Guidelines for Psychological Practice in Health Care Delivery Systems
Psychologists practice in an increasingly diverse range of health care delivery systems (HCDS). This diversification is due to widening recognition of psychology as a health profession (Belar, 2002; Brown, Freeman, Brown, Belar, Hersch, & Hornyak, 2002), of the unique skills of psychologists, and of the value of psychological services for health and well-being. It is also due to rapidly evolving systems in which health care is being delivered (American Psychological Association (APA), 2009). At the same time, psychologists' roles within these settings are expanding, and multidisciplinary collaboration within health care is becoming commonplace. The following guidelines are intended to assist psychologists, other health care providers, administrators in health care delivery systems, and the public to conceptualize the roles and responsibilities of psychologists in these diverse contexts.
These guidelines are informed by the Ethical Principles of Psychologists and Code of Conduct ("APA Ethics Codes") (APA, 2002a, 2010) and the Record Keeping Guidelines (APA, 2007). These guidelines address psychologists' roles and responsibilities related to service provision and clinical care, including teaching and administrative duties. There are additional obligations related to conducting research in health care delivery systems that will not be included here; guidance in this area can be found in the APA Ethics Code (APA Ethics Code 8.0 through 8.15). In accordance with ethical standards, the practice of psychology in health care delivery systems is based on established scientific and professional knowledge (APA Ethics Code 2.04).
These guidelines may also be used to inform rule making and decision making in health care delivery systems about the roles of psychologists that are commensurate with their training and licensure. Federal and state laws, (including those governing service delivery, payment arrangements and business structures), standards of accrediting bodies (e.g., Joint Commission, 2009), and institutional bylaws are also relevant to these rules and decisions. These guidelines build upon earlier guidelines regarding hospital privileges, credentialing and bylaws specific to hospital settings (APA Board of Professional Affairs, Task Force on Hospital Privileges, 1991) and draw on the issues highlighted in an additional APA document regarding practicing psychology in hospitals from that same time period (APA Practice Organization (APAPO), 1998).
There are a wide variety of systems for health care delivery, including, but not limited to, primary care and integrative care facilities, tertiary care hospitals, rehabilitation centers, nursing homes, outpatient surgery centers, and substance abuse treatment centers. Similarly, there are a wide variety of patient populations with whom psychologists work within these systems (e.g., pediatric, geriatric, acutely versus chronically ill, those being treated for mental health or medical conditions, those from diverse cultures and socioeconomic groups, etc.) There are also different entry points for psychologists to deliver professional services for both direct and indirect patient care within health care delivery systems, ranging from being employed by the organization to being independent practitioners with either contractual arrangements or following their patients as they enter a health care delivery system. In all cases, psychologists have special expertise in communication, behavioral issues, patient decision making, human interaction and systems that is relevant to the full spectrum of health and mental health issues and settings; these guidelines apply to that full spectrum. It is recognized that there is rapid growth in the use of technology (in areas such as telehealth) with unique considerations for practice that are beyond the scope of these guidelines. Ethical and legal standards for the practice of psychology pertain to the full range of health care delivery systems, and to every professional psychological role within such systems, unless otherwise specified.
The term "guidelines" refers to statements that suggest or recommend specific professional behavior, endeavors, or conduct for psychologists. Guidelines differ from "standards" in that standards are mandatory and may be accompanied by an enforcement mechanism. Thus, guidelines are aspirational in intent. They are intended to facilitate the continued systematic development of the profession and to help ensure a high level of professional practice by psychologists. Guidelines are not intended to be mandatory or exhaustive and may not be applicable to every professional and clinical situation. They are not definitive and they are not intended to take precedence over the judgment of psychologists.
The following glossary of terms found in these guidelines may be helpful. For the purpose of these guidelines, "psychologists" are considered "health service providers" (APA, 1996), having been duly trained and experienced in the delivery of preventive, assessment, diagnostic and therapeutic intervention services related to the psychological and physical health of consumers, based on: 1) having completed scientific and professional training resulting in a doctoral degree in psychology; 2) having completed an internship and supervised experience in health care settings; and 3) having been licensed as psychologists at the independent practice level.
We use the term "patient" to refer to the child, adolescent, adult, older adult, couple, family, group, organization, community, or other population receiving psychological services in health care delivery systems. However, we recognize that in many situations there are important and valid reasons for using such terms as "client" or "person" in place of "patient" to describe the recipient of services. Finally, we use the term "multidisciplinary" throughout the guidelines but recognize that in some instances psychologists may actually be working in a "transdisciplinary" context where holistic care is being provided that crosses disciplinary boundaries.
1. Psychologists remain cognizant of their ethical and legal obligations as members of a distinct and autonomous profession.
Rationale: Participation in multidisciplinary diagnosis and treatment within complex systems necessitates psychologists' careful attention to maintaining their distinct professional identity and responsibilities. Persons treated in health care delivery systems, as in all other settings, should receive the highest quality of psychological services. Integration of psychological services into a broad range of modalities and systems of care necessitates that these services be the best available care delivered or supervised by psychologists with the necessary training and experience.
Application: Consistent with applicable legal requirements, psychologists strive to avoid providing services beyond the boundaries of their competence (APA Ethics Code 2.01). Similarly, they strive to avoid delegating work to persons who cannot be expected to perform competently on the basis of their education, training, or experience, either independently or with the level of supervision being provided (APA Ethics Code 2.05). They strive to avoid compromising their professional judgment in response to constraints or pressure posed by other professionals or systemic factors (APA Ethics Code 1.03, APA, 2010). Psychologists advocate for adequate budgeting, staffing, business arrangements (e.g., contracts, billing), supervision, and specialty competence for psychological services. When psychologists are administratively responsible to someone of a different professional discipline, they seek to sensitize the administrator to the psychologist's own responsibility for planning, directing and reviewing psychological services.
2. Psychologists seek to understand the internally and externally imposed expectations and requirements of the systems within which they practice.
Rationale: Effective and appropriate patient care depends upon sufficient familiarity with the environment, culture, and context in which such care is delivered. Psychologists recognize that they sometimes need to address or negotiate system requirements in relation to the needs of patients. Health care delivery systems are complex and highly structured organizations that rely upon the prompt and accurate availability of personal data and clinical services. Psychologists are typically obliged to disclose to patients the nature of their relationship with the organization, the probable use of the services provided and information obtained, and who will have access to the information (APA Ethics Code 4.02). Psychologists strive to educate themselves about the different tiers of health care record release that are based upon the sensitivity of the health care information (APA, 2007; APA Ethics Code 2.01, 6.02; Drogin, Connell, Foote and Sturm, 2010).
Application: Psychologists strive to maintain a comprehensive and up-to-date understanding of the health care delivery systems within which they practice, including site-specific expectations and requirements for: patient admission, management, and discharge; assessment and treatment protocols; emergencies; patient safety, restraint, and restrictions of freedom; procedure codes and billing/bundling; informed consent; documentation, record keeping systems,sharing of patient information; and other issues. They seek to learn the institutional by-laws, administrative reporting, multidisciplinary relations, and organizational and governing structure of the institutions. They also strive to familiarize themselves with the pertinent regulations of the accrediting bodies for the health care delivery systems, the Health Insurance Portability and Accountability Act (HIPAA) (1996) (APA Practice Organization, 2005, 2007, 2009; U.S. Department of Health and Human Services, 2003, 2009), and applicable state and federal laws governing the practice of psychology and hospital licensure. Psychologists recognize that active participation in the administration of health care delivery systems enables them to contribute to the development of optimal institutional policies and procedures regarding psychological practice and records, thereby maintaining high professional standards. In turn, this enhances the capacity of the health care delivery system to utilize psychologists' expertise to provide maximum benefit to patients and to the organization itself.
Psychologists appreciate that their ethical obligations to protect patient confidentiality may be more stringent than, or qualitatively and/or procedurally different from, other rules governing the exchange of health information among providers within the health care delivery system. This discrepancy necessitates vigilance on the part of psychologists in their informal communication with multidisciplinary colleagues, their communication with patients via technology, and in formal documentation within patient records. Psychologists strive to adhere to their ethical obligations while participating effectively in integrated care. In settings where it is relevant, psychologists strive to inform both institutional policies and technology for safeguarding confidential mental health information in electronic or other health records. Psychologists working in health care delivery systems where electronic health records are utilized strive to inform patients about efforts to protect confidential information (APA, 2007; APA Ethics Code 3.10, 4.02; Benefield, Ashkanazi, & Rozensky, 2006; Condie, Grossman, Robinson & Condie, in press; Drogin, Connell, Foote and Sturm, 2010; Richards, 2009).
3. Psychologists are prepared to clarify their distinct roles and services and how these relate to those of other health care professionals.
Rationale: The successful development, integration, and delivery of psychological services in health care delivery systems depends upon psychologists' ability, willingness, and opportunity to explain how they might contribute to effective prevention, diagnosis, consultation, treatment, rehabilitation, and/or end of life care. Psychologists' aim to enhance patient participation in decision making about, satisfaction with, and adherence to recommended care. Fostering other professionals' understanding of the skills and potential contributions of psychologists is dependent upon psychologists' reciprocal understanding of the roles, skills and contributions of other professional disciplines. Psychologists maintain a level of familiarity with the APA Ethics Code that enables them to convey its requirements in an appropriate fashion and accessible language to their non-psychologist colleagues.
Application: Psychologists strive to create opportunities for collegial as well as public discourse regarding their distinct roles and services, and to demonstrate how psychologists' knowledge, skills, training, education, and experience complement and enhance those of other health care professionals. In order to do this effectively, psychologists continually strive to understand and appreciate fully the roles and services of other professionals within the health care delivery system. When organizational demands conflict with ethical obligations, psychologists clarify the nature of the conflict, establish their commitment to mandatory sources of ethical guidance, and take reasonable steps to resolve the conflict consistent with the APA Ethics Code. (APA Ethics Code 1.03, APA, 2010). These processes reflect the general purpose that, when indicated and professionally justified, psychologists cooperate with other professionals in order to serve their patients effectively and appropriately (APA Ethics Code 3.09; Institute of Medicine, 2001a, 2009).
4. Psychologists are encouraged to seek appropriate staff appointments and clinical privileges within health care delivery systems.
Rationale: Psychologists seek the highest level of staff membership within the departments, specialty units and/or clinical programs in health care delivery systems, as well as the broadest range of privileges within those systems, that is consistent with their training and expertise. They develop an accurate understanding of the medical staff categories and the range of clinical privileges for which they may be eligible, including the training and experience qualifications required for each. Psychologists' applications for staff appointments and privileges reflect the boundaries of their professional competence and the nature of their involvement in a given health care delivery system. They recognize that they may need to seek temporary privileges to deliver services to their patients when they move into a health care delivery system. Psychologists strive to establish the expectation that they be addressed by colleagues, staff and patients as "doctor" if that formal title is used within a given medical culture. This title connotes their extensive doctoral-level education and training, as well as their longstanding history of independent licensure and independent management of patient care.
Application: The nature and requirements for staff appointments within health care delivery systems are determined by institutional bylaws and accreditation standards (e.g., Joint Commission), and, in some cases, state and federal laws. Health care delivery systems vary in terms of the categories for staff appointments (e.g., "full medical staff," "allied health provider," "active," "consulting," etc.). Most, however, distinguish between full-time, part-time, and temporary staff. Whenever possible, psychologists seek a level of staff appointment that allows voting for bylaws, officers, and other governance matters; typically this will mean full medical staff membership and privileges (Eckleberry-Hunt, Van Dyke, Stucky, & Misch, 2009). The criteria for assigning clinical privileges (patient care responsibilities) are determined by the rules of clinical departments, specialty units or programs, under the auspices of the medical staff. There may be regional differences in established practices within health care delivery systems. Psychologists working in rural and underserved regions are encouraged to obtain the level of privileges necessary and available to provide high quality care for patients.
Psychologists who do not have privileges or appointments but will continue to provide psychological services to patients within a health care delivery system (e.g. when a patient is hospitalized) seek temporary privileges or appointments to permit continuity of care. It is important for psychologists to understand the staff categories, clinical privileges, application processes, and timeline for review and approval, as well as the supervision requirements for patient care pending the assignment of privileges. Psychologists are encouraged to familiarize themselves with procedures governing staff appointments, privileges, sanctions, and appeals.
5. Psychologists strive to be involved in the development of institutional policies regarding professional scope of practice and participation in service delivery.
Rationale: Psychologists recognize that active participation in the administration of health care delivery systems enables them to contribute to, as well as to monitor, the development and implementation of institutional policies and procedures that affect and promote the practice of psychology. In turn, optimal policies and procedures for the practice of psychology ensure that their expertise is utilized appropriately and for maximum benefit, and that high professional standards for psychological practice are upheld.
Application: Commensurate with their training and expertise, psychologists seek to be involved in program, service, and departmental leadership, including participation in establishing criteria for specific clinical privileges for psychologists (e.g., admitting privileges). They seek and accept appointment to medical staff committees for credentialing that provide peer review and oversight for the granting and renewal of both staff appointments and clinical privileges, as well as the determination of internal sanctions for psychologists who violate rules and regulations. Similarly, they strive to be actively involved in leadership activities concerned with quality improvement and risk management. Psychologists seek to recognize and create opportunities for workforce development and retention, particularly when providing services to underserved populations or in underresourced settings or systems. They strive to develop and maintain awareness and strategies to minimize health disparities in health care delivery systems that are in part due to race/ethnicity and socioeconomic status. (Adler & Rehkopf, 2008; Agency for Healthcare Research and Quality, 2009; Institute of Medicine, 2003, 2008; President's New Freedom Commission on Mental Health, 2003; U.S. Department of Health and Human Services, 2005).
6. Psychologists are encouraged to function in multidisciplinary positions with diverse roles and responsibilities.
Rationale: Psychologists may continue to provide traditional psychological services in health care delivery systems, such as mental status examinations, emergency evaluation and triage, diagnostic evaluation and assessment, and psychotherapy. However, psychologists are increasingly performing other services within multidisciplinary teams in health promotion and disease prevention programs, primary care, behavioral medicine (or mind-body medicine) programs, care of patients with acute and chronic medical conditions, and end-of-life care.
Application: Psychologists' scope of practice includes direct service delivery, consultation, and training within teams of other health care providers. Their training and expertise are well-suited for collaboration with other disciplines, such as: enhancing communication with patients; observing behavior change in relation to symptom/disease progression, medication, and other interventions; attending to problems with continuity of care; facilitating decision-making; problem-solving to maximize adherence to treatment regimens; adjusting practices as needed for patients with developmental, behavioral, or psychiatric conditions; attending to gender, age, culture, spirituality, socioeconomic status and other factors related to health beliefs and behavior; attending to life span developmental issues and aging; involving family or other support systems in order to maximize treatment outcome; ensuring quality of life considerations in treatment decision making, including end-of-life care; and negotiating differences of opinion among patients, families, or health care providers. Therefore, psychologists are urged to seek ways to integrate their unique expertise in diverse aspects of patient care, including the integral use of science as it pertains to psychological practice (APA, 2005, 2009; APA Ethics Code 2.04; Belar, 2000; Institute of Medicine, 2001a, 2001b, 2009; President's New Freedom Commission, 2003). Psychologists remain mindful that, as members of a multidisciplinary team and as a result of their expertise, they may be called on to help team members address issues such as those arising from the stress associated with professional caregiving and maintaining work-life balance.
7. Psychologists are encouraged to promote the optimal delivery of their services through effective and timely communication with other health care professionals.
Rationale: Health care delivery systems are comprised of providers from a variety of disciplines and training backgrounds. To effect optimal patient care, psychologists strive to learn and speak the "languages" of the systems in which they work (e.g., medical terminology) and are mindful of communicating psychological concepts in a manner that is comprehensible to other professionals. Psychologists seek to communicate in a timely manner and participate in interdisciplinary team meetings, rounds and case consultations, where the goals, observations, and services of different providers can be integrated for optimal care.
Application: As participants in multidisciplinary health care delivery systems, psychologists understand the formal and informal means by which information is exchanged and documented. Psychologists are prepared to communicate their ideas, opinions, and questions in language that is understandable to the nonpsychologist health care providers with whom they interact. Psychologists operationalize discipline-specific terms and concepts, including those explicating the mind-body connection in the context of the specific health issues in question. They appreciate that the timeliness of their communication can determine the degree to which it is perceived as being helpful for patient care.
8. Psychologists strive to provide collaborative services in the broadest range of health care settings, and to apply their expertise to the full spectrum of health issues.
Rationale: As health care delivery systems become increasingly diverse and comprehensive, the roles played by psychologists also become more varied and potentially complex. Psychologists are increasingly found in a variety of health care settings dealing with the full range of conditions and diagnoses, whether considered medical, behavioral, developmental, or psychiatric.
Application: Psychological expertise is useful in a wide range of settings (e.g., psychiatric and general hospitals, primary care and other outpatient settings, surgery centers, rehabilitation facilities, nursing homes, and assisted living centers), serving patients with a variety of conditions, (e.g., infectious diseases, obesity, diabetes, cancer, cardiac conditions, traumatic injuries,and neurological, developmental, and psychiatric/conditions). Specifically, psychologists' roles include, but are not limited to: helping patients and families adjust to diagnoses of acute, chronic and/or life-threatening medical conditions, including assisting them with complex treatment decisions; preparing patients for invasive medical procedures; assisting patients with adherence to difficult treatment or rehabilitation regimens; assisting patients and providers with pain management; evaluating candidates for surgery or transplantation; promoting positive health behaviors, such as smoking cessation and adherence with diet and exercise regimens; providing consultation to physicians and other providers regarding effective ways to communicate with patients and their families; providing developmental, psychological, or neuropsychological assessment; providing or overseeing intervention for developmental or behavioral problems; evaluating and treating psychiatric conditions; helping patients and families with access to resources; and consulting with providers in systems other than health care delivery systems (e.g., schools, corrections, social service agencies, and independent practitioners). Additionally, some psychologists collaborate with medical providers regarding medications or prescribe medication themselves; discussion of these roles can be found in the Practice Guidelines Regarding Psychologists' Involvement in Pharmacological Issues (APA, 2009a).
Psychologists recognize the need to continually explore how their skills and training may apply to new and emerging health care environments (APA, 2009b). They strive to adapt their practice to new and evolving service delivery models and emerging technologies, including thoughtful consideration of the issues involved in the use of technology and electronic media in psychology.
9. Psychologists involved in practice within health care delivery systems strive to gain and maintain appropriately specialized competence.
Rationale: In health care delivery systems, psychologists are called to take on wide-ranging roles within their areas of expertise. These include, but are not limited to: providing psychological assessment; developing and implementing prevention programs; consulting; leading and participating in multidisciplinary treatment planning; conducting psychotherapeutic or counseling intervention; taking a leadership role in admission, diagnosis, treatment, consultation order, and discharge decision making; training and professional development for both psychologists and professionals from other disciplines; engaging in scientific research; and serving in health care delivery system management and administration roles. Psychologists are qualified to fulfill these roles in health care delivery systems by virtue of their doctoral-level education, specialized training, and experience. It is important that they keep abreast of the specific knowledge and skills and scientific literature relevant to their particular job roles and duties and practice only within the boundaries of their competence (APA Ethics Code 2.01).
Application: Psychologists are encouraged to seek continuing education and training that would enhance the performance of their specific job roles and duties within health care delivery systems. In new emerging areas in health care service delivery, they strive to take reasonable steps to ensure the competence of their work by using relevant research, training, consultation, and/or study (Belar, Brown, Hersch, Hornyak, Rozensky, & Sheridan, 2001). It is important that they maintain cultural competence for health care delivery to diverse patient groups, including specific competence for working with patients of varying gender, race and ethnicity, language, culture, socioeconomic status, sexual orientation, religious orientation, and disabilities (APA, 2002b; APA Ethics Code 2.01). Psychologists are mindful of the specialized training needed for working with pediatric or geriatric populations. As the issues with which they are faced become increasingly complex, and the potential emotional burden of their work increases, psychologists actively seek to maintain self care to ensure their continued competence (APA Ethics Code 2.06).
10. Psychologists are encouraged to offer their special expertise in the administration and management of both psychological and other professional practice within health care delivery systems.
Rationale: The doctoral-level education and training of psychologists includes: clinical service delivery; research methodology and program evaluation; program, system, and organizational development; and human behavior in groups and organizational systems. In conjunction with their specific training and experience working within health care delivery systems, psychologists offer unique perspectives and expertise in the administration and management of psychological and other professional practice.
Application: Psychologists strive to be involved in those aspects of the management of psychological and other professional practice within health care delivery systems that are within the scope of their education, training and expertise. These include, but are not limited to: the supervision of psychological and related services; involvement in health care ethics committees; and membership on Institutional Review Boards (IRBs). Psychologists are also encouraged to be involved in those organizational bodies within health care delivery systems that conduct peer review, address scope of practice issues, grant initial and continued credentialing, and oversee quality improvement initiatives.
These guidelines revise and build upon earlier guidelines regarding hospital privileges, credentialing, and bylaws specific to hospital settings (APA Board of Professional Affairs, Task Force on Hospital Privileges (1991)). Renamed, Guidelines for Psychological Practice in Health Care Delivery Systems, these were developed by the Committee on Professional Practice and Standards (COPPS). Members of COPPS during the development of this document were Mary Ann McCabe (chair, 2010), Lisa Drago Piechowski (chair, 2009), Eric Y. Drogin (chair, 2007-2008), Bonita Cade, Lois Condie, Nabil El Ghoroury (BPA Liaison, 2007-2008), Ruth Fassinger (BPA Liaison, 2009-2010), Terry S.W. Gock, Robert Kinscherff, Stephen J. Lally, Gary D. Lovejoy, Julia Ramos-Grenier, Bonnie Spring, and John Zervopoulos. COPPS is grateful for the support and guidance of the Board of Professional Affairs (BPA), and particularly to BPA Chairs Judith Patterson (2010), Cynthia A. Sturm (2009), and Jaquelyn Liss Resnick (2008). COPPS acknowledges the helpful consultation of APA Practice Directorate Legal and Regulatory Affairs staff Maureen Testoni, as well as Shirley Higuchi, Alan Nessman, and Stacey Larson. COPPS extends its sincere appreciation to the APA Practice Directorate staff who facilitated both the work of COPPS and this revision effort: Mary G. Hardiman, Lynn F. Bufka, Ronald S. Palomares, Ayobodun Bello, LeShawn Lumpkin and Sheila Kerr. Finally, COPPS wishes to thank the many other APA colleagues and governance groups who offered comments on earlier drafts of these guidelines.
This document is scheduled to expire in February 2021, ten years from the date of approval by APA Council of Representatives. After this date, users are encouraged to contact the APA Practice Directorate to confirm that this document remains in effect.
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