Families, Systems, & Health 2014, Vol. 32, No. 4, 426 – 432
© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000078
BRIEF REPORT
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Medical Provider Attitudes About Behavioral Health Consultants in Integrated Primary Care: A Preliminary Study Nicole D. Torrence, MA, Anne E. Mueller, PhD, Allison A. Ilem, PhD, BCBA, and Brenna N. Renn, MA
Brian DeSantis, PsyD Peak Vista Community Health Centers, Colorado Springs, Colorado
University of Colorado at Colorado Springs
Daniel L. Segal, PhD University of Colorado at Colorado Springs Integrated behavioral health increases service utilization and treatment success, particularly with high-risk populations. This study assessed medical personnel’s attitudes and perceptions of behavioral health clinicians (BHCs) in primary care using a brief self-report measure. A 6-item survey was given to medical providers (n ⫽ 45) from a health care system that includes integrated behavioral health services. Survey items assessed providers’ attitudes and perceptions about BHCs. Attitudes about behavioral health were largely favorable. For all items, 73.3% to 100% of participants endorsed strongly agree or agree. Chi-square analyses revealed that those who interacted more frequently with BHCs were more comfortable discussing behavioral health issues with their patients, 2(6, n ⫽ 45) ⫽ 13.43, p ⬍ .05, and that physicians believe that BHCs help patients effectively address their behavioral health problems, 2(2, n ⫽ 45) ⫽ 6.36, p ⬍ .05. Age, gender, and health center in which the providers worked were not significantly related to any survey items. Medical providers surveyed believe that BHCs are valuable members of integrated health care, improving their abilities to provide care and to address their patients’ physical and behavioral health problems. Although these preliminary results are promising, the setting surveyed has well-integrated behavioral health care services and thus might not be representative of other settings without such integration. Future studies should address medical providers’ opinions of BHCs in a variety of settings with larger samples. Keywords: behavioral health, integrated care, medical provider attitudes
The integration of behavioral health services into primary care settings is increasingly common. A preponderance of symptoms that bring patients to primary care are behavioral or psy-
chological in nature; thus, primary care is where behavioral health disorders are often initially assessed and treated (Blount, 2003; Hunter, Goodie, Oordt, & Dobmeyer, 2009; Petterson,
This article was published Online First October 20, 2014. Nicole D. Torrence, MA, Anne E. Mueller, PhD, Allison A. Ilem, PhD, BCBA, and Brenna N. Renn, MA, Department of Psychology, University of Colorado at Colorado Springs; Brian DeSantis, PsyD, Behavioral Health, Peak Vista Community Health Centers, Colorado Springs, Colorado; Daniel L. Segal, PhD, Department of Psychology, University of Colorado at Colorado Springs.
This research was supported by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA; Graduate Psychology Education Program, D40HP19634) to Daniel L. Segal. Correspondence concerning this article should be addressed to Daniel L. Segal, PhD, Department of Psychology, University of Colorado at Colorado Springs, Colorado Springs, 1420 Austin Bluffs Parkway, CO 80918. E-mail: [email protected] 426
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
MEDICAL PROVIDER ATTITUDES
Miller, Payne-Murphy, & Phillips Jr., 2014). As such, positioning behavioral health services within primary care can increase service utilization and optimize care, especially with high risk populations (Bartels et al., 2004). Integrated behavioral health services improve financial and clinical outcomes including patient engagement, increased use of preventative approaches, improvements in treatment outcomes for both physical (e.g., diabetes, chronic pain) and psychological conditions (e.g., depression, anxiety), and increases in family involvement (Gallo et al., 2004). However, integrating behavioral health into traditional medical settings requires a paradigm shift, to which some providers may be resistant (Kessler, 2008). Effectively integrating care requires the willingness of primary care providers (PCPs) to reshape their practice patterns, modify their established clinical flow, include the role of behavioral health providers as part of the medical team, and position behavioral health as a valued service in primary care. Previous research has been mixed with regard to medical provider attitudes about behavioral health. Generally, PCPs are receptive to collaborative primary care for individuals with comorbid and complex physical and behavioral health problems (Levine et al., 2005). For example, Serrano and Monden (2011) surveyed attitudes about an integrated depression care model among medical providers at a single-site federally qualified health center (FQHC). FQHCs are nonprofit health centers that receive federal grant support to provide comprehensive primary care for medically underserved populations and areas, regardless of patient ability to pay. Serrano and Monden concluded that their specific primary care behavioral health program was accepted by medical providers and resulted in improved patient care; however, their study was restricted to depression care. Similarly favorable provider attitudes about integrated behavioral health have been documented in diverse health care settings such as Veterans Affairs clinics (Funderburk et al., 2010) and university health centers (Westheimer, Steinley-Bumgarner, & Brownson, 2008). Less favorable attitudes typically relate to a lack of understanding of psychological treatment, referral barriers, and enduring stigma of psychiatric disorders (Beacham, Herbst, Streitwieser, Scheu, & Sieber, 2012). Beacham et al. (2012) compared
427
attitudes about behavioral health among medical providers from an FQHC with those from community-based clinics. They generally found low rates of referrals and low perceived helpfulness of behavioral health; however, respondents were not consistently exposed to behavioral health professionals at their clinics. Given the critical role of the medical provider in successfully integrating behavioral health into primary care settings, the present study assessed PCPs’ attitudes and perceptions of behavioral health clinicians (BHCs) embedded in a multiclinic FQHC offering colocated primary care behavioral health services. The level of integration follows definitions provided by Heath, Wise-Romero, and Reynolds (2013). Few studies have directly addressed how medical providers view the integration of behavioral health. Even less is known about integrated care in FQHCs, where unique barriers likely exist in treating medically underserved and low-income patient populations. In an effort to expand on the work of Serrano and Monden (2011), this study examined PCPs views of integrated behavioral health with regards to (a) perceived importance, (b) helpfulness in discussing and treating behavioral health issues, (c) perceived potential impact on patient care, and (d) efficiency. We hypothesized that medical providers would hold generally favorable attitudes about BHCs, but because of the exploratory nature of the study, we did not provide further hypotheses. Method Setting Experimenters surveyed a sample of PCPs from a large FQHC in Colorado. This FQHC serves low-income and/or medically indigent individuals across the life span, with more than 66,000 patients seen annually. Notably, behavioral health services have been integrated since 2003 and are offered through close collaboration with PCPs and some system integration. At the time of the study, a diverse group of BHCs (including 9 full-time behavioral health consultants, 2 part-time psychiatrists, and approximately 5 part-time clinical psychology practicum trainees) worked across 12 primary care clinics. BHCs are embedded in the FQHC with colocated office space, integrated electronic health records, shared primary care reception-
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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TORRENCE, MUELLER, ILEM, RENN, DESANTIS, AND SEGAL
ists, and personal communication with PCPs. Patients are seen for brief, short-term interventions delivered in 15- to 30-minute sessions in either medical exam rooms or in dedicated BH office space. Interventions encompass primary care behavioral health (e.g., treatment of medical and/or comorbid psychological conditions), colocated care for psychiatric disorders, and care management as indicated. There is a basic understanding between BHCs and PCPS of each other’s roles, and BHCs are used as consultants to the PCPs to provide expertise though same day covisits (BHCs see patients appointed to their PCP) and through short-term follow-up sessions with the BHC. Participants Forty-five of the 73 providers completed the survey (69% women, Mage ⫽ 43.3 years, SD ⫽ 10.9 years, 82% Caucasian; see Table 1 for full demographics), resulting in a 62% response rate. Of these providers, 53% were midlevel providers (i.e., nurse practitioners, physician assistants) and 47% were physicians (see Table 1). The ratio of midlevel providers to physicians in this study (approximately 1:1) is very similar to the ratio of such providers throughout the FQHC. The health care providers deliver services to individuals across a number of clinics in the health care system (e.g., family health, pediatrics, seniors). These providers had access to onsite, colocated, collaborative, and/or integrated behavioral health services delivered by licensed/credentialed professional BH staff (i.e., licensed psychologists, licensed clinical social workers, licensed professional counselors, clinical psychology doctoral candidates and postdoctoral fellows), one or more days per week. Measure The survey, adapted from that used by Serrano and Monden (2011), consisted of six selfreport items assessing medical provider attitudes and perceptions of BHCs (see full survey in Figure 1). Although no information regarding the psychometric properties of the original scale is available, the internal consistency for this adapted scale in our study was excellent (Cronbach’s alpha ⫽ .90). The items were selected to assess various aspects of providers’ perceptions on how BHCs impact their practice. The items
Table 1 Descriptive Statistics of Survey Respondents Statistic Ethnicity Caucasian Black/AA Hispanic Asian/PI Other/multiracial Missing Total Gender Female Male Total Type of provider Mid-level Physician Total Frequently working with behavioral health consultants 0–3 times/week 4–6 times/week 6⫹ times/week Never Total Health center Developmental disabilities Family health Pediatrics Ronald McDonald care mobile Senior Women’s health Missing Total Age in years, M (SD)
n
%
37 2 1 2 1 2 45
82% 4% 2% 6% 2% 4% 100%
31 14 45
69% 31% 100%
24 21 45
53% 47% 100%
15 16 14 0 45
33% 36% 31% 0% 100%
1 25 6 1 2 8 1 45 43.3 (10.9)
2% 56% 13% 2% 4% 18% 2% 100%
measured how medical provider’s perceived the impact of BHCs on service efficiency, overall patient care, behavioral and physical health of patients, provider level of comfort discussing behavioral health issues, and importance of BHCs to the practice. Each item was rated on a Likert-type scale (1 ⫽ strongly agree to 5 ⫽ strongly disagree). Providers also endorsed how frequently they interact with BHCs, the length of time they have been working with the agency, and demographic information. Procedure Medical staff were provided with informed consent information as well as hard copies of the survey during a meeting with the Director of Behavioral Health. The medical providers were
MEDICAL PROVIDER ATTITUDES
429
EVALUATING BEHAVIORAL HEALTH SERVICES
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N/A
Strongly Disagree
Disagree
Neutral
Strongly Agree
Please indicate the extent to which you agree with the following statements:
Agree
This brief measure is designed to assess the attitudes and perceptions of our integrated model of care at Peak Vista. The term Behavioral Health Consultants (BHCs) refers to licensed non-prescribing BH staff and supervised graduate students.
1. Using BHCs improves my efficiency as a healthcare provider. 2. Using BHCs improves overall patient care. 3. BHCs effectively help patients address their mental health problems. 4. BHCs effectively help patients address their physical health problems. 5. Working with BHCs has increased my comfort in discussing mental health issues with my patients. 6. BHCs are an important part of my practice. 7. On average, how often do you currently refer to or consult with BHCs (on a weekly basis)? 0-3 times/week
4-6 times/week
6+ times/week
Never
8. Type of provider: Physician
Mid-level
Full-time PCP
Part-time PCP
Per Diem PCP
9. Please indicate the Health Center(s) at which you work: DDHC
Family Health Myron Stratton
Senior Health North
Family Health Divide
Family Health Union
Senior Health South
Family Health Fountain
Homeless
Women’s Health Center
Family Health Internat’l Cir.
Pediatric Health Center
10. How long have you worked at Peak Vista? 0-2 years
3-6 years
7-10 years
11. Please indicate your gender: _____ Male
10+ years
_____ Female
_____ Other (please specify)
12. Please indicate your age: _____ years 13. Please indicate your race/ethnicity (select as many as apply): White/Caucasian Black/African American Hispanic American Indian
Asian/Pacific Islander
Other/Multiracial (please specify) ____________________
14. Additional comments or opinions about behavioral health in integrated care:
Figure 1.
Attitudes about behavioral health consultants survey.
encouraged to complete the survey but participation was voluntary. To preserve anonymity, the providers were instructed to return the survey anonymously in a sealed envelope to an administrative assistant, who then tuned over all
packets to the research team. Participants were given approximately one month to return the completed surveys. This study was approved by the University’s institutional review board.
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TORRENCE, MUELLER, ILEM, RENN, DESANTIS, AND SEGAL
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Results IBM SPSS 21 was used for data analyses. Data were missing at random and listwise deletion was performed to address missing values. Attitudes about BHCs were largely favorable. For all items, 73.3% to 100% of participants endorsed strongly agree or agree (see Table 2). Chi-square test for independence analyses revealed that those who interacted more frequently (four to six times a week and six or more times a week) with behavioral health were more likely to endorse strongly agree on Item 5, Working with BHCs has increased my comfort in discussing mental health issues with my patients, 2(6, n ⫽ 45) ⫽ 13.43, p ⬍ .05. Chisquare test for independence also revealed that physicians were more likely to endorse strongly agree or agree on Item 3 than midlevel providers, BHCs effectively help patients address their mental health problems, 2(2, n ⫽ 45) ⫽ 6.36, p ⬍ .05. Age and gender of provider as well as length of time the provider worked at Peak Vista were not related to any item on the measure. The data for the health center in which the providers worked were moderately skewed (skewness ⫽ .84) in favor of the Family Health, Pediatrics, and Women’s Health Clinics. Both the Developmental Disability Health Center and Ronald McDonald Care Mobile clinics were outliers. When they were removed from the analysis, the clinic in which these providers worked were not related to any item on the measure. Discussion This preliminary study assessed medical providers’ attitudes about behavioral health care providers in a federally qualified integrated primary
care setting. In our sample, PCPs believed that BHCs were valuable members of integrated teams, improved their ability to deliver care, and enhanced their ability to address their patients’ physical problems and behavioral health problems. Additionally, PCPs who had higher rates of contact with BHCs reported increased comfort discussing mental health concerns with their patients. This latter finding is congruent with literature suggesting that the extent of integration and the frequency of opportunities for consultation may impact provider perspectives about the necessity, usefulness, and value of BHCs (Beacham et al., 2012). Also of note, approximately one quarter of PCPs did not perceive that BHCs addressed the physical health needs of their patients. This may represent the tendency for greater utilization of BHCs for traditional mental health concerns such as anxiety and depression, as opposed to behavioral medicine or chronic disease management (Beacham et al., 2012). Interestingly, physicians were more likely than midlevel providers to endorse that BHCs helped patients address mental health problems. One possible explanation of this finding is that most midlevel providers have less training than physician counterparts in the identification and treatment of psychosocial aspects of health care, and thus some midlevel providers may not fully appreciate the role of BHCs in this capacity. However, further research is necessary to examine this hypothesis. This study adds to the growing integrated care literature by highlighting perspectives of medical providers who provide services to low-income and ethnically diverse patients in both general practice (e.g., family practice) and populationspecific (e.g., developmental disabilities, geriatric) FQHC primary care clinics. This study expands
Table 2 Medical Provider Attitudes About Behavioral Health Consultants Survey item
Strongly agree
Agree
Neutral
Disagree N/A
1. Using BHCs improves my efficiency as a healthcare provider. 2. Using BHCs improves overall patient care. 3. BHCs effectively help patients address their mental health problems. 4. BHCs effectively help patients address their physical health problems. 5. Working with BHCs has increased my comfort in discussing mental health issues with my patients. 6. BHCs are an important part of my practice.
32 (71%) 30 (67%)
9 (20%) 3 (7%) 12 (26%) 2 (4%)
1 (2%) 0 (0%)
0 0
33 (73%)
9 (20%) 3 (7%)
0 (0%)
0
9 (20%)
25 (56%) 7 (15%)
4 (9%)
0
16 (36%) 30 (67%)
17 (37%) 9 (20%) 11 (24%) 2 (4%)
3 (7%) 2 (4%)
0 0
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
MEDICAL PROVIDER ATTITUDES
on the work of Serrano and Monden (2011), who investigated depression-specific outcomes by further assessing, in our study, PCP perspectives about a broader scope of comprehensive behavioral health services that include, but are not limited to, depression treatment. Although these preliminary results are promising, there are several limitations to the present study. Although the brief nature of the survey may have encouraged a higher response rate from busy medical providers, in-depth information was not obtained. The format of the survey prevented researchers from understanding the qualitative explanations regarding reasons why some providers had neutral or unfavorable beliefs about behavioral health care. The survey also utilized a retrospective self-report format, which may have led to recall biases. Follow-up studies should extend knowledge of provider attitudes to objective data, such as utilization of BHCs, referral rates, and treatment outcomes. There was also the potential social desirability response bias, particularly in clinics where there were fewer medical providers. Finally, behavioral health is well-integrated in this FQHC, and thus may not be representative of other primary care and medical settings without well-established behavioral health services. Future studies should address medical providers’ opinions of BHCs in a variety of medical settings with larger samples, using measures which assess both depth and breadth of attitudes and perceptions as well as objective service utilization outcome measures. On a broader scale, continued investigation is warranted regarding systematic barriers that prevent integration of behavioral health services, as well as mechanisms of change that facilitate the organizational union of behavioral and physical health care. Psychological research and evidence is rarely used to affect health care practice and policy (Kessler, 2008), however understanding of this integrative process is crucial and the skill set espoused by psychologists is well-suited to the task. After all, the burden of integration rests on behavioral health to demonstrate their expertise and added value. This study adds to the growing and vital literature in this important area. References Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., Miles, K. M., Areán, P. A., . . . the PRISM-E Investigators. (2004). Improving access to geriatric
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mental health services: A randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. The American Journal of Psychiatry, 161, 1455–1462. http://dx.doi.org/10 .1176/appi.ajp.161.8.1455 Beacham, A. O., Herbst, A., Streitwieser, T., Scheu, E., & Sieber, W. J. (2012). Primary care medical provider attitudes regarding mental health and behavioral medicine in integrated and non-integrated primary care practice settings. Journal of Clinical Psychology in Medical Settings, 19, 364 –375. http://dx.doi.org/10.1007/s10880-011-9283-y Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, & Health, 21, 121–133. http://dx.doi.org/10.1037/1091-7527.21 .2.121 Funderburk, J. S., Sugarman, D. E., Maisto, S. A., Ouimette, P., Schohn, M., Lantinga, L., . . . Strutynski, K. (2010). The description and evaluation of the implementation of an integrated healthcare model. Families, Systems, & Health, 28, 146 –160. http://dx.doi.org/10.1037/a0020223 Gallo, J. J., Zubritsky, C., Maxwell, J., Nazar, M., Bogner, H. R., Quijano, L. M., . . . the PRISM-E Investigators. (2004). Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: Results from a multisite effectiveness trial (PRISM-e). Annals of Family Medicine, 2, 305–309. http://dx.doi.org/10 .1370/afm.116 Heath, B., Wise-Romero, P., & Reynolds, K. A. (March, 2013). Standard framework for levels of integrated healthcare. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions. Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. Washington, DC: American Psychological Association. Kessler, R. (2008). The difficulty of making psychology research and clinical practice relevant to medicine: Experiences and observations. Journal of Clinical Psychology in Medical Settings, 15, 65– 72. http://dx.doi.org/10.1007/s10880-008-9096-9 Levine, S., Unützer, J., Yip, J. Y., Hoffing, M., Leung, M., Fan, M. Y., . . . Langston, C. A. (2005). Physicians’ satisfaction with a collaborative disease management program for late-life depression in primary care. General Hospital Psychiatry, 27, 383– 391. http://dx.doi.org/10.1016/j.genhosppsych .2005.06.001 Petterson, S., Miller, B. F., Payne-Murphy, J. C., & Phillips Jr., R. L. (2014). Mental health treatment in the primary care setting: Patterns and pathways. Families, Systems, and Health, 32, 157–166.
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Serrano, N., & Monden, K. (2011). The effect of behavioral health consultation on the care of depression by primary care clinicians. Wisconsin Medical Journal, 110, 113–118. Westheimer, J. M., Steinley-Bumgarner, M., & Brownson, C. (2008). Primary care providers’ perceptions of and experiences with an integrated
healthcare model. Journal of American College Health, 57, 101–108. Received April 14, 2014 Revision received July 27, 2014 Accepted August 8, 2014 䡲
Call for Nominations The Publications and Communications (P&C) Board of the American Psychological Association has opened nominations for the editorships of Developmental Psychology and the Journal of Consulting and Clinical Psychology for the years 2017–2022. Jacquelynne S. Eccles, PhD, and Arthur M. Nezu, PhD, respectively, are the incumbent editors. Candidates should be members of APA and should be available to start receiving manuscripts in early 2016 to prepare for issues published in 2017. Please note that the P&C Board encourages participation by members of underrepresented groups in the publication process and would particularly welcome such nominees. Self-nominations are also encouraged. Search chairs have been appointed as follows: ● Developmental Psychology, Suzanne Corkin, PhD, and Mark Sobell, PhD ● Journal of Consulting and Clinical Psychology, Neal Schmitt, PhD, and Annette LaGreca, PhD Candidates should be nominated by accessing APA’s EditorQuest site on the Web. Using your Web browser, go to http://editorquest.apa.org. On the Home menu on the left, find “Guests.” Next, click on the link “Submit a Nomination,” enter your nominee’s information, and click “Submit.” Prepared statements of one page or less in support of a nominee can also be submitted by e-mail to Sarah Wiederkehr, P&C Board Search Liaison, at [email protected]. Deadline for accepting nominations is January 7, 2015, when reviews will begin.
© 2014 American Psychological Association 1091-7527/14/$12.00 http://dx.doi.org/10.1037/fsh0000078
BRIEF REPORT
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Medical Provider Attitudes About Behavioral Health Consultants in Integrated Primary Care: A Preliminary Study Nicole D. Torrence, MA, Anne E. Mueller, PhD, Allison A. Ilem, PhD, BCBA, and Brenna N. Renn, MA
Brian DeSantis, PsyD Peak Vista Community Health Centers, Colorado Springs, Colorado
University of Colorado at Colorado Springs
Daniel L. Segal, PhD University of Colorado at Colorado Springs Integrated behavioral health increases service utilization and treatment success, particularly with high-risk populations. This study assessed medical personnel’s attitudes and perceptions of behavioral health clinicians (BHCs) in primary care using a brief self-report measure. A 6-item survey was given to medical providers (n ⫽ 45) from a health care system that includes integrated behavioral health services. Survey items assessed providers’ attitudes and perceptions about BHCs. Attitudes about behavioral health were largely favorable. For all items, 73.3% to 100% of participants endorsed strongly agree or agree. Chi-square analyses revealed that those who interacted more frequently with BHCs were more comfortable discussing behavioral health issues with their patients, 2(6, n ⫽ 45) ⫽ 13.43, p ⬍ .05, and that physicians believe that BHCs help patients effectively address their behavioral health problems, 2(2, n ⫽ 45) ⫽ 6.36, p ⬍ .05. Age, gender, and health center in which the providers worked were not significantly related to any survey items. Medical providers surveyed believe that BHCs are valuable members of integrated health care, improving their abilities to provide care and to address their patients’ physical and behavioral health problems. Although these preliminary results are promising, the setting surveyed has well-integrated behavioral health care services and thus might not be representative of other settings without such integration. Future studies should address medical providers’ opinions of BHCs in a variety of settings with larger samples. Keywords: behavioral health, integrated care, medical provider attitudes
The integration of behavioral health services into primary care settings is increasingly common. A preponderance of symptoms that bring patients to primary care are behavioral or psy-
chological in nature; thus, primary care is where behavioral health disorders are often initially assessed and treated (Blount, 2003; Hunter, Goodie, Oordt, & Dobmeyer, 2009; Petterson,
This article was published Online First October 20, 2014. Nicole D. Torrence, MA, Anne E. Mueller, PhD, Allison A. Ilem, PhD, BCBA, and Brenna N. Renn, MA, Department of Psychology, University of Colorado at Colorado Springs; Brian DeSantis, PsyD, Behavioral Health, Peak Vista Community Health Centers, Colorado Springs, Colorado; Daniel L. Segal, PhD, Department of Psychology, University of Colorado at Colorado Springs.
This research was supported by a grant from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA; Graduate Psychology Education Program, D40HP19634) to Daniel L. Segal. Correspondence concerning this article should be addressed to Daniel L. Segal, PhD, Department of Psychology, University of Colorado at Colorado Springs, Colorado Springs, 1420 Austin Bluffs Parkway, CO 80918. E-mail: [email protected] 426
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
MEDICAL PROVIDER ATTITUDES
Miller, Payne-Murphy, & Phillips Jr., 2014). As such, positioning behavioral health services within primary care can increase service utilization and optimize care, especially with high risk populations (Bartels et al., 2004). Integrated behavioral health services improve financial and clinical outcomes including patient engagement, increased use of preventative approaches, improvements in treatment outcomes for both physical (e.g., diabetes, chronic pain) and psychological conditions (e.g., depression, anxiety), and increases in family involvement (Gallo et al., 2004). However, integrating behavioral health into traditional medical settings requires a paradigm shift, to which some providers may be resistant (Kessler, 2008). Effectively integrating care requires the willingness of primary care providers (PCPs) to reshape their practice patterns, modify their established clinical flow, include the role of behavioral health providers as part of the medical team, and position behavioral health as a valued service in primary care. Previous research has been mixed with regard to medical provider attitudes about behavioral health. Generally, PCPs are receptive to collaborative primary care for individuals with comorbid and complex physical and behavioral health problems (Levine et al., 2005). For example, Serrano and Monden (2011) surveyed attitudes about an integrated depression care model among medical providers at a single-site federally qualified health center (FQHC). FQHCs are nonprofit health centers that receive federal grant support to provide comprehensive primary care for medically underserved populations and areas, regardless of patient ability to pay. Serrano and Monden concluded that their specific primary care behavioral health program was accepted by medical providers and resulted in improved patient care; however, their study was restricted to depression care. Similarly favorable provider attitudes about integrated behavioral health have been documented in diverse health care settings such as Veterans Affairs clinics (Funderburk et al., 2010) and university health centers (Westheimer, Steinley-Bumgarner, & Brownson, 2008). Less favorable attitudes typically relate to a lack of understanding of psychological treatment, referral barriers, and enduring stigma of psychiatric disorders (Beacham, Herbst, Streitwieser, Scheu, & Sieber, 2012). Beacham et al. (2012) compared
427
attitudes about behavioral health among medical providers from an FQHC with those from community-based clinics. They generally found low rates of referrals and low perceived helpfulness of behavioral health; however, respondents were not consistently exposed to behavioral health professionals at their clinics. Given the critical role of the medical provider in successfully integrating behavioral health into primary care settings, the present study assessed PCPs’ attitudes and perceptions of behavioral health clinicians (BHCs) embedded in a multiclinic FQHC offering colocated primary care behavioral health services. The level of integration follows definitions provided by Heath, Wise-Romero, and Reynolds (2013). Few studies have directly addressed how medical providers view the integration of behavioral health. Even less is known about integrated care in FQHCs, where unique barriers likely exist in treating medically underserved and low-income patient populations. In an effort to expand on the work of Serrano and Monden (2011), this study examined PCPs views of integrated behavioral health with regards to (a) perceived importance, (b) helpfulness in discussing and treating behavioral health issues, (c) perceived potential impact on patient care, and (d) efficiency. We hypothesized that medical providers would hold generally favorable attitudes about BHCs, but because of the exploratory nature of the study, we did not provide further hypotheses. Method Setting Experimenters surveyed a sample of PCPs from a large FQHC in Colorado. This FQHC serves low-income and/or medically indigent individuals across the life span, with more than 66,000 patients seen annually. Notably, behavioral health services have been integrated since 2003 and are offered through close collaboration with PCPs and some system integration. At the time of the study, a diverse group of BHCs (including 9 full-time behavioral health consultants, 2 part-time psychiatrists, and approximately 5 part-time clinical psychology practicum trainees) worked across 12 primary care clinics. BHCs are embedded in the FQHC with colocated office space, integrated electronic health records, shared primary care reception-
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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TORRENCE, MUELLER, ILEM, RENN, DESANTIS, AND SEGAL
ists, and personal communication with PCPs. Patients are seen for brief, short-term interventions delivered in 15- to 30-minute sessions in either medical exam rooms or in dedicated BH office space. Interventions encompass primary care behavioral health (e.g., treatment of medical and/or comorbid psychological conditions), colocated care for psychiatric disorders, and care management as indicated. There is a basic understanding between BHCs and PCPS of each other’s roles, and BHCs are used as consultants to the PCPs to provide expertise though same day covisits (BHCs see patients appointed to their PCP) and through short-term follow-up sessions with the BHC. Participants Forty-five of the 73 providers completed the survey (69% women, Mage ⫽ 43.3 years, SD ⫽ 10.9 years, 82% Caucasian; see Table 1 for full demographics), resulting in a 62% response rate. Of these providers, 53% were midlevel providers (i.e., nurse practitioners, physician assistants) and 47% were physicians (see Table 1). The ratio of midlevel providers to physicians in this study (approximately 1:1) is very similar to the ratio of such providers throughout the FQHC. The health care providers deliver services to individuals across a number of clinics in the health care system (e.g., family health, pediatrics, seniors). These providers had access to onsite, colocated, collaborative, and/or integrated behavioral health services delivered by licensed/credentialed professional BH staff (i.e., licensed psychologists, licensed clinical social workers, licensed professional counselors, clinical psychology doctoral candidates and postdoctoral fellows), one or more days per week. Measure The survey, adapted from that used by Serrano and Monden (2011), consisted of six selfreport items assessing medical provider attitudes and perceptions of BHCs (see full survey in Figure 1). Although no information regarding the psychometric properties of the original scale is available, the internal consistency for this adapted scale in our study was excellent (Cronbach’s alpha ⫽ .90). The items were selected to assess various aspects of providers’ perceptions on how BHCs impact their practice. The items
Table 1 Descriptive Statistics of Survey Respondents Statistic Ethnicity Caucasian Black/AA Hispanic Asian/PI Other/multiracial Missing Total Gender Female Male Total Type of provider Mid-level Physician Total Frequently working with behavioral health consultants 0–3 times/week 4–6 times/week 6⫹ times/week Never Total Health center Developmental disabilities Family health Pediatrics Ronald McDonald care mobile Senior Women’s health Missing Total Age in years, M (SD)
n
%
37 2 1 2 1 2 45
82% 4% 2% 6% 2% 4% 100%
31 14 45
69% 31% 100%
24 21 45
53% 47% 100%
15 16 14 0 45
33% 36% 31% 0% 100%
1 25 6 1 2 8 1 45 43.3 (10.9)
2% 56% 13% 2% 4% 18% 2% 100%
measured how medical provider’s perceived the impact of BHCs on service efficiency, overall patient care, behavioral and physical health of patients, provider level of comfort discussing behavioral health issues, and importance of BHCs to the practice. Each item was rated on a Likert-type scale (1 ⫽ strongly agree to 5 ⫽ strongly disagree). Providers also endorsed how frequently they interact with BHCs, the length of time they have been working with the agency, and demographic information. Procedure Medical staff were provided with informed consent information as well as hard copies of the survey during a meeting with the Director of Behavioral Health. The medical providers were
MEDICAL PROVIDER ATTITUDES
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EVALUATING BEHAVIORAL HEALTH SERVICES
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N/A
Strongly Disagree
Disagree
Neutral
Strongly Agree
Please indicate the extent to which you agree with the following statements:
Agree
This brief measure is designed to assess the attitudes and perceptions of our integrated model of care at Peak Vista. The term Behavioral Health Consultants (BHCs) refers to licensed non-prescribing BH staff and supervised graduate students.
1. Using BHCs improves my efficiency as a healthcare provider. 2. Using BHCs improves overall patient care. 3. BHCs effectively help patients address their mental health problems. 4. BHCs effectively help patients address their physical health problems. 5. Working with BHCs has increased my comfort in discussing mental health issues with my patients. 6. BHCs are an important part of my practice. 7. On average, how often do you currently refer to or consult with BHCs (on a weekly basis)? 0-3 times/week
4-6 times/week
6+ times/week
Never
8. Type of provider: Physician
Mid-level
Full-time PCP
Part-time PCP
Per Diem PCP
9. Please indicate the Health Center(s) at which you work: DDHC
Family Health Myron Stratton
Senior Health North
Family Health Divide
Family Health Union
Senior Health South
Family Health Fountain
Homeless
Women’s Health Center
Family Health Internat’l Cir.
Pediatric Health Center
10. How long have you worked at Peak Vista? 0-2 years
3-6 years
7-10 years
11. Please indicate your gender: _____ Male
10+ years
_____ Female
_____ Other (please specify)
12. Please indicate your age: _____ years 13. Please indicate your race/ethnicity (select as many as apply): White/Caucasian Black/African American Hispanic American Indian
Asian/Pacific Islander
Other/Multiracial (please specify) ____________________
14. Additional comments or opinions about behavioral health in integrated care:
Figure 1.
Attitudes about behavioral health consultants survey.
encouraged to complete the survey but participation was voluntary. To preserve anonymity, the providers were instructed to return the survey anonymously in a sealed envelope to an administrative assistant, who then tuned over all
packets to the research team. Participants were given approximately one month to return the completed surveys. This study was approved by the University’s institutional review board.
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Results IBM SPSS 21 was used for data analyses. Data were missing at random and listwise deletion was performed to address missing values. Attitudes about BHCs were largely favorable. For all items, 73.3% to 100% of participants endorsed strongly agree or agree (see Table 2). Chi-square test for independence analyses revealed that those who interacted more frequently (four to six times a week and six or more times a week) with behavioral health were more likely to endorse strongly agree on Item 5, Working with BHCs has increased my comfort in discussing mental health issues with my patients, 2(6, n ⫽ 45) ⫽ 13.43, p ⬍ .05. Chisquare test for independence also revealed that physicians were more likely to endorse strongly agree or agree on Item 3 than midlevel providers, BHCs effectively help patients address their mental health problems, 2(2, n ⫽ 45) ⫽ 6.36, p ⬍ .05. Age and gender of provider as well as length of time the provider worked at Peak Vista were not related to any item on the measure. The data for the health center in which the providers worked were moderately skewed (skewness ⫽ .84) in favor of the Family Health, Pediatrics, and Women’s Health Clinics. Both the Developmental Disability Health Center and Ronald McDonald Care Mobile clinics were outliers. When they were removed from the analysis, the clinic in which these providers worked were not related to any item on the measure. Discussion This preliminary study assessed medical providers’ attitudes about behavioral health care providers in a federally qualified integrated primary
care setting. In our sample, PCPs believed that BHCs were valuable members of integrated teams, improved their ability to deliver care, and enhanced their ability to address their patients’ physical problems and behavioral health problems. Additionally, PCPs who had higher rates of contact with BHCs reported increased comfort discussing mental health concerns with their patients. This latter finding is congruent with literature suggesting that the extent of integration and the frequency of opportunities for consultation may impact provider perspectives about the necessity, usefulness, and value of BHCs (Beacham et al., 2012). Also of note, approximately one quarter of PCPs did not perceive that BHCs addressed the physical health needs of their patients. This may represent the tendency for greater utilization of BHCs for traditional mental health concerns such as anxiety and depression, as opposed to behavioral medicine or chronic disease management (Beacham et al., 2012). Interestingly, physicians were more likely than midlevel providers to endorse that BHCs helped patients address mental health problems. One possible explanation of this finding is that most midlevel providers have less training than physician counterparts in the identification and treatment of psychosocial aspects of health care, and thus some midlevel providers may not fully appreciate the role of BHCs in this capacity. However, further research is necessary to examine this hypothesis. This study adds to the growing integrated care literature by highlighting perspectives of medical providers who provide services to low-income and ethnically diverse patients in both general practice (e.g., family practice) and populationspecific (e.g., developmental disabilities, geriatric) FQHC primary care clinics. This study expands
Table 2 Medical Provider Attitudes About Behavioral Health Consultants Survey item
Strongly agree
Agree
Neutral
Disagree N/A
1. Using BHCs improves my efficiency as a healthcare provider. 2. Using BHCs improves overall patient care. 3. BHCs effectively help patients address their mental health problems. 4. BHCs effectively help patients address their physical health problems. 5. Working with BHCs has increased my comfort in discussing mental health issues with my patients. 6. BHCs are an important part of my practice.
32 (71%) 30 (67%)
9 (20%) 3 (7%) 12 (26%) 2 (4%)
1 (2%) 0 (0%)
0 0
33 (73%)
9 (20%) 3 (7%)
0 (0%)
0
9 (20%)
25 (56%) 7 (15%)
4 (9%)
0
16 (36%) 30 (67%)
17 (37%) 9 (20%) 11 (24%) 2 (4%)
3 (7%) 2 (4%)
0 0
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MEDICAL PROVIDER ATTITUDES
on the work of Serrano and Monden (2011), who investigated depression-specific outcomes by further assessing, in our study, PCP perspectives about a broader scope of comprehensive behavioral health services that include, but are not limited to, depression treatment. Although these preliminary results are promising, there are several limitations to the present study. Although the brief nature of the survey may have encouraged a higher response rate from busy medical providers, in-depth information was not obtained. The format of the survey prevented researchers from understanding the qualitative explanations regarding reasons why some providers had neutral or unfavorable beliefs about behavioral health care. The survey also utilized a retrospective self-report format, which may have led to recall biases. Follow-up studies should extend knowledge of provider attitudes to objective data, such as utilization of BHCs, referral rates, and treatment outcomes. There was also the potential social desirability response bias, particularly in clinics where there were fewer medical providers. Finally, behavioral health is well-integrated in this FQHC, and thus may not be representative of other primary care and medical settings without well-established behavioral health services. Future studies should address medical providers’ opinions of BHCs in a variety of medical settings with larger samples, using measures which assess both depth and breadth of attitudes and perceptions as well as objective service utilization outcome measures. On a broader scale, continued investigation is warranted regarding systematic barriers that prevent integration of behavioral health services, as well as mechanisms of change that facilitate the organizational union of behavioral and physical health care. Psychological research and evidence is rarely used to affect health care practice and policy (Kessler, 2008), however understanding of this integrative process is crucial and the skill set espoused by psychologists is well-suited to the task. After all, the burden of integration rests on behavioral health to demonstrate their expertise and added value. This study adds to the growing and vital literature in this important area. References Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., Miles, K. M., Areán, P. A., . . . the PRISM-E Investigators. (2004). Improving access to geriatric
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mental health services: A randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. The American Journal of Psychiatry, 161, 1455–1462. http://dx.doi.org/10 .1176/appi.ajp.161.8.1455 Beacham, A. O., Herbst, A., Streitwieser, T., Scheu, E., & Sieber, W. J. (2012). Primary care medical provider attitudes regarding mental health and behavioral medicine in integrated and non-integrated primary care practice settings. Journal of Clinical Psychology in Medical Settings, 19, 364 –375. http://dx.doi.org/10.1007/s10880-011-9283-y Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems, & Health, 21, 121–133. http://dx.doi.org/10.1037/1091-7527.21 .2.121 Funderburk, J. S., Sugarman, D. E., Maisto, S. A., Ouimette, P., Schohn, M., Lantinga, L., . . . Strutynski, K. (2010). The description and evaluation of the implementation of an integrated healthcare model. Families, Systems, & Health, 28, 146 –160. http://dx.doi.org/10.1037/a0020223 Gallo, J. J., Zubritsky, C., Maxwell, J., Nazar, M., Bogner, H. R., Quijano, L. M., . . . the PRISM-E Investigators. (2004). Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: Results from a multisite effectiveness trial (PRISM-e). Annals of Family Medicine, 2, 305–309. http://dx.doi.org/10 .1370/afm.116 Heath, B., Wise-Romero, P., & Reynolds, K. A. (March, 2013). Standard framework for levels of integrated healthcare. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions. Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. Washington, DC: American Psychological Association. Kessler, R. (2008). The difficulty of making psychology research and clinical practice relevant to medicine: Experiences and observations. Journal of Clinical Psychology in Medical Settings, 15, 65– 72. http://dx.doi.org/10.1007/s10880-008-9096-9 Levine, S., Unützer, J., Yip, J. Y., Hoffing, M., Leung, M., Fan, M. Y., . . . Langston, C. A. (2005). Physicians’ satisfaction with a collaborative disease management program for late-life depression in primary care. General Hospital Psychiatry, 27, 383– 391. http://dx.doi.org/10.1016/j.genhosppsych .2005.06.001 Petterson, S., Miller, B. F., Payne-Murphy, J. C., & Phillips Jr., R. L. (2014). Mental health treatment in the primary care setting: Patterns and pathways. Families, Systems, and Health, 32, 157–166.
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Serrano, N., & Monden, K. (2011). The effect of behavioral health consultation on the care of depression by primary care clinicians. Wisconsin Medical Journal, 110, 113–118. Westheimer, J. M., Steinley-Bumgarner, M., & Brownson, C. (2008). Primary care providers’ perceptions of and experiences with an integrated
healthcare model. Journal of American College Health, 57, 101–108. Received April 14, 2014 Revision received July 27, 2014 Accepted August 8, 2014 䡲
Call for Nominations The Publications and Communications (P&C) Board of the American Psychological Association has opened nominations for the editorships of Developmental Psychology and the Journal of Consulting and Clinical Psychology for the years 2017–2022. Jacquelynne S. Eccles, PhD, and Arthur M. Nezu, PhD, respectively, are the incumbent editors. Candidates should be members of APA and should be available to start receiving manuscripts in early 2016 to prepare for issues published in 2017. Please note that the P&C Board encourages participation by members of underrepresented groups in the publication process and would particularly welcome such nominees. Self-nominations are also encouraged. Search chairs have been appointed as follows: ● Developmental Psychology, Suzanne Corkin, PhD, and Mark Sobell, PhD ● Journal of Consulting and Clinical Psychology, Neal Schmitt, PhD, and Annette LaGreca, PhD Candidates should be nominated by accessing APA’s EditorQuest site on the Web. Using your Web browser, go to http://editorquest.apa.org. On the Home menu on the left, find “Guests.” Next, click on the link “Submit a Nomination,” enter your nominee’s information, and click “Submit.” Prepared statements of one page or less in support of a nominee can also be submitted by e-mail to Sarah Wiederkehr, P&C Board Search Liaison, at [email protected]. Deadline for accepting nominations is January 7, 2015, when reviews will begin.
