Gaining Psychology’s Participation in the National Health Service Corps and Federally Qualified Community Health Centers
In 1994 Education GRO staff, in collaboration with Practice Directorate Rural Health Committee (RHC) staff, launched an effort to gain psychologists’ access to the National Health Service Corps (NHSC) programs. Particular emphasis was given to the NHSC Loan Repayment and Scholarship Programs whereby psychologists would receive financial aid in exchange for working in a designated facility in an underserved rural or urban community. [The majority of the designated facilities are federally qualified health centers (FQHCs) and most of those are Community Health Centers (CHCs).] The initiative began with a meeting with NHSC officials in Senator Daniel Inouye’s (D-HI) office arranged by his Chief of Staff, APA Member Patrick DeLeon, PhD, JD.
Over the next twelve years Education GRO staff, with the assistance of Practice Rural Health Committee staff, extended the initiative to promote integrated health care at the FQHCs by including the hiring of psychologists and use of psychology interns. To accomplish this, a three part approach was utilized, with a focus on congressional action through authorizing legislation, appropriations and federal agency regulations. Because of the increased attention on the NHSC and its Loan Repayment Program in 1995 the Corps began to allow participation of mental and behavioral health professionals, including psychologists in the NHSC Loan Repayment Program. Since then the demand for psychological services has increased significantly. Of the 1,058 mental and behavioral health professionals serving in the NHSC in 2008, 471 or 45 % were psychologists. That being said most of the psychologists were not placed in Community Health Centers but in other facilities with Mental Health Professional Shortage designations including prisons. Moreover, as of 2009 there are 340 psychology vacancies in the NHSC Loan Repayment Program.
Expanding Efforts through Public Relations Campaign & Outreach
The Education GRO staff also worked with the Health Resources & Services Administration, which has oversight over the NHSC and FQHC programs, on a public relations campaign to promote integrated mental/behavioral health care services and describe what psychologists and other mental/behavioral health professionals do. APA also participated in the NHSC 25th anniversary conference, as well as annual conferences for its Ambassadors Program. As a result, the FQHC Program began a new focus on “depression collaboratives” and “chronic illness collaboratives,” which illustrated its increasing awareness of the need to address both mental and behavioral health issues in the populations served by CHCs.
Education GRO staff also reached out to the National Association of Community Health Centers (NACHC) to garner the support of its leadership to advance the use of integrated health care and increase the role of psychologists in CHCs. As a result APA members were invited by NACHC to attend their annual conference and provide an article in their newsletter. Education GRO staff also successfully advocated for $1 million FY 2000 appropriations, which was sponsored by Congressman Bill Young (R-FL), then Chair of the House Appropriations Committee. The $ 1 million supported regional meetings of key local and state stake holders in health care to underserved populations for the development of a plan to confront financial and other obstacles that prevented them from collaborating in the provision of mental/behavioral health services. The initial funding provided for 25 states. However, the effort was so successful that all 50 states requested and received funding to also develop a plan for providing mental/behavioral health services to their underserved communities.
Seeking Support from Congress and Federal Agencies
During this period of time there was one opportunity to influence the law governing these federal programs. In 2000 Congress began considering the reauthorization of both the NHSC and the FQHC programs. In 2002, President Bush signed the legislation, known as the Safety Net bill, into law. Education GRO staff succeeded in gaining specific statutory language for the inclusion of mental/behavioral health professionals and services in both the NHSC and the FQHC titles. In addition, a technical amendment was accepted that changed the term “clinical psychologist” to “health service psychologist” to allow for the eligibility of doctoral level counseling and school psychologists.
In a simultaneous effort, Education GRO staff began advocating for a revision of the designation that determined a Mental Health Professional Shortage Area (MHPSA) to ensure that underserved communities have access to mental/behavioral health professionals, including psychologists. The timing was right since the Office of Shortage Designation already had plans to revise the medical and dental designations, and thus adding mental health made sense. The University of North Carolina Shep Center, which lead the MHPSA project, completed the research for revising all three designations and the first, the medical definition, was published in the Federal Register for Comment. Unfortunately the final process of vetting the changes is arduous and time consuming; therefore, the mental health definition is still not public and most likely will not be for a number of years. Using the non-revised designation, according to the Office of Designation, there are currently over 3,700 Mental Health HPSAs nation wide. However, given that there are 6,1,00 Primary Care Medical HPSAs, there should be at least that same number of Mental Health HPSAs. Consequently, it is expected that the revision of the mental health designation criteria should more accurately depict the actual need and more closely resemble the primary care need.
Exploring New CHC State-based Initiative
In 2006, more than 10 years after the initiative began, it became clear there was significant progress with the NHSC but not enough with the Federally Qualified Health Centers (FQHC). With 7,000 sites nation,-wide the FQHC program is a $2.2 billion federal effort to provide health care to our nations’ uninsured and underinsured persons. Thus, after consultation with the Bureau of Primary Health Care, Education GRO focused on the federally supported Primary Care Associations (PCAs) that represent the CHCs in each state. Then, Education GRO, in collaboration with the California Psychology Association (CPA) and the Practice Rural Health Committee, reached out to the California PCA. As a result of this effort, the California PCA expressed a serious interest in working with CPA and APA to get more psychologists hired by California CHCs, and to explore the possibility of creating psychology internships as well.
Ironically, the California PCA had been resistant in the past about utilizing an integrated approach to health care, but was now focused on including mental and behavioral health at their CHCs and on their own had been working with the California legislature to remove barriers and facilitate the flow of funds for mental/behavioral health services at California’s CHCs. Clearly, the timing is right for this new and exciting initiative.
Special Meeting to Advance APA’s Integrated Health Care Initiative
On September 19th during the fall 2008 APA Consolidated Meetings in Washington, DC, the Education GRO and the Practice Directorate Committee on Rural Health (CHC) hosted an all-day meeting on the role of psychologists and trainees in FQHCs. Attending were key APA members with interest and expertise in rural health, integrated health care, and those in underserved communities represented by the Public Interest Directorate Socioeconomic Status Committee. Other invited guests included Gina Capra, a representative for the US Bureau of Primary Health Care (BPHC) in the Health Resources and Services Administration, and Michael Lardiere of the National Association of Community Health Centers (NACHC). Both spoke about the FQHC program and the efforts to address the mental and behavioral health needs of the underserved.
Dr. Newman and representatives of the California Central Valley FQHCs reported on efforts by community health centers in that state to employ psychologists. Parinda Khatri, PhD of the Cherokee Health Systems in Talbot, Tennessee presented on their integrated health care model, which includes medical, dental and mental health services, and on their psychology internship program. Dr. Kahtri noted that research provided by the Cherokee Health Systems illustrates that one of the benefits of integrated health care services is a significant decrease in medical utilization of Medicaid patients, including pediatric patients. Ben Miller, PsyD of the University of Massachusetts’ School of Medicine, shared information about his program's focus on integrated health care and its interdisciplinary approach to training, which uses an "integrated household" model that includes psychology interns, fellows and residents.
It also became apparent at the meeting that some of the attendees were Graduate Psychology Education (GPE) grantees, including Gilbert Newman, PhD, from The Wright Institute Berkeley, CA; Parinda Khatri, PhD from a FQHC in Talbot, Tennessee; and Michael Lardiere of NACHC who was associated with the Lutheran Medical Center in Brooklyn, New York when it had a GPE grant. Everyone noted that the interdisciplinary training required by the GPE grant is extremely worthwhile in preparing psychology students for work in integrated health care and the innumerable benefits that this approach provides for communities in need.
The goals of the meeting were to: 1) Learn what has worked to create positions for psychologists and psychology trainees in FQHCs; 2) create an action plan to translate lessons learned for use in CA and other states; and 3) build the foundation for a partnership among state, provincial and territorial psychological associations (SPTAs), state primary care associations, relevant federal agencies and national organizations, and the American Psychological Association to further the initiative.
The meeting concluded with a number of suggested recommendations, including:
Facilitating important data collection/analysis (e.g., tracking patients in a disease registry) by connecting graduate programs of psychology with FQHCs.
Learning more about the "medical home" model and work to get the term changed to "health care home".
Developing materials to educate FQHC administrators on the positive health outcomes of employing psychologists.
Sharing publications (e.g., APA Presidential Task Force's Blueprint for Change: Achieving Integrated Health Care for an Aging Population) with key players in the FQHC program at the federal, state and local levels.
Training psychology students (future clinical leaders) on integrated health care and teach them how to deal with such barriers as reimbursement and licensing issues.
Drafting talking points for use by psychologists willing to reach out to their state PCA.
Finally, participants also agreed to focus on a couple of states recommended by the BPHC where there is interest on the part of the Rural Health Coordinator, SPTAs, and the state PCA to work collaboratively on integrated health care that includes the utilization of psychologists and psychology trainees. Some candidate states include: New Mexico, Maine, and Missouri. Dr. Newman noted that in building collaborations with SPTAs we are also educating the broader profession of psychology about the emerging discipline of primary care psychology and the need for psychology to take a more active role in the future of health care reform.