Keys to making integrated care work

Integrated-care models improve access to treatment when they include three elements: brief psychological interventions, strong communications with local health-care providers and "one-stop" health care, said speakers at an APA 2011 Annual Convention session on integrated care.

"Having everything happen in one place is really critical, and can increase patient satisfaction and coordination of care," said Patricia Arean, PhD, a professor at University of California, San Francisco.

The models of care highlighted at the session were:

Chase Brexton Health Services, Baltimore. When this federally qualified health center opened its first clinic in 1978, it helped mostly gay patients cope with HIV/AIDS and make end-of-life decisions, said staff psychologist Robin Mullican, PsyD. Now, its four clinics provide "one-stop" health care, including primary care, HIV specialty care, dental care, behavioral health services, case management and pharmacy services to nearly 20,000 patients annually.

In a program launched last year, psychologists team with providers in the medical clinic, offering behavioral health services to patients as an integral part of the primary-care visit. Primary-care providers "handoff" patients to psychologists to be seen in the exam rooms immediately after their medical appointments. Psychologists assess for co-occurring mental health and addictions issues, and work with patients to help motivate healthy behaviors and address obstacles to adherence and self-care, she said.

University of Alabama's Interdisciplinary Behavioral Healthcare Team. Once a week between 2008 and 2010, as many as 10 University of Alabama doctoral clinical psychology students, nurses, social workers, social work students and rural medical scholars climbed in an R.V. and drove to provide care to rural residents and seniors in western Alabama's "Black Belt." Often the seniors there have multiple chronic health conditions, such as diabetes, hypertension and depression and lack access to mental health professionals, said geriatric psychology student Latrice Vinson. "Depression goes unrecognized, and when it is recognized, it may go untreated, due to a lack of psychological services," she said.

The R.V. parked at grocery stores, churches and senior centers to provide free checkups, including blood-pressure screening, as well as tests for HIV and glucose and cholesterol levels. In 2008–09, the team performed 2,056 health screenings; 88 percent of the tests screened positive for hypertension or its precursor, she said. A nurse gave patients their results, educated them about the dangers of untreated hypertension and recommended a local physician for follow-up treatment.

Molokai Community Health Center, Hawaii. This federally qualified health center provides sliding-fee scale, low-cost health care to the island's 7,400 residents, almost a quarter of whom live in poverty. Almost half of patients seen at the center have co-morbid chronic physical diseases, said Darryl Salvador, PsyD, who served as the center's behavioral health director from 2006 to earlier this year.

Salvador said psychology can be successfully integrated into primary-care settings when practitioners help run the center as members of its executive management team. Success also requires consulting with physicians, being accessible, readily available and figuring out how you can help your fellow health-care providers and patients, Salvador said.

"Talk with the primary-care providers about how you can help with their patients, be a team player and remember that we're there for the patients," he said.

UCSF HEARTS (Healthy Environments and Response to Trauma in Schools). Located in three San Francisco public schools, this program helps traumatized children by encouraging teachers to guide them away from behavioral blowups using empathy and skill-building instead of harsh punishment, said Joyce Dorado, PhD, project director and associate clinical psychology professor at University of California, San Francisco.

Children traumatized by family and community violence often get in trouble with their teachers when a non-threatening event—such as a schoolmate accidentally jostling them when they're already agitated—causes a "fight, flight or freeze" reaction in the classroom. To prevent blowups, for example, teachers can notice when children are becoming stressed and pre-emptively have them do a soothing activity to calm down, she said.

Preliminary results indicate school staff are using more trauma-sensitive skills, and reporting a decrease in discipline referrals to school principals, Dorado said. "You need to understand and adjust to school culture and language, and build collaborative relationships that respect the expertise and strength of educators," she said.

Indian Health Service/Office of Clinical and Preventive Services. The Indian Health Service started introducing an intervention called the Alcohol Screening and Brief Intervention at its 45 hospitals and 480 clinics nationwide in 2007. The intervention intercepts young adults and teens who have come to an emergency room or primary-care clinic with an alcohol-related injury stemming from incidents such as motor vehicle accidents, said Rose Weahkee, PhD, who directs the IHS Division of Behavioral Health.

The intervention follows the "brief negotiated interview" developed at Yale University. It consists of an alcohol screening, brief feedback and motivational interviewing, during which the provider helps the patient make the connection between their alcohol use and the injury that's brought them in for treatment. If a patient expresses a willingness to change his or her behavior, the provider helps work out a plan for change, with the goal of reducing drinking.

According to David Boyd, MD, national trauma systems coordinator for IHS Emergency Services, the intervention has reduced injury-related emergency room readmissions up to 50 percent for several years, Weahkee said.