Brief Report

Integrating Systems-Based Practice, CommunityPsychiatry, and Recovery Into Residency Training

Stephanie LeMelle, M.D.

Melissa R. Arbuckle, M.D., Ph.D.

Jules M. Ranz, M.D.

Background: Behavioral health services involving multiple sys-tems of care are increasingly being provided in community aswell as hospital settings. Residents therefore should be familiarwith multiple systems and the role of the psychiatrist in these sys-tems. The authors describe a curriculum incorporating principlesof systems-based practice (SBP), community psychiatry, andrecovery.

Methods: This curriculum was designed to include lectures,clinical rotations, specialized written/oral presentations, andsupervision focused on SBP and recovery principles. Residentsalso participate in home and site visits for further immersioninto the multiple systems that their patients have to navigate.

Results/Conclusion: The essential elements of this curricu-lum are the 1) consistent review and emphasis on the fourresearched-based SBP roles of the psychiatrist; 2) recoveryprinciples of person-centered care and shared decision-making; 3) requirement that residents interact with patients incommunity and home settings; 4) integration of didacticcourses and clinical rotations; and 5) focus on the supervisor/supervisee relationship.

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Our healthcare system is undergoing dramatic changeunder the rubric of the Patient Protection and Afford-

able Care Act (ACA) (1). Many psychiatrists have beenmarginalized in the current health system, functioning pri-marily as medication managers. The changes required bythe ACA represent an opportunity for psychiatrists to pro-mote the integration of health and behavioral health caresystems. To take advantage of this opportunity, a specialfocus on workforce development is needed. This develop-ment can be carried out at multiple levels, including medicalschool, residency, fellowship, mentorship, and early-careerdevelopment (2).

This article will focus on the incorporation of SystemsBased Practice (SBP), recovery, and community psychiatryinto a residency curriculum developed by the Public Psychi-atry Education Program at Columbia University MedicalCenter Department of Psychiatry.

The Accreditation Council of Graduate Medical Educa-tion (ACGME) requires SBP as one of six core competen-cies. SBP is defined by the ACGME as an “awareness ofand responsiveness to the larger context and system ofhealth care, as well as the ability to call effectively on otherresources in the system to provide optimal health care” (3).The Psychiatry Residency Review Committee (RRC) ofACGME in 2007 added community psychiatry as a requiredclinical experience within the competency of Patient Care.

ACGME does not yet require the teaching of recoveryprinciples. However, many psychiatry training programs re-gard recovery principles as a foundation for the teaching ofSBP and community psychiatry.

Recovery is defined as the processes by which people areable to live, work, learn, and participate fully in their com-munities (4). The ACGME definition of community psychi-atry focuses on people with “persistent and chronic” illness.The concept of recovery has now been broadened to includeall patients receiving mental health care in public and

Received March 19, 2012; revised May 30, 2012; accepted July 5, 2012.From the Dept. of Psychiatry, NY State Psychiatric Institute, New York,NY, and the Dept. of Psychiatry, Columbia University, New York, NY.Send correspondence to Dr. LeMelle; e-mail: Lemelle@nyspi.columbia.edu

Copyright © 2013 Academic Psychiatry

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community settings. Accordingly, discussions are ongoingwith ACGME to broaden its definition of community psy-chiatry along the same lines.Most residency programs provide limited didactic or clin-

ical training in SBP, community psychiatry, or recovery. Toaddress these issues, we have developed a recovery-orientedtraining program that incorporates SBP in community psy-chiatry settings. This program is informed by a study dem-onstrating SBP to be best conceived of as four rolesperformed by psychiatrists. The four roles are identified as1) Patient Care Advocate; 2) TeamMember; 3) InformationIntegrator; and 4) Resource Manager. In brief, the PatientCare Advocate role involves the one-on-one relationshipwith the patient and shared decision-making. The TeamMember role includes the typical multidisciplinary team andalso involves service providers, other clinicians, and family.The Information Integrator role involves the gathering,analysis, and implementation of an action plan based onthe analysis of information. The Resource Manager role in-volves effective use of resources (fiscal, human, material,and time) available to the patient (micro) and to the system(macro). Detailed definitions of these roles were publishedpreviously (5). We have chosen to teach these principlesthrough multiple educational modalities, including didacticclasses, clinical rotations, supervision, and oral and writtencase presentations. Teaching in each of these modalitiesunfolds over the course of the 4-year training program.

Didactics

The didactic lectures are designed as a continuum acrossall 4 years of training. Each lecture uses clinical examplesto illustrate key points and recovery principles. The lecturesare directly linked to residents’ clinical experiences, andresidents are encouraged to participate in discussions byusing their experiences to illustrate points. All lectures alsoemphasize SBP and highlight the roles of the psychiatrist ineach of the systems presented.The PGY1 lectures introduce the history of community

psychiatry in the United States. The lectures review three ofthe key system changes that led to the downsizing of thestate hospitals: new treatments (psychotherapy and phar-macology), the civil rights movement, and shifts in fundingstreams.ThePGY2 lectures focus on recovery-oriented systems and

evidence-based practices (EBP). These lectures are designedto give the residents a basic exposure to the different systemsthat people with mental illness navigate. The lectures also setthe foundation of knowledge that residents will need as they

carry out the four roles conceptualized as the fundamentals ofSBP. We present the following EBPs: Housing First, Sup-ported Employment, and Wellness Self-Management in thePGY2 lectures, and Co-Occurring Substance Abuse Treat-ment and Assertive Community Treatment (ACT) in thePGY3 lectures. These lectures emphasize the role of thepsychiatrist as Patient Care Advocate and Team Member.Residents are encouraged to identify these two roles in theinpatient systems of care to which they have been exposed asPGY1 and PGY2 residents.PGY3 residents frequently work in outpatient settings.

In these settings, residents tend to act more independentlyand need to work with multiple systems of care. ThePGY3 lectures therefore focus on integrated systems ofcare to provide better continuity and access to care for pa-tients. Lectures focus on co-occurring substance abuse,co-occurring physical health issues, involvement in thecriminal justice system, ACT, and the role of peers in theworkforce.PGY4 residents often act as junior attending physicians

and get more involved inmanagement and policy-making inmental health settings. It is important for them to understandthe administrative, financial, and political mechanisms thatgovern mental health care and to take a leadership role inmolding such systems. PGY4 lectures, therefore, focus onthe role of the psychiatrist in leadership and management.Lectures highlight the Information Integrator and ResourceManager roles in recovery-oriented practices.

Clinical Rotations

Wehave developed SBPmilestones tomeasure residents’achievements across all 4 years of training. PGY1 residentsspend much of the year on medicine rotations and are oftenthe clinicians who are responsible for the bulk of the directpatient care. Accordingly, at the end of the PGY1, residentsshould be proficient in the role of Patient Care Advocate.The PGY2 is primarily an inpatient year, where residentsare members of multidisciplinary teams. At the end of thePGY2, residents should be proficient as Team Members.PGY3 residents are in the outpatient clinics and must get

information from multiple systems, analyze the infor-mation, and help patients formulate comprehensive treat-ment plans. At the end of the PGY3, residents should beproficient as Information Integrators. PGY4 residents spendmost of the year in electives, with some authority to maketreatment decisions based upon available resources. At theend of PGY4, residents should be proficient as ResourceManagers.

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INTEGRATING AREAS OF RESIDENCY TRAINING

A crucial aspect of this program is a PGY3 year-long,half-day-per-week outpatient rotation. This rotation ful-fills the ACGME/RRC requirement for the community-psychiatry expectation. In this setting, residents have theopportunity to learn and observe how people with mentalillness live and function in the community.

Person-Centered Systems Evaluation (PCSE)

Each resident chooses one patient from his/her caseload,and, during the initial assessment, reviews with the patientthe various systems of care that he or she navigates. This re-view is broken into eight components: mental health, physicalhealth, substance abuse/use, social/family life, vocational/educational needs, housing, legal issues, and financial is-sues. The project includes a home visit and culminates in aformal write-up and presentation. Residents incorporate re-covery principles by helping patients prioritize these systems.Residents are encouraged to actively use all four SBP roles inworkingwith patients. If performingone role does not help thepatient achieve her/his goals, residents are encouraged toswitch roles and try a different approach.

Site Visits

PGY2 and PGY3 residents participate in site visits tocommunity programs. For PGY2 residents, programs areselected that incorporate specific evidence-based practices.For PGY3 residents, programs are selected that exemplifyintegrated systems of care.

Supervision

A crucial aspect of this program is clinical supervision. Thesupervisor–supervisee relationship in psychiatry is generallyfocused on psychotherapy and medication management. TheSBP and recovery approach emphasizes taking into consid-eration the whole person and all of the systems of care he orshe navigates. To address this, we have developed in-servicetraining for clinical supervisors. The in-service training re-views the four roles of SBP and focuses on measurable ob-jectives and goals of the clinical rotations. The training usesvignettes and resident evaluation tools that have been de-veloped to measure residents’ knowledge and clinical skill incarrying out the four roles of SBP. Resident and supervisorfeedback has been uniformly positive. Specifically, super-visors have felt that using a milestone approach to evaluatingresidents’ performance of the four SBP roles is particularlyhelpful. The resident evaluation tool is being formally tested.

Essential Elements of Integrating SBP,Community Psychiatry, and Recovery

The essential elements are the 1) consistent review andemphasis on the four research-based SBP roles; 2) recoveryprinciples of person-centered care and shared decision-making; 3) importance of having residents interact withpatients in community settings and home visits; 4) in-tegration between didactic courses and clinical rotations,taking into consideration the nuances of each site; and 5)focus on the supervisor–supervisee relationship.

Conclusion

This model curriculum is informing an ongoing SBPConsultation Project being carried out by the Public Psy-chiatry Education (PPE) program at Columbia UniversityMedical Center Department of Psychiatry, where this cur-riculum has been implemented for the past 5 years. Attheir request, PPE is consulting with a number of psychia-try residency training programs around the country to helpaugment their SBP training. As part of the consultation,recommendations and guidance are offered for imple-mentation of this curriculum. This model has been adaptedto fit the needs of the participating training programs. Themodel curriculum is based on the systems available in anygiven community; therefore, this program can be adaptedto fit urban and rural settings, special populations, and train-ing programswith limited resources. This training is intendedto encourage residents to pursue careers in public psychia-try, thereby meeting the workforce needs of the increas-ingly complex national behavioral healthcare system.

References

1. Public Law 111–148: Patient Protection and AffordableCare Act, http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html, March 23, 2010

2. Sowers W, Pollack D, Everett A, et al: Progress in workforcedevelopment since 2000: advanced training opportunities in pub-lic and community psychiatry. Psychiatr Serv 2011; 62:782–788

3. ACGME Common Program Requirements: Effective July1, 2007; http://www.acgme.org/acWebsite/dutyHours/dh_duty-hoursCommonPR07012007.pdf

4. HoganMF:NewFreedomCommissionReport: The President’sNew Freedom Commission: Recommendations to TransformMental Health Care in America. Psychiatr Serv 2003; 54:1467–1474

5. Ranz J,WeinbergM,ArbuckleM, et al: A Four FactorModel ofSystems-Based Practices in Psychiatry. Acad Psychiatry 2012;36:473–478

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LEMELLE ET AL.