primary care psychology november 28, 2006 melissa stern presentation created by laura williams

Primary Care Psychology

November 28, 2006Melissa Stern

Presentation Created by Laura Williams

REMINDER

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Presentation Outline

Why primary care psychology? Barriers to primary care psychology Models of psychological practice in primary care Pediatric psychology in primary care Training issues in primary care psychology

What is Primary Care?

Primary Care:– First-contact care– Continuous – Comprehensive– Coordinative – Continuing responsibility– Personalized care

(Bray, et al., 2004)

Includes family physicians, general internal medicine physicians, and pediatricians

Primary Care Practice

Short office visits Average = 14 minutes for pediatric visits

Priority is physical health Inadequate training on psychosocial issues

– Why is this even important? Physicians may feel uncomfortable bringing up

psychological issues Patients may feel uncomfortable

(Black & Nabors, 2004; Ferris, et al., 1998; Perrin, 1999)


“the provision of health and mental health services that includes the prevention of disease and the promotion of healthy behaviors in individuals, families, and communities”

(Bray, et al., 2004, p. 8)

Changing role of psychology as a mental health profession to a health profession

Why is psychology important in primary care?

1. Behavioral health factors

7 of the top 10 health risk factors are lifestyle or behavior factors (VandenBos, et al., 1991)

60% of visits to primary care involve behavioral health issues (Cummings, Cummings, & Johnson, 1997)

100% of medical visits involve a psychological or behavioral component (Belar, 1996)

Why is psychology important in primary care?

2. Mental health factors

28% of Americans have a mental disorder– Only ½ of those receive treatment– ½ of those treated receive treatment only through

primary care providers– ADHD is one example!!

20-25% of patients in primary care have a mental disorder (Spitzer, et al., 1995)

Pediatric Psychology & PC

40-80% of parents have questions about their child’s behavior or development (Young, et al., 1998)

11-20% of children in primary care settings have mental disorders (Costello, 1989)

½ of parents have psychosocial concerns at well-child visits (Sharp, et al., 1992)

Pediatric Psychology & PC

Pediatric PC presents a variety of special opportunities for psychologists to intervene

Well Child visits– After immunizations, parents rated developmental and behavior

concerns (e.g., eating habits, school issues, child safety) as the most impt. issues in WC visits (Busey, Schum, & Meurer, 2002)

Patients with Chronic Conditions “High users” of PC

– Not completely accounted for by health status– Psychosocial concerns of child– Parent adjustment: parent stress and efficacy

(Janicke & Finney, 2001 & 2003)

Psychosocial Issues in Pediatric PC

The “hidden morbidity” CBCL given to pediatric PC patients; 25% had

elevated scores Gave DISC to patients with elevated scores and a

random sample of non-elevated patients PCP diagnosed emotional/behavioral problems in 6%

of patients, while 12% of patients were diagnosed based on the DISC

83% of patients with an emotional/behavioral problem were NOT diagnosed by PCP (Costello, 1988)

Identification of Psychosocial Issues in PC

Identification of Ψ problems in PC has increased In 1979: 6.8% identified with Ψ problems In 1996: 18.7% with Ψ problems Largest increases in:

– Attention problems (1.4% to 9.2%)– Emotional problems (.2% to 3.6%)

Medication, counseling, and referrals for Ψ problems also increased Paralleled increases in single-parent families and Medicaid

enrollment Why?

(Kelleher, et al., 2000)

Referral of Pediatric PC Patients

Child Behavior Study 1994-1997– Sampled 400 PCP and 21,000 patients (aged 4-15 yrs)

Of patients with a new Ψ problem presenting in PC (approx 4,000 patients), 76% were not referred

– 46% could be managed by PCP– 35% were already receiving additional services– 15% self-limiting problem

(Rushton, Bruckman, & Kelleher, 2002)

(Rushton, Bruckman, & Kelleher, 2002)

Referral of Pediatric PC Patients

When PCPs identified a Ψ problem, what did they do?– 39% “watchful waiting”/no treatment– 33% PCP counseling– 18% PCP counseling + medication– 10% medication alone– 16% referral for additional services

Most often referred to a psychologist vs. psychiatrist 25% of PCPs reported that Ψ services were available within their

offices at least 1x/week Only 61% of patients given a referral actually initiated services

(Rushton, Bruckman, & Kelleher, 2002)– What’s happening with the other 40%?!?!

Role of Primary Care Psychologists

Assessment of psychosocial or behavioral symptoms

Mood-related symptoms Child behavior problems

Psychosocial management of acute and chronic health conditions

Adherence to physician recommendations Pain management Coping with stressful medical procedures

Role of Primary Care Psychologists

Collaboration with other primary care providers Consulting with physicians, nurses, and other health care

providers

Identification of appropriate experts for referrals Referring patients for additional psychological services

(Bray, et al., 2004; McDaniel, et al., 2002)

Barriers to Psychological Services in Primary Care

Practical issues Time and space

Ethical issues Informed consent Confidentiality

Insurance payment New CPT codes = reimbursement?? Research is needed

Education and training of graduate students(Black & Nabors, 2004; Perrin, 1999; Schroeder, 1999)

Models of Collaboration

1. Psychologist as a tertiary provider

– Traditional model– Physician refers patients with emotional or

behavioral problems – Psychologist is located in separate practice– Empirically validated treatments– Example: UF Psychology Clinic


2. Psychologist as a consultant

– Physician assumes primary responsibility Psychologist provides consultation

– Multidisciplinary teams in medical centers– Example: Schroeder at UNC-CH

Private pediatrics practice Brief parent meetings Consultations with physicians/nurses Telephone consults Parent groups


3. Psychologist as interdisciplinary team member

– Physicians and psychologists share responsibility for patient care

– Billing is done as a team– Managed care has made this model more obsolete– Example: special populations (e.g., diabetes,

failure to thrive, developmental disabilities)


4. Psychologist as community collaborator

– focused on community rather than individuals– leads to programs implemented on a community level – prevention programs– Example: NRBHC

(Black & Nabors, 2004; Drotar, 1995)

Diagnostic & Statistical Manual for Primary Care (DSM-PC):

Child & Adolescent Version

Coding system for the recognition and treatment of common behavioral and developmental symptoms in primary care

Developed by American Academy of Pediatrics, Society of Pediatric Psychology, and others

2 Core Areas: Situations & Child Manifestations

(Drotar, 1999)



1. Situations Describe and evaluate impact of stressful

situations that can impact children’s mental health Similar to psychosocial or environmental factors

coded on Axis IV

(Drotar, 1999)



1. Situations (12)

Challenges to Primary Support GroupChanges in CaregivingOther Functional Change in FamilyEducational ChallengesHousing ChallengesEconomic ChallengesHealth-Related Situations



2. Child Manifestations (10)– Symptoms organized into behavioral

clusters– Allow physicians to consider:

Severity of presenting problem Common developmental presentations Differential diagnosis



2. Child Manifestations

Developmental Competency

Impulsive/Hyperactive or Inattentive Behavior

Negative/Antisocial Behavior

Emotions and Mood

Illness-Related Behavior



Problem Severity:

1. Developmental Variations• Behaviors may raise concern but are within range of typical

for the child’s age

2. Problems• Disrupt child’s functioning but do not warrant a DSM-IV

diagnosis

3. Disorders



Barriers for the use of DSM-PC: Training of pediatricians and/or psychologists More user friendly Very little research Time consuming Use of DSM-PC has not led to improvements in

reimbursement rates

Practicing Primary Care Psychology

Time management– 20-30 min for assessment and recommendations– Framework for assessment/intervention

1. Introductions & informed consent

2. Identify referral question/presenting problem

3. Symptoms

4. Functional impairment

5. Summarize/Conceptualize problem

6. Collaborate on behavior change plan/recommendations


Use of relationship-building strategies– Frequent empathetic statements are not necessary– Implied relationship due to the physician-patient

relationship that already exists– Norm within primary care is “get to the problem”

quickly– Summary statement implies understanding of the

patient’s problem


Selection of appropriate intervention– Use of interventions designed to facilitate small

changes – Use of psychoeducational material– Avoid using the same strategy for every patient

(e.g., a depressed patient may benefit from increased enjoyable activities or reduction in negative thinking)


Inappropriate level of care– Primary care interventions should be tried before

referring for outside mental health services (in most cases)

Overdocumentation– No need for lengthy background information– Notes should be < 1 page


Importance of feedback to the physician– In medical settings, physician’s are accustomed

to receiving succinct, same-day feedback– Interruptions are common in medical settings– Importance of providing feedback to physician

about how to address behavioral concerns


Given managed care restrictions on physician’s time and the prevalence of behavioral and mental health factors in primary care, psychologists can play a vital role

There are several different models of collaboration between primary care providers and psychologists

Pediatric psychologists can help address parent’s behavior and developmental concerns in primary care– DSM-PC


The practice of primary psychology differs in many ways from the traditional practice of psychology in mental health clinics

Significant barriers exist for the successful provision of psychological services in primary care

Future directions in primary care psychology include: improved education/training, more reimbursement for services, research documenting the efficacy/effectiveness of primary care interventions

primary care psychology november 28, 2006 melissa stern presentation created by laura williams

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