Episode 11

Psychologists immersed in integrated health care describe the benefits and challenges to seeing patients in a primary care setting.

About the experts

Christopher L. Hunter, PhD, ABPPChristopher L. Hunter, PhD, ABPP, graduated from the University of Memphis with his PhD in clinical psychology with a specialization in behavioral medicine. He is board certified in clinical health psychology and works for the Defense Health Agency as the Department of Defense (DoD) Program Manager for Behavioral Health in Primary Care.

As the DoD lead for the last nine years, he has worked to develop policy, secure funding, and oversee the rollout of primary care behavioral health services for Military Health System enrollees. He has extensive experience developing integrated primary care behavioral health services as well as training individuals to work in primary care settings treating common mental health conditions (e.g., depression), health behavior problems (e.g. tobacco use, obesity) and chronic medical conditions (e.g., diabetes, chronic pain).

He is also a coauthor on the 2016 book, Integrating Behavioral Health Into the Medical Home: A Rapid Implementation Guide and a coeditor on the 2014 Handbook of Clinical Psychology in Medical Settings: Evidence-Based Assessment and Intervention.

Jeffrey L. Goodie, PhD, ABPPJeffrey L. Goodie, PhD, ABPP, is a board certified clinical health psychologist and an associate professor in the department of Medical and Clinical Psychology and the department of Family Medicine at the Uniformed Services University (USU) in Bethesda, MD. He serves as the Director of Clinical Training of the Clinical Psychology program at USU.

Dr. Goodie earned his PhD from West Virginia University and completed his residency and a post-doctoral fellowship in clinical health psychology at Wilford Hall Medical Center at Lackland Air Force Base.

Dr. Goodie has served as an internal behavioral health consultant in family medicine, internal medicine, and OB/GYN clinics. He has trained psychology and social work residents and providers how to provide behavioral health interventions in integrated primary care settings. He is a Fellow of APA and the Society of Behavioral Medicine.

Rosemary Szczechowski, PsyDRosemary Szczechowski, PsyD, is a licensed psychologist and behavioral health consultant for Christiana Care Health System in Newark, DE. She earned her PsyD in Clinical Psychology from Immaculata University in 1999. Dr. Szczechowski has worked with children, adolescents and adults in a variety of settings, including schools, residential treatment programs, outpatient clinics, skilled nursing and rehabilitation centers, and hospitals. Dr. Szczechowski works with clients experiencing a variety of issues including anxiety, depression, trauma exposure, and school/academic problems. She also works with clients struggling with health issues, including diabetes, hypertension, and obesity.

Transcript

Rosemary Szczechowski: My name is Dr. Rosemary Szczechowski, and I am a behavioral health consultant for Christiana Care. A typical day would normally consist of, on one hand, responding to a provider’s request to do what we call a “warm hand-off,” also referred to sometimes as in-room consultation. A provider would be conducting a medical appointment with a patient and it becomes evident to them that there is a behavioral health concern. So, at that point the doctor or provider makes them aware that, you know, we have behavioral health consultants in our office, and explains what we do, and asks the patient if they’d be interested in speaking with one of us. And many patients do take them up on that opportunity. The provider will let me know what the patient is struggling with and then they will introduce me. That’s called the warm hand-off and that’s what’s very powerful because a patient who trusts their doctor, their PCP, then at the door has some trust in this person. So that’s really very powerful. That’s the warm hand-off.

Jewel Edwards-Ashman: I’m Jewel Edwards-Ashman and welcome to a new episode of Progress Notes: A Podcast Keeping Tabs on the Practice of Psychology. And you just heard Dr. Rosemary Szczechowski give us a taste of what a typical day may be like for a psychologist working in integrated health care. Dr. Szczechowski has been practicing in integrated care for two years now.

Rosemary Szczechowski: It is an area of health care that, I think, now that I’m doing it, it makes so much sense to me. I can say first-hand I can see that patients benefit greatly from it.

What I really love about integrated health care is the idea that or the reality that you are going to be able to reach many more people, and you actually engage with them in a way, because the work we do is short-term, problem-focused, you engage with them in a way where you may then see within either that first contact, a shift or a change, maybe in terms of giving or offering some recommendations, and hearing what they are struggling with. Maybe being able to offer a suggestion and when you do a follow-up a week or two later, they report that they are feeling better.

Jewel Edwards-Ashman: The number of psychologists participating in integrated health care is growing as insurers and patients call for more collaboration between health care providers. Also, the federal government continues to explore new ways to reduce health care costs.

The Centers for Medicare and Medicaid Services’ new quality payment program for Medicare providers (known as the Merit-based Incentive Payment System) even rewards clinicians and practices that provide integrated health care services. In MIPS, integrated care is categorized as a “clinical practice improvement activity” because it’s proven to promote better health outcomes for patients. It also improves patients’ “Access to care” which is one of the recurring themes you’ll hear when talking to psychologists about why they enjoy practicing in integrated health care settings. There are just more opportunities to reach more people with mental health issues while working in a practice with primary care physicians.

Christopher Hunter: The amount of time, effort and persistence it takes for folks to get to specialty services, can be, frankly, overwhelming for folks. So, we know that people are going to see their primary care providers, and we know that people are coming with a whole range of problems. A whole range of biopsychosocial difficulties that are impacting how they function, that are impacting what their symptoms are, that are maybe impacting, either making worse, or perpetuating a variety of different medical conditions. And so the chance to be able to interact with those folks and to work with a primary care team and to have whole-person focus, for me, has been an incredibly rewarding part of my career.

Jewel Edwards-Ashman: That’s Dr. Christopher Hunter. He’s the Program Manager for Behavioral Health and Primary care at the Department of Defense. Dr. Hunter is good friends with Dr. Jeff Goodie, director of clinical training in the department of Medical and Clinical Psychology at the Uniformed Services University of Health Sciences. Together, with Drs. Mark S. Oordt and Anne C. Dobmeyer, they wrote the book Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention. This is a book for psychologists who want to know more about integrated care practice. Both editions of the book were published by APA.

Christopher Hunter: We're on our second edition and the purpose of this book, was when I got into working in integrated behavioral health and primary care 17 years ago, there wasn't anything out there at that time that I could pick up at that time that told me, well, what questions do I need to be asking that are appropriate for primary care? How do I adapt evidenced-based and evidence-informed interventions for primary care?

How do I manage my time? How do I do screening and assessment questions in a way that is focused and yields rich information? And how is that different from what's in specialty mental health when you have 50-plus minutes? How do I give feedback to a primary care provider? Should I give feedback? How do I document the medical record? What kinds of measures should I be using? How do I, in a 10-minute timeframe, how do I collaborate with a patient, get them, layout what are the potential options for treatment or an intervention, have them collaboratively choose what they want to do, and then get them going on that in 10 minutes? That's a real different skillset than what you have in a specialty mental health clinic. We wrote the book we wanted to have when we started working in primary care.

Jewel Edwards-Ashman: To explain some of the benefits of working in integrated primary care, Dr. Goodie and Dr. Hunter often use the example of patients visiting their primary care physicians for common medical problems, and then sometimes being referred to a specialist for further treatment.

Christopher Hunter: People who have recurrent headaches come in and see their primary care provider. Their primary care provider tries to manage, assess and treat that headache in the clinic and many people get better. They manage their headaches and their headaches go away. And there’s a smaller subset of folks with headache problems where nothing changes. Well, those are the folks that we need to help facilitate them going to specialty services. So, let’s set them up to see a neurologist who can spend more time, and do more tests and maybe engage in some different kinds of treatments that really you can’t do in primary care.

Jewel Edwards-Ashman: Dr. Goodie says some psychologists may view integrated primary care as not providing adequate treatment for patients with mental health issues. Some may even be concerned that this type of care will replace traditional mental health care or specialty care, but he says that's not the point of this type of practice.

Jeff Goodie: This is not intended to be a substitute for those individuals who need that care. Rather it’s really to take what’s being done in primary care already where we know the vast majority of behavioral health care is happening in the country anyway, be able to enhance what’s being done in primary care and to better identify those individuals who could be helped right in primary care, and then to identify those folks who really need the specialty care. And to in some ways triage those folks and to help to get those folks, for whom it’s going to go kind of beyond what can be done in primary care, and get them to those behavioral health providers, who can take the time to do those fuller assessments, to do those longer therapies, that are going to be needed.

Jewel Edwards-Ashman: Psychologists can also play a vital role in medication management for patients in primary care by demonstrating how cognitive and behavioral interventions may be more effective than medication in certain cases.

Jeff Goodie: Most medical providers their primary focus in their training often times is use of medications to treat what conditions are kind of coming in. One of the advantages of having behavioral health providers in the clinic is that it gives medical providers an opportunity to see that behavioral health interventions can be effective without medication. It gives them greater faith in that end. It helps that they have somebody they can trust, you know, to deliver those interventions within the context of the clinic.

Jewel Edwards-Ashman: Integrated care is touted by the psychologists who practice it, it’s recommended by CMS, and supported by APA and the Practice Organization. But even if every practitioner read their book, Dr. Goodie and Dr. Hunter recognize that working in an integrated primary care practice or other integrated setting may not the right all psychologists.

Jeff Goodie: It does require I think some reflection on whether or not you, as a psychologist feel like you want to develop a new skillset because you might have all the knowledge. You might be excellent in terms of your behavioral health care. This does require changing how you provide care if you’re going to really integrate.

Jewel Edwards-Ashman: Some of these skills include teamwork, using an electronic health record or dealing with frequent interruptions.

Rosemary Szczechowski: There was definitely an adjustment period. I had never worked with an electronic medical record before, so that did take several months to really get comfortable with doing that.

It is important I think when you work in integrated care to recognize that you’re not working as a therapist. That was probably the biggest adjustment so for example in my setting we do not have offices. I'm at a workstation. And that's a station where I can work on my notes. But when I’m called to do a warm hand-off I’m going into an exam room. And I'm in the exam room with the patient. This is the same exam room where they completed their medical appointments with their PCP. For follow-up appointments I'm also having patients come back and we’re meeting in another exam room.

Christopher Hunter: If working as part of a team is not something that particularly calls to you, then working in primary care is not going to be a good match for how you professionally want to move forward. If you are concerned about documenting in a medical record at the same time that you’re seeing a patient, which is what you need to do or you’ll never get out of the clinic, again that might not be a good match for you. You’re going to get interrupted, when you’re seeing patients. There are no "do not disturb" signs in primary care, nurses are going to come knock on your door. Docs are going to knock on your door.

Jewel Edwards-Ashman: Measuring clinical outcomes is another important aspect of working with other health care providers in integrated care.

Christopher Hunter: I think patient outcomes are incredibly important. And I think you are doing both your patient and, I will go as far as saying, your discipline a disservice if you’re not measuring patient outcomes.

Jeff Goodie: I think all of medicine is moving away from the idea of fee-for-service and is moving toward fee-for-performance. And that performance is, you know, measured based on patient outcomes and whether or not you’re helping the majority of your patients to improve their functioning. And unless you’re doing regular measurement of where they are at it’s going to be really hard for you to demonstrate the impact that you’re having on patients.

Christopher Hunter: Now there’s a variety of different kind of patient outcomes. And I think looking at, as a general rule, looking at both patient symptom change and patient functioning change is important. Because sometimes a patient’s symptom report, might not vary, but how they improve and how they function in their daily life and their quality of life has dramatic increases depending on the problem that you’re looking at.

Jeff Goodie: Medicine is full of these measures that are being assessed to determine, you know, whether the interventions or the treatments are working. And if we’re not doing the same then we’re going to look different from the other providers within that clinic and I think that’s going to be to our detriment.

Christopher Hunter: I think it’s also important for people that are paying for this. And I think that’s one of the big barriers out there which I hope is changing. And that’s if people are paying to add this, to have integrated whole-person care how do they know that what you’re doing is having any impact? If you don’t measure it, all you have is what you think is happening. You can’t actually show them any data. So I think it’s clinically useful. I think business-wise it’s useful. To me, I mean, I’ve been steeped in this so long, sometimes I forget this can be very new and very different for a lot of psychologists. But can you imagine that it would ever be OK for a primary care provider to assess somebody has high blood pressure, put them on a high blood pressure medication, and then never test their blood pressure again to see if that medication was working? I mean no one would ever tolerate that.

Jewel Edwards-Ashman: Tracking behavioral health outcomes is one way that psychologists are helping to show how integrated health care achieves what’s known as “the triple aim:” improving a patient’s health outcomes, enhancing their experiences while also decreasing per capita health care costs. CMS adopted the triple aim framework. and health care systems and other commercial insurers are following suit. Dr. Hunter says there are several areas to consider when measuring cost reduction aspect.

Christopher Hunter: Whether it impacts overall costs I think is a challenging question to answer because it depends on how people measure costs. Does having the integrated behavioral health provider, does that decrease the medications that an individual takes? Does it decrease the number of primary care provider appointments that individual has? Does it increase the number of medical in-patient or psychiatric hospitalizations that individual has?

Does it keep them from crossing over into an actual disease range where they have to get more services over the span of their life and does that cost more money? Does it avoid ER visits? So, there’s a variety pieces to look at, and so that’s challenging.

Jewel Edwards-Ashman: Discussions have also turned to how integrated care is accomplishing the Quadruple Aim, which includes the three facets of the triple aim and adds a fourth goal: provider well-being.

Jeff Goodie: I think if you talk to a lot of primary care providers, one of the most frustrating things for them is their patients not changing their behaviors and having to deal with some of the behavioral health and mental health issues that often was a source of frustration. So to have somebody that they can immediately send their patients to if needed I think is one way of helping to improve their satisfaction with providing care and can help their burnout.

Christopher Hunter: I’ve started integrated practices in multiple clinics and it was not uncommon within the first three months--because they’ve got to get a chance to know you and hear back from their patients that they liked seeing Dr. Hunter and this has been helpful—and then you’ll get a knock on the door at about three o’clock in the afternoon as clinic is running down. They’ll say, “Hey Chris, do you have a sec? I wanted to run something by you, and they’ll come in and talk about challenges they are having at work. And you as a colleague can discuss how they might deal with those. They sometimes might discuss personal challenges they are having outside of work and you can still have some of that colleague back and forth. But if it turns into something where you’re actually providing an identified assessment intervention, that can be OK, too, within limits. They have a resource in the clinic they didn’t have before.

Jewel Edwards-Ashman: If you’re interested in working in integrated health care, APA’s Integrated Health Care Alliance can help with the transition. Right now, psychologists can enroll in APA’s free program, and receiving support and training to work in an integrated health care practice. To learn more and to enroll, visit apa.org/ihca.

This episode of Progress Notes was produced, produced by me, with help from Hannah Calkins, Luana Bossolo. Be sure to subscribe to this podcast on iTunes or so you can listen to our next episode on members of the Committee for the Advancement of Professional Practice, also known as CAPP.

Kate Brown, PhD: The more robust a group of nominations that we have just makes our CAPP leadership more effective. That can make for just a wonderful alignment in terms of our committee’s priorities.

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