Feature

A refugee from Burundi sees a physician at Cherokee Health Systems in Knoxville, Tenn., for pain in her stomach and arms. The physician finds nothing physically wrong, so she calls in a psychologist stationed steps away. After interviewing the woman, the psychologist learns she's endured genocide-related trauma in Burundi. Over the next few months, the psychologist works with the woman to treat her traumatic stress until her symptoms resolve.

If a psychologist had not been located in the same primary-care clinic, this woman would likely never have received psychological services, says psychologist Parinda Khatri, PhD, Cherokee's director of integrated care. That's why the network of community health centers uses an interdisciplinary teamwork model for its services to underserved people, offering social workers, psychologists, pharmacists, cardiologists and physical therapists all in the same place.

"This model is nothing new, but it's being driven by the growing body of robust literature showing benefits of simultaneously addressing physical and behavioral health — in heart disease, for example, psychological factors affect physical factors and vice versa," says Khatri.

Health-care reform is also pushing the interprofessional team model to the fore with its focus on patient-centered and community/population-focused care, safety, quality and outcomes, says Catherine Grus, PhD, APA's deputy executive director for education. The movement has taken solid root in academic and community health primary care and is spreading to private settings, say industry observers.

But do psychologists have the skills needed for interprofessional practice? It depends. Some doctoral, internship and postdoctoral psychology programs are set up to provide such preparation, and other programs in psychology and other disciplines are working to adopt more of it, says Grus. A national effort to encourage more interprofessional education recently bore fruit with the launch of a new Web-based resource portal, she adds.

In addition, a directory of education and training programs offering training in primary care, an APA strategic plan initiative, has been completed. Meanwhile, a growing trove of competency-building guidance is catering to practitioners already in the field — one recently published report spans the health disciplines and another soon-to-be-published one targets psychologists in primary care.

A rise of resources

While most psychologists understand the importance of multi-disciplinary teamwork, many were trained in an era when professionals never uttered the phrase. In an effort to reach beyond training only students in interdisciplinary work and guide these practicing professionals as well, organizations across the country are compiling research-backed resources. Here's a look at a few:

  • A report from the Interprofessional Education Collaborative lays out core competencies for interprofessional practice needed across the health professions. In February, APA's Council of Representatives voted to endorse the competencies in the report.
  • IPEC-MedEdPortal, also launched by the Interprofessional Education Collaborative (APA is a member of the advisory committee), offers interprofessional resources to education and training programs.
  • A report that articulates interprofessional teamwork competencies for psychologists in primary care, produced by a working group convened by APA Past President Suzanne Bennett Johnson, PhD, is under review for publication by APA. The guide is a starting point for skill development, says working group chair Susan McDaniel, PhD, associate chair of the University of Rochester Medical Center's department of family medicine. Among other areas, it covers leadership coaching for physicians, 15-minute behavioral consultations, student training and improvement projects for primary-care teams.

Continuing-education sessions, such as ones offered at APA's Annual Convention, can also provide key interdisciplinary team guidance, says McDaniel.

Psychologists who want to work on interdisciplinary primary-care teams need to prepare for frontline delivery of services to large populations, according to McDaniel. "It really requires you to think across mental health and health care," she says. "Rather than being an independent provider, you are part of a team delivering services."

Serving on these teams requires flexibility because models of collaboration and financial compensation vary, says Alan Delamater, PhD, director of clinical psychology at the Mailman Center for Child Development at the University of Miami Miller School of Medicine, who is known for his expertise in integrative care. At his center, outpatients start by seeing a physician, who calls in a psychologist as needed. When patients need ongoing psychological services — as do many of the clinic's young clients with diabetes — they often book multiple back-to-back appointments with the psychologist and other providers. Some of the patients are privately insured. Others' behavioral health services are covered through a contract with Children's Medical Services, a Florida state program for children from low-income families.

At present, most integrated services are funded in the traditional fee-for-service manner, says Delamater. But not all are. For example, the state of Florida prepays the Mailman Center for psychological services provided through the Children's Medical Services contract. Various types of prepaid and bundled-services models are being piloted across the country.

Payment model aside, "What stays the same is that you have on-the-spot consultation with the psychologist, and that's the beauty of the integrated team," says Delamater. "Because if you refer people out, they often don't follow through. Having us there in the clinic, we're normalized and the stigma goes away. And it gives us the opportunity to screen and be preventive."

Needed skills

What also stay the same, says Delamater, are the skills needed to deliver services collaboratively. As he related in a presentation at APA's 2012 Annual Convention, he's found that for psychologists to work well on such teams, they need to:

  • Understand disease. The psychologist needs to know more than a disease's physiological effects — he or she needs to be fluent in tests, labs and values, says Delamater. "You need to really speak the language of that illness," he says. "Because if you don't, you lose credibility, and nobody will go to you. No. 1 is having the confidence of patients and your colleagues."
  • Be visible and responsive. Psychologists need to be in the clinic walking the halls, not sitting in the office waiting for their phones to ring, says Delamater. That way, he says, people get accustomed to your input and miss it if you're not around. "It's also important to attend team meetings where everyone reviews the patients being seen," he says. "You need that face time so everybody recognizes what you bring."
  • Communicate concisely. Physicians and other providers are busy with clinical demands, so they need you to quickly describe the problem. "If we write a 10-page report, they will not read that report," Delamater says. "They just want conclusions and recommendations. Tell it simply and get to the punch line." He also suggests psychologists share notes with other providers in the same electronic charts, at least to the extent that this does not threaten confidentiality of sensitive issues.
  • Teach and train. With their disciplinary knowledge of what makes teams work, psychologists can help teams resolve conflicts and coach team leaders, says Delamater. They can also advance other team members' understanding of what behavioral health providers contribute by sharing articles and research findings and offering seminars for other health professionals, he says.
  • Promote informal bonding. As psychologists know, informal interpersonal relations are the social glue of teams, so it's well worth making time for small talk, lunches, happy hours and other relationship-building activities, says Delamater.
  • Respect their team members. "You don't tell each other what to do. You inform and ask what each other's opinions are," says Larry Mauksch, MEd, past chair of the Collaborative Family Health Care Association, co-editor of the APA journal Families, Systems, & Health, and a senior lecturer in the University of Washington's department of family medicine. "You share concerns, ask questions. You brainstorm to problem-solve when you come across difficult situations. So there's a sense of shared responsibility that takes over. And the guild mentality, the silo kind of functioning, goes away."

Khatri says this is how treatment delivery works at Cherokee Health Systems, where she and colleagues catch and treat the range of behavioral health issues — including depression, anxiety and substance use — that may underlie many physical maladies. "The fact is we're much better able to meet treatment goals when we work on functioning teams as opposed to alone in silos," she says.

Bridget Murray Law is a writer in Silver Spring, Md.

Further reading

  • Auxier, A., Farley, T., & Seifert, K. (2011). Establishing an integrated care practice in a community health center. Professional Psychology: Research and Practice, 42, 391–397.

  • Blount, A., et al. (2007). The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research and Practice, 38, 290–297.

  • 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: APA.

  • Katon, W., Roy-Byrne, P., Russo, J., & Cowley, D. (2002). Cost Effectiveness and Cost Offset of a Collaborative Care Intervention for Primary Care Patients with Panic Disorder. Archives of General Psychiatry, 59, 1098–1104.

  • Melek, S.P. (2012) Bending the Medicaid healthcare cost curve through financially sustainable medical behavioral integration. Retrieved from http://publications.milliman.com/publications/health-published/pdfs/bending-medicaid-cost-curve.pdf

  • Pyne, J.M.,et al. (2003). Cost-effectiveness of a primary care depression intervention. Journal of General Internal Medicine, 18, 432–441.