Supervising Behavioral Health Services in Integrated Primary Care Session # I4B October 29, 2011 10:30 AM Supervising Behavioral Health Services in Integrated Primary Care Kevin M. McKay, Ph.D. Staff Psychologist / Clinical Assistant Professor The Miriam Hospital / Brown University, Alpert Medical School Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Collaborative Family Healthcare Association 12th Annual Conference

Faculty Disclosure I have not had any relevant financial relationships during the past 12 months. This should match your response on the Faculty Disclosure form from CE Central Collaborative Family Healthcare Association 12th Annual Conference

Need/Practice Gap & Supporting Resources Competent primary care psychologists are in demand and high quality training and supervision will help ensure an adequate supply. What is the scientific basis for this talk? Collaborative Family Healthcare Association 12th Annual Conference

Objectives This presentation will suggest that the unique culture of integrated primary care requires an innovative approach to supervision and propose that a model advanced by our physician‐colleagues (“The Five-Step Microskill Model”) may be a viable option. Collaborative Family Healthcare Association 12th Annual Conference

Expected Outcomes Upon completion of this presentation, participants will… …be able to use statistical reasoning to discuss the advantages/disadvantages of primary care/behavioral health integration. …be able to deduce that the demand for competent primary care psychologists will soon outweigh the existing supply. …have a working definition of competent practice in integrated primary care. …be conversant with regards to existing models of academic training and clinical supervision. …have an appreciation of the unique culture of primary care and the way in which it may be advantageous for supervisors to be innovative with their approach to training. …be familiar with the five steps included in “The Five-Step Microskills Model of Clinical Teaching” and the empirical evidence supporting the efficiency and effectiveness thereof. What do you plan for this talk to change in the participant’s practice? Collaborative Family Healthcare Association 12th Annual Conference

Why Are We Integrating? (Some Familiar Statistics) “Seven Good Reasons for Integrating Mental Health Into Primary Care” The burden of mental disorders is great. Mental and physical health problems are interwoven. The treatment gap for mental disorders is enormous. Primary care settings for mental health services enhance access. Delivering mental health services in primary care settings reduces stigma and discrimination. Treating common mental disorders in primary care is cost effective. The majority of people with mental disorders treated in collaborative primary care have good outcomes. “Why Should Mental Health Problems Be Priorities in the Patient Centered Healthcare Home?” “Psychiatric Disorders are Only The Tip of The Iceberg” Numerous authors have provided statistics that illustrate the prevalence of mental health problems, particularly those problems presenting in primary care, and statistics suggesting that many patient with mental health problems receive inadequate care. Funk & Ivbijaro (2008) reviewed the international data and identified “Seven Good Reasons for Integrating Mental Health into Primary Care.” These reasons include: The burden of mental disorders is great The World Health Organization’s Mental Health Survey (2004) estimated that the one-year prevalence of mental disorders ranges from 4% to 26%, internationally. The prevalence of mental disorders among adults in primary care settings has ranged between 10% and 60%. Mental and physical health problems are interwoven. There is significant empirical evidence suggesting multidirectional links between mental and physical health and illness. The treatment gap for mental disorders is enormous. In high income countries, the gap between the prevalence of mental disorders and the number of people receiving care ranges from 32% (for schizophrenia and other psychotic disorders) to 78% (for alcohol abuse and dependence). In low- and middle-income countries, the treatment gap is likely to be much greater. Primary care for mental health enhances access. Primary care for mental health promotes respect of human rights. Mental health services delivered in primary care minimize stigma and discrimination because they are treated in the same way as people with other health conditions. Primary care for mental health is affordable and cost effective. Primary care for mental health generates good health outcomes. Croghan and Brown (2010) reviewed the national data and argued that mental health problems should be priorities in the Patient-Centered Health Care Home because: National studies estimate that during a 1-year period, up to 30 percent of the U.S. adult population meets criteria for one of more mental health problems. Empirical evidence suggests that mood and anxiety disorders are especially common among primary care patients. It is estimated that these disorders occur in approximately 20 to 25 percent of patients seen in clinics serving mixed-income populations and in as many as 50 percent of patients seen in clinics serving low-income patients. Mental health problems are 2 to 3 times more common in patients with chronic medical conditions. Approximately 28% of Americans experience a diagnosable psychaitric disorder in any give year, but 50% of this group receives no care at all. Of those that do, only about 50% (i.e. 14 % of Americans) get the care from a specialty mental health clinic. Most rely on other health care providers, especially primary care providers (PCPs). In keeping with these statistics, an overwhelming majority of prescriptions for psychotropic medications are written not by psychiatrists, but by non-psychiatric physicians. Mental health problems are typically under-identified and when they are identified treatment is typically “sub-optimal” and characterized by inadequate follow-up and monitoring. However, as outlined by Robinson and Reiter (2007), mental health problems are only “The Tip of The Iceberg” in primary care: 85% of the most common presenting problems (e.g. IBS, headaches, insomnia, chronic pain) can not be traced to an organic etiology. In addition, PCPs are PCPs are often confronted with issues such as somatization and “sub-threshold syndromes” (e.g. marital conflict, domestic violence, bereavement). Unhealthy behaviors are responsible for most of the top ten causes of mortality and morbidity (e.g. smoking, poor diet, lack of exercise, alcohol and drug use, seat belt/helmet use). Up to 70% of primary care appointments are for problems stemming from psychosocial issues. Since 80% of the population visit their PCP over the course of the year, psychologists are primed to improve the treatment of behavioral problems in primary care.

Demand for Primary Care Psychologists v Demand for Primary Care Psychologists v. Supply of Competent Practitioners ”Achieving psychology’s potential to contribute to primary care services for the public depends on the development of well-trained professionals” (McDaniel et al., 2002). “We see a need for addressing the looming workforce shortage as behavioral health services in primary care become more widely implemented” (Blount & Miller, 2009). “Training for BHPs who can work in primary care is woefully behind demand” (Blount et al., 2007). In other words, The Adoption of Collaborative Care IS Accelerating and WE ARE Reaching the Tipping Point. However, are we prepared to meet the demand for competent primary care psychologists? Since 80% of the population visit their PCP over the course of the year, psychologists are primed to improve the treatment of behavioral problems in primary care. Given these statistics and the movement towards developing Patient Centered Healthcare Homes, it is predicted that competent primary care psychologists will be in high demand. This was well-captured by McDaniel et al. (2002) when writing that ”Achieving psychology’s potential to contribute to primary care services for the public depends on the development of well-trained professionals.” Blount and Miller (2009) expressed a similar sentiment when they wrote “We see a need for addressing the looming workforce shortage as behavioral health services in primary care become more widely implemented.” Stated somewhat more emphatically, Blount et al. (2007) wrote “Training for BHPs who can work in primary care is woefully behind demand.” In other words, The Adoption of Collaborative Care IS Accelerating and WE ARE Reaching the Tipping Point. However, are we prepared to meet the demand for competent primary care psychologists? In order to answer the question as to whether we are prepared to meet the demand for competent primary care psychologists, we must fits define what a competent primary psychologist is.

Defining Competent Practice in Integrated Primary Care (Summary) In order to function as competent primary care psychologists, practitioners require foundational knowledge and skills in: General psychology Health psychology Effective interdisciplinary functioning In addition, practitioners require specific primary care mental health knowledge and skills: Knowledge of broad health care systems and administrative issues Specific assessment, intervention, and consultation skills appropriate for the primary care environment. These competencies can be thought of as “targets” of academic training and clinical supervision. While various models of competent practice have been advanced, three models stand out as exemplars – the APA Model, the McDaniel Model, and the Strosahl Model. Dobmeyer, Rown, Etherage, and Wilson (2003) summarized these models and suggested that in order to function as competent primary care psychologists, practitioners require foundational knowledge and skills in: General psychology Health psychology Biological, social, cultural, affective, and cognitive factor affecting health and disease. Effective interdisciplinary functioning In addition, practitioners require specific primary care mental health knowledge and skills: Knowledge of broad health care systems and administrative issues. Understanding hospital practices and economics of health care. Primary care policies and procedures. Ethical, legal, and professional issues relevant to practicing in the primary care setting. Specific assessment, intervention, and consultation skills appropriate for the primary care environment. Assessment and treatment of problems commonly seen in primary care. Allocation of time and resources. Practice management skills. Collaborative assessment and treatment. Behavioral health consultation skills. Taken collectively, these competencies can be thought of as “targets” of academic training and clinical supervision. Adapted from: Dobmeyer, Rowan, Etherage, & Wilson (2003)

Academic Training and Clinical Supervision for the Development of Competent Practitioners Several authors have described academic and clinical training models aimed at various levels of trainee development: Pre-doctoral academic training models (e.g. Talen, Fraser, & Cauley, 2005). Pre-doctoral practicum training models (e.g. Pisani, Berry, & Goldfarb, 2005). Pre-doctoral internship training models (e.g. Dobmeyer, Rowan, Eherage, & Wilson, 2003). Post-doctoral training models (e.g. Bray, 2004). Clinical supervision, wherein a licensed psychologist provides supervision to a psychologist-in-training is central to clinical training. However, to-date there have been few recommendations as to adopting the process of clinical supervision to the culture of integrated primary care. Academic training and clinical supervision are widely accepted as the “pathways” to competent practice as psychologists, generally, and primary care psychologists, in particular. Several authors have described academic and clinical training models aimed at various levels of trainee development: Pre-doctoral academic training models (e.g. Talen, Fraser, & Cauley, 2005). Pre-doctoral practicum training models (e.g. Pisani, Berry, & Goldfarb, 2005). Pre-doctoral internship training models (e.g. Dobmeyer, Rowan, Eherage, & Wilson, 2003). Post-doctoral training models (e.g. Bray, 2004). Clinical training models rely on various modalities (i.e. assigned reading, didactics, individualized discussion, group discussion, etc.). Clinical supervision, wherein a licensed psychologist provides supervision to a psychologist-in-training is central to clinical training. However, to-date there have been few recommendations as to the process of clinical supervision in integrated primary care.

The Culture of Primary Care and Clinical Supervision Cultural differences exist between primary care and traditional mental health. In order to adapt to the culture of primary care, it is recommended that psychologists: Speak the same language. Adopt the primary care pace. Provide brief, focused interventions to a large number of patients within the practice, rather than providing comprehensive care to the most severe cases. Ensure that your feedback to providers is succinct and prompt. Make recommendations that are brief, specific, and action-oriented. Familiarize yourself with the organizations that are important to the PCPs. Understand what resources PCPs use to get information, particularly about behavioral health concerns. Bray (1996) provided an overview regarding the cultural differences between primary care and traditional mental health. These include differences in the following domains: Theoretical orientation. Language. Practice style. Expectations for assessment and treatment. Adapted from: Bray (1996), Hunter, Goodie, Oordt, and Dobmeyer (2009)

The Culture of Primary Care and Clinical Supervision In order to provide training that is consistent with the culture of primary care, it is recommended that clinical supervisors be innovative in their provision of supervision. The “Five-Step Microskills Model of Clinical Teaching” (a.k.a. the “One-Minute Preceptor Model”) advanced by our physician-colleagues may be a viable option.

The Five-Step Microskills Model of Clinical Teaching Get a Commitment Objective: To help the supervisee process the information he or she has just collected concerning the patient. Sample Question: “What do you think is going on?” Probe for Supporting Evidence Objective: To understand the supervisee’s clinical reasoning and identify deficits in his or her knowledge base. Sample Question: “What factors did you consider in making that decision?”. Teach General Rules Objective: Teach one or more general rules which are targeted to the current case but generalize to similar cases. Samples: Summarize features of a diagnosis, management of a demanding patient, or effective use of consultation 4/5. Reinforce What Was Done Right / Correct Mistakes Objective: Reinforce effective behaviors and suggest behaviors that may be helpful in the future. Get a Commitment Objective: To help the supervisee process the information he or she has just collected concerning the patient. Sample Question: “What do you think is going on?” Probe for Supporting Evidence Objective: To understand the supervisee’s clinical reasoning and identify deficits in his or her knowledge base. Sample Question: “What factors did you consider in making that decision?”. Teach General Rules Objective: Teach one or more general rules which are targeted to the current case but generalize to similar cases. Samples: Summarize features of a diagnosis, management of a demanding patient, or effective use of consultation 4/5. Reinforce What Was Done Right / Correct Mistakes Objective: Reinforce effective behaviors and suggest behaviors that may be helpful in the future. A helpful question to ask at this point may be “What did you do well and what would you like to do better in the future? Adapted from: Neher, Gordon, Meyer, and Stevens (1992) and Neher and Stevens (2003)

The Five-Step Microskills Model of Clinical Teaching Evidence Supporting the Efficiency of The Five-Step Microskills Model in Family Medicine. Clinical teachers rated encounters as more efficient than traditional encounters.1 The duration of the teaching discussion was the same as traditional encounters, but preceptors spent more time listening to their students.2 Evidence Supporting the Effectiveness of The Five-Step Microskills Model in Family Medicine. Teachers more accurately diagnose the patient’s problem.1 Teachers are more confident in their evaluation of the learner.1, 2 Teachers are better able to encourage the learner to do independent learning and outside reading.2, 3 Teachers give learners higher quality feedback.2 Teachers give learners feedback more frequently.2, 3 Aargard, Teherani, & Irby (2004) Salerno et al. (2002) Furney et al. (2001)

Bringing it All Together Competent primary care psychologists are in demand and high quality training and supervision will help ensure an adequate supply. This presentation suggested that the unique culture of integrated primary care requires an innovative approach to supervision and proposed that a model advanced by our physician‐colleagues (“The Five-Step Microskill Model”) may be a viable option.

Questions & Answers

Session Evaluation Thank you! Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you! This should be the last slide of your presentation Collaborative Family Healthcare Association 12th Annual Conference