INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 45(4) 367-376, 2013
WIN/WIN: CREATING COLLABORATIVE TRAINING OPPORTUNITIES FOR BEHAVIORAL HEALTH PROVIDERS WITHIN FAMILY MEDICINE RESIDENCY PROGRAMS*
NANCY BREEN RUDDY, PHD Mountainside Family Practice Residency, Verona, New Jersey DOROTHY BORRESEN, PHD, APN, PMHNP-BC UMDNJ-RWJ Medical School, Trenton, New Jersey LINDA MYERHOLTZ, PHD Mercy Health Partners Family Medicine Residency Program, Toledo, Ohio
ABSTRACT
Integrating behavioral health into primary healthcare offers multiple advantages for patients and health professionals. This model requires a new skill set for all healthcare professionals that is not emphasized in current educational models. The new skills include interprofessional team-based care competencies and expanded patient care competencies. Health professionals must learn new ways to efficiently and effectively address health behavior change, and manage behavioral health issues such as depression and anxiety. Learning environments that co-train mental health and primary care professionals facilitate acquisition of both teamwork and patient care competencies for mental health and primary care professional trainees. Family Medicine Residency programs provide an excellent opportunity for co-training. This *Financial support for the collaborative care training program was provided by the Wayne State University Department of Family Medicine and Public Health Sciences. Manuscript based on material presented at the 33rd Annual Forum for Behavioral Science Education in Family Medicine, 2012. 367 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.45.4.g http://baywood.com
368 / RUDDY, BORRESEN AND MYERHOLTZ
article serves as a “how to” guide for residency programs interested in developing a co-training program. Necessary steps to establish and maintain a program are reviewed, as well as goals and objectives for a co-training curriculum and strategies to overcome barriers and challenges in co-training models. (Int’l. J. Psychiatry in Medicine 2013;45:367-376)
Key Words: interdisciplinary training, integrated primary care, training
CONCEPTUAL BACKGROUND Family Medicine educators must prepare trainees to function in a quickly changing and uncertain healthcare delivery system. While nothing is certain, the Patient Centered Medical Home model likely will be a defining feature of primary care. Many provisions of the Affordable Care Act support this transformation [1]. The Patient Centered Medical Home is a model of primary healthcare that emphasizes an ongoing relationship between a primary care medical provider and a patient. The primary care provider’s role is to support the patient in managing his or her own health and to ensure that medical care is coordinated across providers. The model recognizes that medical care is best provided by teams of professionals in which each professional’s relevant expertise is utilized to optimize care for the patient [2]. This model requires skills that are not emphasized in current educational models. The new skills include interprofessional team-based care competencies and expanded patient care competencies to effectively address health behavior change and behavioral health issues such as depression and anxiety [2, 3]. These skills are included in Accreditation Council for Graduate Medical Education (ACGME) Competencies for Family Medicine Residents and are reflected in the Family Medicine Milestones Project [4, 5]. Currently, healthcare training is separated by disciplines and programs rarely “cross fertilized.” Educational silos are starting to erode as educators recognize that cross-discipline training facilitates collaborative healthcare efforts and enhance patient care. The Interprofessional Educational Collaborative (IEC) convened an expert panel of educators representing dentistry, nursing, medicine, pharmacy, and public health to collaboratively compile interprofessional competencies for healthcare professional education. They released a report emphasizing that healthcare professional training models need to be expanded to include “team-based competencies.” These fell into four core competency domains: Interprofessional Ethics, Understanding Professional Roles and Responsibilities, Interprofessional Communication Skills, and Team and Teamwork Competencies [6]. It is notable that educators from the mental health disciplines were absent from this dialogue. The traditional schism between the medical and mental health
INTEGRATED BEHAVIORAL HEALTH TRAINING /
369
treatment delivery systems is paralleled in the educational systems. This is unfortunate given the critical role that behavior and mental health play in PCMH initiatives [7]. The panel’s recommendations for cross-disciplinary education can, and should, be generalized to include mental health professionals. One strategy is to create co-training opportunities for mental health and medical trainees. Beyond addressing cross disciplinary team competencies, co-training mental health and medical trainees also exposes trainees to the integration of behavioral health services into primary care. Integrated Primary Care is not new, but only recently has been adopted more widely by public health services, and health services offered through the Department of Defense and the Veterans’ Administration and Federally Qualified Health Centers [8]. This model of integrated healthcare delivery requires a new skill set for healthcare professionals. Table 1 provides an outline of proposed competencies for the practice of integrated primary care [9].
CURRICULUM DEVELOPMENT Pioneers in Integrated Primary Care have trained mental health professionals in a primary care for decades, often in Family Medicine residencies [10, 11]. Family Medicine residencies were excellent breeding ground for co-training because they already house both medical and mental health faculty, and most espouse the biopsychosocial model of patient care.
Table 1. Integrated Primary Care Competencies [9] Behavioral and developmental aspects of health and illness Biological and cognitive components of health and illness Sociocultural components of health and illness Common primary care problems Assessment and intervention in primary care Interprofessional collaboration in primary care Ethical, legal, and professional issues in primary care
370 / RUDDY, BORRESEN AND MYERHOLTZ
Only recently has there been a push to generalize this model by engaging professional organizations and training communities across disciplines to raise awareness of the integrated care model and its benefits for preparing professionals to work as part of a team, and to optimize patient care regarding health behaviors and behavioral health issues. Both Family Medicine and mental health faculty recognize the “win-win” nature of co-training, but need assistance to make necessary cross-discipline connections and to develop necessary curriculum and clinical experiences to achieve this end. In the remainder of this article we outline recommended steps to establish co-training opportunities for behavioral health trainees within Family Medicine residency programs. CURRICULUM GOALS AND OBJECTIVES The overarching goal of the curriculum is to promote integrated behavioral health services in primary care. The curricular innovation is aimed at both faculty and trainees. There are two stages of curriculum. The first focuses on preparation prior to placing a trainee in a family medicine residency, and the second focuses on the initial phases of the placement and ongoing maintenance training. Prior to Beginning Co-training Clinical Placement The curriculum initially focuses on faculty development aimed at increasing awareness of the integrated primary care model and its benefits for training and patient care. The learning objectives for medical faculty include: 1. to differentiate integrated primary care from typical care; 2. to understand how a co-training model supports a culture of a biopsychosocial approach to care and enhances resident learning regarding behavioral health; 3. to become aware of the preponderance of mental health issues in primary care; 4. to understand the links between mental health issues, behavioral choices, and health outcomes, particularly for patients with chronic medical conditions; and 5. to be able to integrate discussions of the above issues and use of the integrated care model into supervision of residents at different levels of training and readiness. The learning objectives for faculty in mental health training programs are: 1. to become familiar with primary care-based mental health issues; 2. to become familiar with primary care medical culture, and how mental health professionals function differently in a medical setting; 3. to be able to differentiate integrated care models from typical care;
INTEGRATED BEHAVIORAL HEALTH TRAINING /
371
4. to understand how integrated care models improve access to care, preventative mental health, health behaviors, and patient and provider satisfaction; and 5. to become aware of the knowledge, skills and attitudes that trainees need to be successful in a primary care setting. Prior to placing a mental health trainee in a primary care setting, it is important that medical providers and staff undergo training to prepare them to work with the trainee optimally. Learning objectives for medical trainees, providers, and staff include: 1, to be able to define and promote the integrated primary care model; 2. to enhance providers’ ability to identify clinical situations that might benefit from integrated primary care; 3. to learn strategies to optimize chronic disease management using integrated primary care; 4. to increase comfort with the biopsychosocial nature of all clinical encounters; and 5. to instill team-based competencies. Both mental health and medical trainees are likely to have a set “schema” of mental health services based on traditional psychotherapy. In a traditional model, the medical provider must discern that the patient would benefit from mental health services, and then refer the patient to the mental health provider who provides psychotherapy. In contrast, in an integrated model the mental health professional helps identify patients in need of intervention, and intervenes collaboratively with the medical provider. These interventions generally are quite brief and very different than traditional mental health services. In order to avoid replicating the “traditional model,” trainees must learn how integrated services differ from the traditional referral model, how to describe the model to patients, and their role in an integrated system. It is helpful to give “scripts” for discussing integrated care with patients, and to use case-based examples and case conferences. In addition, supervisors must be attuned to trainee’s tendency to “drift” toward the standard model because it is a relative comfort zone for them. These strategies help identify patients who might benefit from integrated care, and how such care can alter the course of treatment.
CURRICULUM FOR MENTAL HEALTH TRAINEES Curriculum for mental health trainees generally starts with simple exposure to the integrated care model. This can occur as a lecture series within a course or a colloquium series. Lectures both educate about primary care behavioral health and facilitate recruitment of students whose interests and personality are a good
372 / RUDDY, BORRESEN AND MYERHOLTZ
fit to primary care. Learning objectives from this brief curriculum would be at the exposure level regarding: 1. defining and promoting the integrated primary care model, emphasizing the role of the mental health professional in an integrated setting; 2. content information about the interplay of behavior and health, preponderance of mental health issues in primary care, common primary care medical and mental health presentations; 3. awareness of non-traditional brief mental health and health behavior interventions; and 4. review of the chronic disease management model, and readiness to change models. In general, the family medicine behavioral health faculty member who will serve as the supervisor should deliver the introductory curriculum. In most cases the supervisor must be from the same discipline as trainees. The implementation of a dialogue about hosting a trainee and of the exposure curriculum should begin 9-12 months before the clinical experience to start. This allows both programs time to create the necessary infrastructure. In addition, since many mental health training programs determine clinical placements 6 to 9 months before the beginning of the academic year, this timeframe includes extra time for this type of recruitment cycle. Overcoming Barriers and Challenges to Co-Training Creating interest and mutual understanding amongst medical and mental health faculty, students, and staff is only the first step to creating a clinical experience for the mental health trainee in primary care. There are numerous logistical and resource issues that must be managed, as well. The residency and mental health training program must have an institutional agreement. Many residencies already have institutional agreements with other training institutions from which they host trainees (e.g., medical schools, nursing schools, etc.). The agreement must be reviewed and approved by each institution’s legal counsel, and renewed over time. There are numerous resource issues. The hosting program must ensure adequate space and support staff for the trainee. Support staff’s role for the trainee’s clinical work should be clarified. The behavioral health faculty and program director should clarify the amount of time necessary in the faculty’s schedule for orientation of the new student, didactics, and ongoing supervision. If the trainee is to be paid for the services provided, the program must create a budget for the position. The program also must determine if patients will be billed for clinical services conducted by the trainee, and how to ensure that billing is appropriate and reimbursable. Crisis management strategies should be outlined. The trainee must complete all occupational health and credentialing processes
INTEGRATED BEHAVIORAL HEALTH TRAINING /
373
before starting the experience. The faculty should review residents’ educational offerings to determine which would be helpful for the mental health trainee, and to ensure that the trainee has opportunities to interact with residents in a variety of settings. Finally, the program must address documentation issues, and ensure that the trainee has appropriate access and training to electronic medical records. Curriculum Goals and Objectives during Co-Training As outlined, a great deal of planning, educating, and negotiating must occur before a mental health trainee can be placed into a Family Medicine Residency for training. The steps outlined thus far are necessary but not sufficient for the success of a co-training program. This section will outline the ongoing efforts required after the mental health trainee starts the clinical training experience in the primary care setting. To begin, the mental health trainees must be oriented to the primary care setting in the first weeks of the experience, ideally before they begin to provide clinical services. It can be very helpful for them to shadow medical support staff and medical providers at different levels of training and expertise. This helps them learn the role of each member of the team, and become more familiar with the logistics of the primary care office. The trainee also needs to learn how to use the electronic health record, and how documentation in primary care is different than in a traditional mental health system. If the trainee is billing for services, coding and billing issues also must be reviewed. During this time, the trainee should be provided with readings and guidance regarding their new role, with specific focus on the following learning objectives: 1. identify collaboration opportunities with residents and other medical profession in order to provide integrative patient care; 2. conduct chart reviews and other screening mechanisms to determine which patients might benefit from the integrated model; and 3. engage in a medical case review process and precepting interactions to learn from clinical presentations, and facilitate biopsychosocial care. Specific skills that should be a focus of early training and supervision are outlined in Table 2. Most of these skills can be developed through clinical experience, modeling by the faculty, and through clinical supervision. Faculty should monitor the clinical case mix of the trainee to ensure that it is varied and appropriate to the trainee’s interests and skill level. Also, since mental health trainees’ “comfort zones” may be in more traditional psychotherapy modalities, the supervisor should ensure that these modalities do not “take over” the trainee’s schedule. In addition to reviewing specific clinical presentations and encounters, supervision should include a discussion of consultation and collaboration skills to help trainees develop interprofessional team competencies. The supervisor also should monitor the mental health trainee’s interactions with the medical trainees.
374 / RUDDY, BORRESEN AND MYERHOLTZ
Table 2. Clinical Skills for Primary Care Mental Health Trainees o Warm Handoff
o Single Session Work
o Consultation
o Medical/MH Culture Differences
o Crisis Management
o Motivational Interviewing
o Screening/Assessment
o Common Primary Care Problems
o Substance Abuse
o Collaboration/educating residents
o Medication Consults
o Managing Pt/Provider Conflict
o Brief Interventions
o Group Medical Appointments
This allows the supervisor to help the trainees optimize their interprofessional collaboration skill set, and give feedback regarding their skills. Optimally, the mental health trainee will become part of the training program and be treated as an equal colleague with the medical trainees. To facilitate this camaraderie, mental health trainees should spend as much time as possible in common areas with medical trainees. Simple socialization breaks down barriers between disciplines. Trainees develop an understanding of the rigors of training outside their own specialty, and may have increased empathy for the challenges of training in other disciplines. The mental health trainee should attend educational activities that are relevant to their duties, as this creates further opportunities for interaction and shared experiences. Ideally, the mental health trainee should develop and implement some training for the medical trainees, either via shared case conferences, problem-based learning modules, or didactic presentations. Supervisors should attend to the trainee’s experiences creating cross-discipline connections and coach the trainee as needed.
PERFORMANCE TO DATE Outcomes data regarding integrated training models is still needed. There is some initial data indicating changes in attitudes about patient care, behavioral issues, and mental health in programs with integrated training models. A survey of family practice residents who co-trained with psychologists revealed that they felt the experience helped them improve their communication skills, positively impacted team dynamics to improve patient care, and increased their understanding of and ability to work with individuals from different professions [12]. More systematic information is needed about impact of integrated training models on behavioral health trainees and medical residents as well as the impact on overall patient care and satisfaction.
INTEGRATED BEHAVIORAL HEALTH TRAINING /
375
GENERALIZATION There are several family medicine residency programs that are currently providing integrated training opportunities for behavioral health providers [10, 12-15]. In addition, there are multiple opportunities for psychologists to receive predoctoral, internship, and postdoctoral training in primary care psychology. The American Psychological Association Education Directorate has recently released on-line directories of these opportunities (http://www.apa.org/ed/ graduate/primary-care-psycholog.aspx) [16]. Reviews of these directories illustrate that co-training of mental health and medical professionals in primary care, particularly Family Medicine, is growing. Currently there are 18 doctoral psychology programs that list primary care-based co-training in academic health centers. There are over 200 internships and post-doctoral programs that offer training for psychologists in primary care, many in the Veterans Administration and Federally Qualified Healthcare systems. Below is a listing of additional resources to facilitate the implementation of an integrated training model: • Integrated Primary Care—integratedprimarycare.com • Patient Centered Primary Care Collaborative—http://www.pcpcc.net • The Collaborative Family Healthcare Association (CFHA)—http://www. cfha.net/ • SAMHSA-HRSA Center for Integrated health Solutions: integration.samhsa. gov • Integrated Behavioral Health Care Project—http://www.ibhp.org REFERENCES 1. Community health centers and the affordable care act. Increasing access to affordable, cost effective, high quality care, 2011. Retrieved March 19, 2013 from http://www. healthcare.gov/news/factsheets/2010/08 increasing-access.html 2. Patient Centered Primary Care Collaborative. Joint principles of the patient-centered medical home. Retrieved March 19, 2013 from http://www.pcpcc.net/joint-principles 3. Croghan TW, Brown JD. Integrating mental health treatment into the patient centered medical home. Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2. AHRQ Publication No. 10-0084-EF. Rockville, MD: Agency for Healthcare Research and Quality, June 2010. 4. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine, 2011. Retrieved March 19, 2013 from http://www.acgme.org/acgmeweb/Portals/0/PFAssets/Program Requirements/120pr07012007.pdf 5. Accreditation Council for Graduate Medical Education. The next accreditation system, 2012. Retrieved March 19, 2013 from http://www.acgme-nas.org/index.html 6. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel, 2011. Washington, DC:
376 / RUDDY, BORRESEN AND MYERHOLTZ
7.
8.
9.
10.
11.
12. 13.
14.
15.
16.
Interprofessional Education Collaborative. Retrieved March 19, 2013 from http:// www.aacp.org/resources/education/Documents/10-242IPECFullReportfinal.pdf DeGruy FV, Etz RS. Attending to the whole person in the patient-centered medical home: The case for incorporating mental healthcare, substance abuse care, and health behavior change. Families, Systems, and Health 2010;28:298-307. Substance Abuse and Mental Health Services Administration (SAMHSA) Federal Partners Senior Workgroup on Mental Health Transformation Integration of Primary Care and Mental Health Workgroup. Compendium of primary care and mental health integration across various participating federal agencies, 2008. Retrieved March 19, 2013 from http://www.samsha.gov/Matrix/MHST/Compendium_Mental %20Health.pdf McDaniel SH, Hargrove DS, Belar CD, Schroeder C, Freeman EL. A training curriculum for professional psychologist in primary care. Professional Psychology: Research and Practice 2002;33:65-72. Vogel M, Kirkpatrick H, Fimiani M. Integrated training and practice in primary care: Postdoctoral psychology fellowship and medical residency training partnership at Genesys Regional Medical Center in Grand Blanc, Michigan. The Register Report. Fall 2008. Stucky K, Chew C, McIntosh S. The Integration of Psychology Services at Hurley Medical Center in Flint, Michigan: The Benefits of Parallel Training for Physicians and Psychologists. The Register Report. Fall 2008. Retrieved March 19, 2013 from http://www.nationalregister.org/integrated_hc_stucky.htmlTRR Cubic B, Gatewood E. ACGME Core Competencies: Helpful information for psychologists. Journal of Clinical Psychology in Medical Settings 2008;15(1):28-39. Garcia-Shelton L, Vogel M. Primary care health psychology training: A collaborative model with family practice. Professional Psychology: Research and Practice 2002; 33:546-556. Elder W. Practicing integrated healthcare in a primary care setting: University of Kentucky Department of Family and Community Medicine. The Register Report. 2008 Fall. Smith P, Crockett K. Health psychology in primary care: Postdoctoral fellowship training at the University of Mississippi Medical Center. The Register Report. 2008 Fall. American Psychological Association. Education and training for psychology practice in primary care, 2013. Retrieved March 19, 2013 from http://www.apa.org/ed/ graduate/primary-care-psycholog.aspx
Direct reprint requests to: Nancy Breen Ruddy 70 Pollard Rd. Mountain Lakes, NJ 07046 e-mail: [email protected]
WIN/WIN: CREATING COLLABORATIVE TRAINING OPPORTUNITIES FOR BEHAVIORAL HEALTH PROVIDERS WITHIN FAMILY MEDICINE RESIDENCY PROGRAMS*
NANCY BREEN RUDDY, PHD Mountainside Family Practice Residency, Verona, New Jersey DOROTHY BORRESEN, PHD, APN, PMHNP-BC UMDNJ-RWJ Medical School, Trenton, New Jersey LINDA MYERHOLTZ, PHD Mercy Health Partners Family Medicine Residency Program, Toledo, Ohio
ABSTRACT
Integrating behavioral health into primary healthcare offers multiple advantages for patients and health professionals. This model requires a new skill set for all healthcare professionals that is not emphasized in current educational models. The new skills include interprofessional team-based care competencies and expanded patient care competencies. Health professionals must learn new ways to efficiently and effectively address health behavior change, and manage behavioral health issues such as depression and anxiety. Learning environments that co-train mental health and primary care professionals facilitate acquisition of both teamwork and patient care competencies for mental health and primary care professional trainees. Family Medicine Residency programs provide an excellent opportunity for co-training. This *Financial support for the collaborative care training program was provided by the Wayne State University Department of Family Medicine and Public Health Sciences. Manuscript based on material presented at the 33rd Annual Forum for Behavioral Science Education in Family Medicine, 2012. 367 Ó 2013, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/PM.45.4.g http://baywood.com
368 / RUDDY, BORRESEN AND MYERHOLTZ
article serves as a “how to” guide for residency programs interested in developing a co-training program. Necessary steps to establish and maintain a program are reviewed, as well as goals and objectives for a co-training curriculum and strategies to overcome barriers and challenges in co-training models. (Int’l. J. Psychiatry in Medicine 2013;45:367-376)
Key Words: interdisciplinary training, integrated primary care, training
CONCEPTUAL BACKGROUND Family Medicine educators must prepare trainees to function in a quickly changing and uncertain healthcare delivery system. While nothing is certain, the Patient Centered Medical Home model likely will be a defining feature of primary care. Many provisions of the Affordable Care Act support this transformation [1]. The Patient Centered Medical Home is a model of primary healthcare that emphasizes an ongoing relationship between a primary care medical provider and a patient. The primary care provider’s role is to support the patient in managing his or her own health and to ensure that medical care is coordinated across providers. The model recognizes that medical care is best provided by teams of professionals in which each professional’s relevant expertise is utilized to optimize care for the patient [2]. This model requires skills that are not emphasized in current educational models. The new skills include interprofessional team-based care competencies and expanded patient care competencies to effectively address health behavior change and behavioral health issues such as depression and anxiety [2, 3]. These skills are included in Accreditation Council for Graduate Medical Education (ACGME) Competencies for Family Medicine Residents and are reflected in the Family Medicine Milestones Project [4, 5]. Currently, healthcare training is separated by disciplines and programs rarely “cross fertilized.” Educational silos are starting to erode as educators recognize that cross-discipline training facilitates collaborative healthcare efforts and enhance patient care. The Interprofessional Educational Collaborative (IEC) convened an expert panel of educators representing dentistry, nursing, medicine, pharmacy, and public health to collaboratively compile interprofessional competencies for healthcare professional education. They released a report emphasizing that healthcare professional training models need to be expanded to include “team-based competencies.” These fell into four core competency domains: Interprofessional Ethics, Understanding Professional Roles and Responsibilities, Interprofessional Communication Skills, and Team and Teamwork Competencies [6]. It is notable that educators from the mental health disciplines were absent from this dialogue. The traditional schism between the medical and mental health
INTEGRATED BEHAVIORAL HEALTH TRAINING /
369
treatment delivery systems is paralleled in the educational systems. This is unfortunate given the critical role that behavior and mental health play in PCMH initiatives [7]. The panel’s recommendations for cross-disciplinary education can, and should, be generalized to include mental health professionals. One strategy is to create co-training opportunities for mental health and medical trainees. Beyond addressing cross disciplinary team competencies, co-training mental health and medical trainees also exposes trainees to the integration of behavioral health services into primary care. Integrated Primary Care is not new, but only recently has been adopted more widely by public health services, and health services offered through the Department of Defense and the Veterans’ Administration and Federally Qualified Health Centers [8]. This model of integrated healthcare delivery requires a new skill set for healthcare professionals. Table 1 provides an outline of proposed competencies for the practice of integrated primary care [9].
CURRICULUM DEVELOPMENT Pioneers in Integrated Primary Care have trained mental health professionals in a primary care for decades, often in Family Medicine residencies [10, 11]. Family Medicine residencies were excellent breeding ground for co-training because they already house both medical and mental health faculty, and most espouse the biopsychosocial model of patient care.
Table 1. Integrated Primary Care Competencies [9] Behavioral and developmental aspects of health and illness Biological and cognitive components of health and illness Sociocultural components of health and illness Common primary care problems Assessment and intervention in primary care Interprofessional collaboration in primary care Ethical, legal, and professional issues in primary care
370 / RUDDY, BORRESEN AND MYERHOLTZ
Only recently has there been a push to generalize this model by engaging professional organizations and training communities across disciplines to raise awareness of the integrated care model and its benefits for preparing professionals to work as part of a team, and to optimize patient care regarding health behaviors and behavioral health issues. Both Family Medicine and mental health faculty recognize the “win-win” nature of co-training, but need assistance to make necessary cross-discipline connections and to develop necessary curriculum and clinical experiences to achieve this end. In the remainder of this article we outline recommended steps to establish co-training opportunities for behavioral health trainees within Family Medicine residency programs. CURRICULUM GOALS AND OBJECTIVES The overarching goal of the curriculum is to promote integrated behavioral health services in primary care. The curricular innovation is aimed at both faculty and trainees. There are two stages of curriculum. The first focuses on preparation prior to placing a trainee in a family medicine residency, and the second focuses on the initial phases of the placement and ongoing maintenance training. Prior to Beginning Co-training Clinical Placement The curriculum initially focuses on faculty development aimed at increasing awareness of the integrated primary care model and its benefits for training and patient care. The learning objectives for medical faculty include: 1. to differentiate integrated primary care from typical care; 2. to understand how a co-training model supports a culture of a biopsychosocial approach to care and enhances resident learning regarding behavioral health; 3. to become aware of the preponderance of mental health issues in primary care; 4. to understand the links between mental health issues, behavioral choices, and health outcomes, particularly for patients with chronic medical conditions; and 5. to be able to integrate discussions of the above issues and use of the integrated care model into supervision of residents at different levels of training and readiness. The learning objectives for faculty in mental health training programs are: 1. to become familiar with primary care-based mental health issues; 2. to become familiar with primary care medical culture, and how mental health professionals function differently in a medical setting; 3. to be able to differentiate integrated care models from typical care;
INTEGRATED BEHAVIORAL HEALTH TRAINING /
371
4. to understand how integrated care models improve access to care, preventative mental health, health behaviors, and patient and provider satisfaction; and 5. to become aware of the knowledge, skills and attitudes that trainees need to be successful in a primary care setting. Prior to placing a mental health trainee in a primary care setting, it is important that medical providers and staff undergo training to prepare them to work with the trainee optimally. Learning objectives for medical trainees, providers, and staff include: 1, to be able to define and promote the integrated primary care model; 2. to enhance providers’ ability to identify clinical situations that might benefit from integrated primary care; 3. to learn strategies to optimize chronic disease management using integrated primary care; 4. to increase comfort with the biopsychosocial nature of all clinical encounters; and 5. to instill team-based competencies. Both mental health and medical trainees are likely to have a set “schema” of mental health services based on traditional psychotherapy. In a traditional model, the medical provider must discern that the patient would benefit from mental health services, and then refer the patient to the mental health provider who provides psychotherapy. In contrast, in an integrated model the mental health professional helps identify patients in need of intervention, and intervenes collaboratively with the medical provider. These interventions generally are quite brief and very different than traditional mental health services. In order to avoid replicating the “traditional model,” trainees must learn how integrated services differ from the traditional referral model, how to describe the model to patients, and their role in an integrated system. It is helpful to give “scripts” for discussing integrated care with patients, and to use case-based examples and case conferences. In addition, supervisors must be attuned to trainee’s tendency to “drift” toward the standard model because it is a relative comfort zone for them. These strategies help identify patients who might benefit from integrated care, and how such care can alter the course of treatment.
CURRICULUM FOR MENTAL HEALTH TRAINEES Curriculum for mental health trainees generally starts with simple exposure to the integrated care model. This can occur as a lecture series within a course or a colloquium series. Lectures both educate about primary care behavioral health and facilitate recruitment of students whose interests and personality are a good
372 / RUDDY, BORRESEN AND MYERHOLTZ
fit to primary care. Learning objectives from this brief curriculum would be at the exposure level regarding: 1. defining and promoting the integrated primary care model, emphasizing the role of the mental health professional in an integrated setting; 2. content information about the interplay of behavior and health, preponderance of mental health issues in primary care, common primary care medical and mental health presentations; 3. awareness of non-traditional brief mental health and health behavior interventions; and 4. review of the chronic disease management model, and readiness to change models. In general, the family medicine behavioral health faculty member who will serve as the supervisor should deliver the introductory curriculum. In most cases the supervisor must be from the same discipline as trainees. The implementation of a dialogue about hosting a trainee and of the exposure curriculum should begin 9-12 months before the clinical experience to start. This allows both programs time to create the necessary infrastructure. In addition, since many mental health training programs determine clinical placements 6 to 9 months before the beginning of the academic year, this timeframe includes extra time for this type of recruitment cycle. Overcoming Barriers and Challenges to Co-Training Creating interest and mutual understanding amongst medical and mental health faculty, students, and staff is only the first step to creating a clinical experience for the mental health trainee in primary care. There are numerous logistical and resource issues that must be managed, as well. The residency and mental health training program must have an institutional agreement. Many residencies already have institutional agreements with other training institutions from which they host trainees (e.g., medical schools, nursing schools, etc.). The agreement must be reviewed and approved by each institution’s legal counsel, and renewed over time. There are numerous resource issues. The hosting program must ensure adequate space and support staff for the trainee. Support staff’s role for the trainee’s clinical work should be clarified. The behavioral health faculty and program director should clarify the amount of time necessary in the faculty’s schedule for orientation of the new student, didactics, and ongoing supervision. If the trainee is to be paid for the services provided, the program must create a budget for the position. The program also must determine if patients will be billed for clinical services conducted by the trainee, and how to ensure that billing is appropriate and reimbursable. Crisis management strategies should be outlined. The trainee must complete all occupational health and credentialing processes
INTEGRATED BEHAVIORAL HEALTH TRAINING /
373
before starting the experience. The faculty should review residents’ educational offerings to determine which would be helpful for the mental health trainee, and to ensure that the trainee has opportunities to interact with residents in a variety of settings. Finally, the program must address documentation issues, and ensure that the trainee has appropriate access and training to electronic medical records. Curriculum Goals and Objectives during Co-Training As outlined, a great deal of planning, educating, and negotiating must occur before a mental health trainee can be placed into a Family Medicine Residency for training. The steps outlined thus far are necessary but not sufficient for the success of a co-training program. This section will outline the ongoing efforts required after the mental health trainee starts the clinical training experience in the primary care setting. To begin, the mental health trainees must be oriented to the primary care setting in the first weeks of the experience, ideally before they begin to provide clinical services. It can be very helpful for them to shadow medical support staff and medical providers at different levels of training and expertise. This helps them learn the role of each member of the team, and become more familiar with the logistics of the primary care office. The trainee also needs to learn how to use the electronic health record, and how documentation in primary care is different than in a traditional mental health system. If the trainee is billing for services, coding and billing issues also must be reviewed. During this time, the trainee should be provided with readings and guidance regarding their new role, with specific focus on the following learning objectives: 1. identify collaboration opportunities with residents and other medical profession in order to provide integrative patient care; 2. conduct chart reviews and other screening mechanisms to determine which patients might benefit from the integrated model; and 3. engage in a medical case review process and precepting interactions to learn from clinical presentations, and facilitate biopsychosocial care. Specific skills that should be a focus of early training and supervision are outlined in Table 2. Most of these skills can be developed through clinical experience, modeling by the faculty, and through clinical supervision. Faculty should monitor the clinical case mix of the trainee to ensure that it is varied and appropriate to the trainee’s interests and skill level. Also, since mental health trainees’ “comfort zones” may be in more traditional psychotherapy modalities, the supervisor should ensure that these modalities do not “take over” the trainee’s schedule. In addition to reviewing specific clinical presentations and encounters, supervision should include a discussion of consultation and collaboration skills to help trainees develop interprofessional team competencies. The supervisor also should monitor the mental health trainee’s interactions with the medical trainees.
374 / RUDDY, BORRESEN AND MYERHOLTZ
Table 2. Clinical Skills for Primary Care Mental Health Trainees o Warm Handoff
o Single Session Work
o Consultation
o Medical/MH Culture Differences
o Crisis Management
o Motivational Interviewing
o Screening/Assessment
o Common Primary Care Problems
o Substance Abuse
o Collaboration/educating residents
o Medication Consults
o Managing Pt/Provider Conflict
o Brief Interventions
o Group Medical Appointments
This allows the supervisor to help the trainees optimize their interprofessional collaboration skill set, and give feedback regarding their skills. Optimally, the mental health trainee will become part of the training program and be treated as an equal colleague with the medical trainees. To facilitate this camaraderie, mental health trainees should spend as much time as possible in common areas with medical trainees. Simple socialization breaks down barriers between disciplines. Trainees develop an understanding of the rigors of training outside their own specialty, and may have increased empathy for the challenges of training in other disciplines. The mental health trainee should attend educational activities that are relevant to their duties, as this creates further opportunities for interaction and shared experiences. Ideally, the mental health trainee should develop and implement some training for the medical trainees, either via shared case conferences, problem-based learning modules, or didactic presentations. Supervisors should attend to the trainee’s experiences creating cross-discipline connections and coach the trainee as needed.
PERFORMANCE TO DATE Outcomes data regarding integrated training models is still needed. There is some initial data indicating changes in attitudes about patient care, behavioral issues, and mental health in programs with integrated training models. A survey of family practice residents who co-trained with psychologists revealed that they felt the experience helped them improve their communication skills, positively impacted team dynamics to improve patient care, and increased their understanding of and ability to work with individuals from different professions [12]. More systematic information is needed about impact of integrated training models on behavioral health trainees and medical residents as well as the impact on overall patient care and satisfaction.
INTEGRATED BEHAVIORAL HEALTH TRAINING /
375
GENERALIZATION There are several family medicine residency programs that are currently providing integrated training opportunities for behavioral health providers [10, 12-15]. In addition, there are multiple opportunities for psychologists to receive predoctoral, internship, and postdoctoral training in primary care psychology. The American Psychological Association Education Directorate has recently released on-line directories of these opportunities (http://www.apa.org/ed/ graduate/primary-care-psycholog.aspx) [16]. Reviews of these directories illustrate that co-training of mental health and medical professionals in primary care, particularly Family Medicine, is growing. Currently there are 18 doctoral psychology programs that list primary care-based co-training in academic health centers. There are over 200 internships and post-doctoral programs that offer training for psychologists in primary care, many in the Veterans Administration and Federally Qualified Healthcare systems. Below is a listing of additional resources to facilitate the implementation of an integrated training model: • Integrated Primary Care—integratedprimarycare.com • Patient Centered Primary Care Collaborative—http://www.pcpcc.net • The Collaborative Family Healthcare Association (CFHA)—http://www. cfha.net/ • SAMHSA-HRSA Center for Integrated health Solutions: integration.samhsa. gov • Integrated Behavioral Health Care Project—http://www.ibhp.org REFERENCES 1. Community health centers and the affordable care act. Increasing access to affordable, cost effective, high quality care, 2011. Retrieved March 19, 2013 from http://www. healthcare.gov/news/factsheets/2010/08 increasing-access.html 2. Patient Centered Primary Care Collaborative. Joint principles of the patient-centered medical home. Retrieved March 19, 2013 from http://www.pcpcc.net/joint-principles 3. Croghan TW, Brown JD. Integrating mental health treatment into the patient centered medical home. Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO2. AHRQ Publication No. 10-0084-EF. Rockville, MD: Agency for Healthcare Research and Quality, June 2010. 4. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine, 2011. Retrieved March 19, 2013 from http://www.acgme.org/acgmeweb/Portals/0/PFAssets/Program Requirements/120pr07012007.pdf 5. Accreditation Council for Graduate Medical Education. The next accreditation system, 2012. Retrieved March 19, 2013 from http://www.acgme-nas.org/index.html 6. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel, 2011. Washington, DC:
376 / RUDDY, BORRESEN AND MYERHOLTZ
7.
8.
9.
10.
11.
12. 13.
14.
15.
16.
Interprofessional Education Collaborative. Retrieved March 19, 2013 from http:// www.aacp.org/resources/education/Documents/10-242IPECFullReportfinal.pdf DeGruy FV, Etz RS. Attending to the whole person in the patient-centered medical home: The case for incorporating mental healthcare, substance abuse care, and health behavior change. Families, Systems, and Health 2010;28:298-307. Substance Abuse and Mental Health Services Administration (SAMHSA) Federal Partners Senior Workgroup on Mental Health Transformation Integration of Primary Care and Mental Health Workgroup. Compendium of primary care and mental health integration across various participating federal agencies, 2008. Retrieved March 19, 2013 from http://www.samsha.gov/Matrix/MHST/Compendium_Mental %20Health.pdf McDaniel SH, Hargrove DS, Belar CD, Schroeder C, Freeman EL. A training curriculum for professional psychologist in primary care. Professional Psychology: Research and Practice 2002;33:65-72. Vogel M, Kirkpatrick H, Fimiani M. Integrated training and practice in primary care: Postdoctoral psychology fellowship and medical residency training partnership at Genesys Regional Medical Center in Grand Blanc, Michigan. The Register Report. Fall 2008. Stucky K, Chew C, McIntosh S. The Integration of Psychology Services at Hurley Medical Center in Flint, Michigan: The Benefits of Parallel Training for Physicians and Psychologists. The Register Report. Fall 2008. Retrieved March 19, 2013 from http://www.nationalregister.org/integrated_hc_stucky.htmlTRR Cubic B, Gatewood E. ACGME Core Competencies: Helpful information for psychologists. Journal of Clinical Psychology in Medical Settings 2008;15(1):28-39. Garcia-Shelton L, Vogel M. Primary care health psychology training: A collaborative model with family practice. Professional Psychology: Research and Practice 2002; 33:546-556. Elder W. Practicing integrated healthcare in a primary care setting: University of Kentucky Department of Family and Community Medicine. The Register Report. 2008 Fall. Smith P, Crockett K. Health psychology in primary care: Postdoctoral fellowship training at the University of Mississippi Medical Center. The Register Report. 2008 Fall. American Psychological Association. Education and training for psychology practice in primary care, 2013. Retrieved March 19, 2013 from http://www.apa.org/ed/ graduate/primary-care-psycholog.aspx
Direct reprint requests to: Nancy Breen Ruddy 70 Pollard Rd. Mountain Lakes, NJ 07046 e-mail: [email protected]
