social and other services

Related to the concepts of Medical Home, a single-site, regular source of care for individuals seeking a broad range of biomedical and behavioral health care services and Patient-centered care “Care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (IOM, 2001).

Goal is an Integrated Care Model Focus on biopsychosocial

rather than just biomedical or just psychosocial aspects of care.

Fluid, egalitarian team process

Needs excellent communication Needs respect & understanding

of diverse backgrounds, philosophies, & viewpoints of team members.

Trade-off of provider autonomy for better patient outcomes.

Pharmacist

Psychologist

Nurse-Practitioner

Physician

Patient &

Family

Creating Collaborative Relationships with Primary Care Providers

Differing PerspectivesPrimary Care Patients

Have Multiple Medical and Psychological Needs Most Come in Only When Symptomatic Expect a Brief Visit and that Pharmacological

Treatment(s) will be Offered Psychological Advice or Intervention is

Unexpected and Often Unwanted Referral to Mental Health Seen as Stigmatizing

Differing PerspectivesPrimary Care Providers

Have Large Caseloads of Patients with Multiple Medical and Psychological Needs

Need to Prioritize What to Address at Each Visit Ultimately Accountable for Care Provided by Extenders View of “My Patient” Leads to Expectations

• Coordination of Care• Exchange of Information with Consultants

Time Pressures

Differing PerspectivesPsychologists

Confidentiality Given Utmost Importance Operate Largely in Context of Ongoing

Relationships with Patients Expect to Complete In-depth Assessments Trained to Offer Interventions in Units of Time

(e.g. generally 1 hour visits) Generally Provide Solicited Psychological Advice

or Intervention to Patient or Patient’s Advocate

Psychologists as Team Members Improve Dx & Rx of Mental Disorders

Most Who Need Help Won’t Seek It

80-85% Who Seek Help Go to PCP50% of depressed primary care patients undiagnosed

60-70% Will Be UnderservedInadequate medication dose/ duration

Possible medication compliance and/or cost issues

Very Few Will See a Mental Health Specialist

Patients often refuse mental health referrals

In an integrated care model Psychologists can become especially valued because….Highly trained in an area many

physicians feel poorly equipped to treat

Easily adapt to multiple environmentsInterpersonally skilled

Psychologist’s ContributionsUse empirically based treatment

methods Facilitate adaptation to chronic illness, disability, and

life changes, Facilitate behavioral change Co-manage disorders with medical and psychosocial

determinants. • Understanding of motivational & learning theories

• Cognitive Behavioral Therapy

• Stress management

Psychologists also have a unique contribution to make regarding ACGME Competencies

The ACGME Website provides a toolbox of assessment methods and examples of use

Creativity is needed to determine specialty-specific and institutional-specific application

We’re experts in the development and validation of assessment approaches

can offer institution-wide, cross-specialty assessment especially in domains of communication and

interpersonal skills

Psychologists will be especially valued because…..

A lack of time, educational expertise (especially regarding assessment) and funds mean meeting competencies are a challenge for program directors

ACGME often recommends nontraditional assessment methods, such as standardized patients (SPs) and our training prepares us well to objective evaluate interpersonal interactions

What We Learned at EVMS from aCollaborative Training Model

Grant TitleINTEGRATING PSYCHOLOGY INTERNSHIP

TRAINING IN A PRIMARY CARE SETTINGGrant AuthorsBarbara A. Cubic, Ph.D.Funding SourceHRSAOther Funded Collaborators on the GrantDaniel Bluestein, M.D.Kathrin Hartmann, Ph.D.

The EVMS Clinical Psychology Internship Program

EVMS is a community based medical school founded in 1976 in Norfolk, VA

Norfolk is part of the Tidewater area of southeastern VA, consisting of 7 cities with a population exceeding 1.5 million

Internship Program is in the Department of Psychiatry which has a strong psychology division with 8 full time psychologists on faculty

Internship has existed since 1976-77 and has been APA accredited for 30 years

Accepts 6-8 interns from approximately 120 to 160 applications each year

The EVMS Ghent Family Medicine Residency Program

EVMS is a community based medical school founded in 1976 in Norfolk, VA

Norfolk is part of the Tidewater area of southeastern VA, consisting of 7 cities with a population exceeding 1.5 million

Ghent Family Medicine Residency is in the Department of Family and Community Medicine which has 12 full time faculty

Residency has existed since 1975 and it is an accredited three-year program which meets all the training requirements of the American Board of Family Medicine

Accepts approximately 5 residents per PGY year

Interdisciplinary Behavioral Medicine within the Internship

Internship had a behavioral medicine rotation in the Dept. of Family and Community Medicine (DFCM) in mid 1990's

Training was highly successful for both the interns and DFCM residents, but program lacked funding

Funding through a 2002-2004 HRSA GPE grant allowed us to place 2 psychology interns on major rotations a year with family medicine residents (each for 6 months at a time)

Current HRSA grant is designed to allow us to move towards a complete model of integrated care with every intern rotating in primary care settings 1 day a week or more

Purpose/Rationale of Our TrainingModel rests on reasons why mental health disorders are

under diagnosed and under treated in primary care: The stigma of mental illness Primary care providers’ limited

knowledge of psychiatric disorders Confounds created when mental illness

coincides with chronic physical illness Time constraints for primary care

providers

Purpose/Rationale of Our Training (continued)Model also rests on the rationale for

interdisciplinary training: Historic separation of medical and psychological

training leading to limited understanding of the different backgrounds, values, professional models, and ideologies

Often resulting in redundancy of effort, turf battles, and mixed, confusing, or negative messages to patients

EVMS Grant ObjectivesEnhanced patient careImmediate access to mental health consultation

and treatmentOptimal patient-treatment matchingSpecial exposure to underserved populationsHigh accountability of services providedComplete integration of mental health issues into

overall primary care managementCreation of a workforce that is culturally

competent and prepared to provide integrated care

Proposed Educational ModelDesigned to teach psychology interns subtleties

of working in primary care while concurrently fostering education of DFCM residents in core competences, e.g. basic doctoring skills, mental health, and behavioral health

Psychology interns placed in the role of educators, consultants, and service delivery agents in primary care settings and trained side-by-side with DFCM residents

EVMS Grant MethodologyJoint patient care deliveryAdditional didactics added to DFCM seminar

seriesJoint intensive and collaborative supervision by

Dr. Cubic and DFCM faculty for both psychology interns and DFCM residents

Specialized training in geriatricsSpecialized training in cultural diversityInterns write a paper about a medical condition

and psychology resources/interventions that can be of assistance to the patient and provider

Settings for the Training

Morning rounds in an inpatient setting

Consultation in an outpatient primary care practice 

Carefully created opportunities for exposure to geriatric populations and children in a either a treatment program for attention deficit disorder or in a school program for at risk children

Number of Patient Contacts by Setting

0

20

40

60

80

100

120

140

160

Outpatient Inpatient Nursing HomeNeurofeedback Assisted Living

Males36%

Fem ales64%

Gender Distribution of Patient Population Across all Settings

Caucasian51%

African American

48%

Other1%

Racial Distribution of Patient Population Across all Settings

Low48%Middle

51%

High1%

SES Distribution of Patient Population Across all Settings

<1916%

19-3511%

36-5016%51-65

18%

>6539%

Age Distribution of Patient Population Across all Settings

Mood D/O51%

Anx4%

Sub Use4%

ADHD14%

Cog Px11%

Other16%

Main Psychosocial Issues Addressed Across all Settings

Main Concepts Underscored with Interns

As a psychologist you are like a foreigner in a new country. It is your job to learn the language, not their job to adapt to

you.

Speaking a New Language:“When in Rome

do as the Romans Do”

Skills need for a Psychologist to Thrive in Integrated Care

Practical View of Confidentiality

Coordination

UsefulDocumentation

Efficiency

Diversity of Skills

Succinctness

Real World Knowledge of Primary Care and Confidence

Most Vital SkillMost Vital Skill Supervised Formal Supervised Formal

or Informal Training Experiences in or Informal Training Experiences in Primary Care Should be a Primary Care Should be a PrerequisitePrerequisite

Avoid IntimidationAvoid IntimidationLearn Medical TerminologyLearn Medical TerminologyLet the Unique Skills Psychology Let the Unique Skills Psychology Offers Speak Offers Speak for for Themselves/Provide Practical AdviceThemselves/Provide Practical AdviceMust Have a Good Sense of HumorMust Have a Good Sense of Humor

Understand Concept of a Treatment Understand Concept of a Treatment TeamTeam Full Disclosure to the Patient about Full Disclosure to the Patient about What Will What Will and Will Not be Sharedand Will Not be Shared Understand the Dilemmas Created Understand the Dilemmas Created by Secretsby Secrets Differentiate Between What Needs Differentiate Between What Needs to be Shared to be Shared Versus What is Versus What is PrivatePrivate Use Written Consents in Specific Use Written Consents in Specific Circumstances Circumstances as a Safeguardas a Safeguard

Welcome InterruptionsWelcome Interruptions As the Expert in Interpersonal Interactions You

can Facilitate the Team ProcessRely on Oral Communication Primarily esp. if Treating Patient in the PCP Office (with brief notes to document interactions with the patients or discussions with providers)

Respect the Roles Respect the Roles of Othersof Others

Forget What You Learned About Forget What You Learned About Report Writing In School!!! Report Writing In School!!! PCPs are not Impressed with PCPs are not Impressed with Theories, Lengthy Details or Theories, Lengthy Details or Specific Test Scores. Focus on Specific Test Scores. Focus on Final Conclusions and Final Conclusions and Recommendations!!!Recommendations!!!

Succinct 1-2 Paragraph Descriptions If Documenting in Medical Record

Use Different Color Paper or Designate a Section as the “Mental Health Record”

Use Clear Headings SOAP Notes the Norm Word Issues Carefully (e.g. conversation about a marital affair could be

worded as “discussed interpersonal stressors”)

If Documenting in a Separate Chart Periodic Updates in the Form of a Letter to the PCP Should be Done

(Brief Interactions or Therapy Sessions)

Reports in the Form of a Letter to the PCP Should be Done (1-2 Pages Max)

Most Common Headers History of Present Illness (1-2 Paragraphs Max) Prior History (Only Most Relevant) Behavioral Observations (Quick MSE) Test Results (In Language PCP Can Understand) Diagnostic Impressions (Generally Axis I and II) Case Conceptualization (Main Findings Reviewed) Treatment Plan (Bulleted, Specific, Practical Recommendations)

Offer to Discuss Impressions Further If Needed

(Psychological Evaluations)

Primary Care Visits Are Usually 15 Primary Care Visits Are Usually 15 MinutesMinutesDescribing Your Role to the Patient Describing Your Role to the Patient to Expedite to Expedite InteractionInteraction (e.g. “I’m Dr. Cubic, a clinical (e.g. “I’m Dr. Cubic, a clinical

psychology, and your psychology, and your physician, Dr. Bluestein, has asked me to physician, Dr. Bluestein, has asked me to discuss discuss strategies strategies with you for coping with your with you for coping with your headaches”)headaches”)

Stick to the Issue at HandStick to the Issue at HandCBT and Interpersonal Approaches CBT and Interpersonal Approaches Work WellWork WellHave Patient Handouts on Key Have Patient Handouts on Key IssuesIssues

Offer Broad Based Offer Broad Based Clinical SkillsClinical Skills

Rule of Thumb is thatRule of Thumb is that80-85% of Presenting 80-85% of Presenting Problems should be Managed in the OfficeProblems should be Managed in the Office

Know Your Limitations but Recognize that You Know Your Limitations but Recognize that You Likely Know More about Most Mental Likely Know More about Most Mental

Health Issues than the Other ProvidersHealth Issues than the Other ProvidersBe Prepared to be Asked to Comment about Be Prepared to be Asked to Comment about

Psychotropic Medications Psychotropic Medications (general comments are within (general comments are within

your scope of practice, but specific recommendations are not unless you meet your scope of practice, but specific recommendations are not unless you meet APA Level III training)APA Level III training)

Carry a Tool BoxCarry a Tool BoxAssessment MeasuresAssessment Measures

(e.g. PRIME-MD Patient Health Questionnaire;(e.g. PRIME-MD Patient Health Questionnaire;Beck Depression, Anxiety, Hopelessness Scales;Beck Depression, Anxiety, Hopelessness Scales;Geriatric Depression Scale; Cognistat; Conner’s;Geriatric Depression Scale; Cognistat; Conner’s;MMSE) MMSE)

Patient HandoutsPatient Handouts (e.g. Coping with Depression, Relaxation Scripts, AA Meeting Directories, Pointers (e.g. Coping with Depression, Relaxation Scripts, AA Meeting Directories, Pointers

for Parents with Children with ADHD, Sleep Hygiene)for Parents with Children with ADHD, Sleep Hygiene)

Referral InformationReferral Information (e.g. Keep an index of services, support groups, and internet resources for issues of (e.g. Keep an index of services, support groups, and internet resources for issues of

bereavement, cancer, cardiovascular disease, diabetes, domestic violence, bereavement, cancer, cardiovascular disease, diabetes, domestic violence, fibromyalgia, parenting, pregnancy, senior citizens, social services, substance fibromyalgia, parenting, pregnancy, senior citizens, social services, substance abuse, STDs, transportation) abuse, STDs, transportation)

“I think Sarah has anorexia nervosa, let’s set up a family meeting”

VERSUS“In the last 3 months Sarah’s weight has dropped 18 lbs. She hasn’t had a

menstrual cycle and she is starving herself intentionally. My findings on the Eating Disorder Inventory-II suggest that she has a high degree of dietary restraint and poor interoceptive awareness. Her body image issues place her at risk for a negative prognosis if we don’t involve her family immediately in her care. Are you comfortable with me setting up a meeting between you, me, the dietician, Sarah and her family?”

Professional Development:Strategies for Overcoming Obstacles

Coordination of Coordination of CareCare

BillingBillingDocumentationDocumentation

ReferralsReferrals

The House of MedicineWorking as a Psychologist from the Inside Out

Specialty Specialty ReferralsReferralsSpecialty Specialty ReferralsReferrals

Generic Generic ReferralsReferralsGeneric Generic ReferralsReferrals

Consultations Consultations in Your Officein Your OfficeConsultations Consultations in Your Officein Your Office

Consultations Consultations in PCP Settingin PCP SettingConsultations Consultations in PCP Settingin PCP Setting

Uncompensated Uncompensated ActivitiesActivitiesUncompensated Uncompensated ActivitiesActivities

EVMS Evaluation Methods

Patient Contact Reports # of patients seen, # of patients identified with

mental health issue, other relevant tracking dataPre and Post Physician’s Belief ScalesTrainee Satisfaction RatingsPatient Satisfaction RatingsPre and Post Tests on Knowledge of Primary

Care Medicine, Attitudes about the Elderly and Issues in Treating Children

Pre-Grant Scores on the Physician’s Belief Scalefor the DFCM Residents

(Higher Scores Reflect More Negative Beliefs about Identifying and Treating Psychosocial Issues)

Minimum Score

Maximum Score

Mean Standard Deviation

57 83 69.89 9.85

Feedback Survey Scores from the DFCM Attendings at 6 months1= Strongly Disagree to 4 = Strongly Agree

Item #

Item Content Mean

1. ….lead to an increased emphasis on psychosocial issues overall

3.50

2. ….enhanced my comfort in treating psychosocial pxs

3.17

3. ….I am more likely to investigate psychosocial pxs with my patients

3.50

Feedback Survey (continued) 1= Strongly Disagree to 4 = Strongly Agree

Item #

Item Content Mean

4. ….had no impact on the way I deal with psychosocial issues with patients

*On Item #4 a Lower Score is More Positive

1.50*

5. ….encouraged me to consider both organic and psychosocial pxs in patient care concurrently

3.50

6. ….I am more likely to routinely investigate psychosocial issues myself

3.17

Feedback Survey Scores from the DFCM Attendings at 6 months1= Strongly Disagree to 4 = Strongly Agree

Item # Item Content Mean

7. ….enhanced GFP residency training 3.508. I would be less likely to consult with a psych

intern about a patient…. If they were not in the GFP setting

3.30

9. I view the psych intern as an important personal resource in maintaining my emotional well being

2.50

10. ….enhanced the care received by patients at GFP

3.67

In Summary, the Training Expands the number of Psychology Interns and Family Medicine Residents that are prepared to work within an Integrated Interdisciplinary Model and Prepares both set of Trainees for a Number of Other Settings