Primary Care PsychologyPrimary Care Psychology

Lisa K. Kearney, Ph.D.Lisa K. Kearney, Ph.D.

Primary Care PsychologistPrimary Care Psychologist

South Texas Veterans Health Care South Texas Veterans Health Care SystemSystem

Models of Primary Models of Primary Care PsychologyCare Psychology Co-located Clinics Model: psychology Co-located Clinics Model: psychology

services and medical in same building services and medical in same building Psychologist in Primary Care: provide Psychologist in Primary Care: provide

traditional mental health services, but traditional mental health services, but housed within primary carehoused within primary care

Behavioral Health Consultant Model: Behavioral Health Consultant Model: fully integrated services for variety of fully integrated services for variety of mental and behavioral health problemsmental and behavioral health problems

Staff Adviser Model: psychologist Staff Adviser Model: psychologist serves as consultant to PCPs aloneserves as consultant to PCPs alone

(Gatchel & Oordt, (Gatchel & Oordt, 2003)2003)

Behavioral Health Behavioral Health Consultant ModelConsultant Model

Provides services to broad range of patients, Provides services to broad range of patients, with and without official MH diagnoseswith and without official MH diagnoses

Primarily brief therapy model (1-4 sessions) Primarily brief therapy model (1-4 sessions) Provide services to targeted disorders (e.g., Provide services to targeted disorders (e.g.,

depression, diabetes, chronic pain) who are depression, diabetes, chronic pain) who are high-utilizers of clinic serviceshigh-utilizers of clinic services

Advantages: serve more patients, greater Advantages: serve more patients, greater access to psychologist, assists with access to psychologist, assists with psychiatry back logpsychiatry back log(Gatchel & Oordt, 2003; Rowan & Runyan, 2005)(Gatchel & Oordt, 2003; Rowan & Runyan, 2005)

Behavioral Health Consultant Behavioral Health Consultant vs. Specialty Mental Health vs. Specialty Mental Health

Clinic ModelsClinic Models

Differences fall in the following areas:Differences fall in the following areas: Primary goalsPrimary goals Appointment structureAppointment structure Intervention structureIntervention structure Intervention methodsIntervention methods Termination and follow-upTermination and follow-up Referral structureReferral structure Primary information productsPrimary information products

(Runyan et al., (Runyan et al., 2003)2003)

Behavioral Health Behavioral Health Consultant SkillsConsultant Skills

Focused assessmentFocused assessment Time efficiency: 15-30 minute apptsTime efficiency: 15-30 minute appts Use of cognitive behavioral techniquesUse of cognitive behavioral techniques A stages of change model (Prochaska, A stages of change model (Prochaska,

DiClemente, & Norcross, 1992)DiClemente, & Norcross, 1992) Appreciation for population health Appreciation for population health

focusfocus Good communication with physicians Good communication with physicians

and other staff members of the clinicand other staff members of the clinic(Gatchel & Oordt, 2003; Rowan & Runyan, 2005)(Gatchel & Oordt, 2003; Rowan & Runyan, 2005)

Behavioral Health Behavioral Health Consultant SkillsConsultant Skills Function as a team memberFunction as a team member Respect for hierarchy of the systemRespect for hierarchy of the system Flexibility in schedulingFlexibility in scheduling Understand medical conditions, Understand medical conditions,

procedures, medicationsprocedures, medications Help PCPs become comfortable Help PCPs become comfortable

treating pts with MH diagnoses; treating pts with MH diagnoses; provide educationprovide education

(Bray et al., 2004; Gatchel & Oordt, 2003)(Bray et al., 2004; Gatchel & Oordt, 2003)

The Referral ProcessThe Referral Process

Language in referral process (e.g., Language in referral process (e.g., behavioral health vs. psychology)behavioral health vs. psychology)

Help pts understand behavioral health is Help pts understand behavioral health is part of primary care treatmentpart of primary care treatment

Explain connection between behavioral Explain connection between behavioral and physical health (e.g., diabetes and and physical health (e.g., diabetes and depression/stress, HTN and stress levelsdepression/stress, HTN and stress levels

Be first line referral for variety of Be first line referral for variety of problemsproblems

Allow opportunity for PCP to introduce Allow opportunity for PCP to introduce youyou

(Gatchel & Oordt, 2003; Haley et al., 2004)(Gatchel & Oordt, 2003; Haley et al., 2004)

Setting Up ShopSetting Up Shop

Build rapport with staff; reveal how BH Build rapport with staff; reveal how BH can meet needs in primary carecan meet needs in primary care

““Psychotherapy ain’t enough”Psychotherapy ain’t enough” Find specific need and help address it Find specific need and help address it Work as a team member Work as a team member Market your services and be availableMarket your services and be available Learn primary care culture (e.g., clinic Learn primary care culture (e.g., clinic

pace, how providers refer, feedback) pace, how providers refer, feedback) (Gatchel & Oordt, 2003; Haley et al., 20054(Gatchel & Oordt, 2003; Haley et al., 20054

Common Key ConcernsCommon Key Concerns

Diabetes Diabetes HTN and cardiovascular diseaseHTN and cardiovascular disease Chronic painChronic pain Sleep disturbanceSleep disturbance Non-complianceNon-compliance Depression, anxiety, and PTSDDepression, anxiety, and PTSD Coping with MMPCoping with MMP Substance abuse and dependenceSubstance abuse and dependence

VA Setting ExamplesVA Setting Examples

Behavioral health orientation for Behavioral health orientation for initial intakesinitial intakes– Pts initially referred to orientation Pts initially referred to orientation

for overview of BH services and for overview of BH services and referral optionsreferral options

– Pts complete 1 page intake form Pts complete 1 page intake form and brief depression screeningand brief depression screening

– Follow-up individual phone calls Follow-up individual phone calls made to set up plan of care made to set up plan of care

VA Setting ExamplesVA Setting Examples

Group therapy modelGroup therapy model– 5-6 groups run per week in primary care5-6 groups run per week in primary care– Example groups: Diabetes Support, Mood Example groups: Diabetes Support, Mood

Management Group, Chronic Pain, Healthy Management Group, Chronic Pain, Healthy Living, Medical Problems Support, TraumaLiving, Medical Problems Support, Trauma

Connections with psychiatry through a Connections with psychiatry through a PharmDPharmD– Goal is to manage pts in primary care, Goal is to manage pts in primary care,

assisted by Pharm D when necessaryassisted by Pharm D when necessary– Appropriate referrals to psychiatry: Bipolar, Appropriate referrals to psychiatry: Bipolar,

Schizophrenia, Psychotic Disorders, and non-Schizophrenia, Psychotic Disorders, and non-responsive Depression after 2-3 initial trials responsive Depression after 2-3 initial trials of antidepressant in the clinicof antidepressant in the clinic

VA Setting ExamplesVA Setting Examples

Interdisciplinary team approachesInterdisciplinary team approaches– Talk to PCPs about perception of large Talk to PCPs about perception of large

needs in clinic (e.g., non-compliance)needs in clinic (e.g., non-compliance)– Collaborate with other professionalsCollaborate with other professionals

Dietitian and nurses in the MOVE! Dietitian and nurses in the MOVE! ProgramProgram

Creating healthy living programs (e.g., Creating healthy living programs (e.g., hypertension, diabetes, vascular risk hypertension, diabetes, vascular risk reduction) which incorporate a team reduction) which incorporate a team including a dietitian, PharmD, including a dietitian, PharmD, psychologist, and a nursepsychologist, and a nurse

VA Setting ExamplesVA Setting Examples

Assist with management of pts Assist with management of pts newly diagnosed with depression newly diagnosed with depression and placed on anti-depressant and placed on anti-depressant medicationmedication– Group co-led by physician and Group co-led by physician and

behavioral health consultant with 3 behavioral health consultant with 3 visits scheduled in 3 months after visits scheduled in 3 months after onsetonset

Use of patient workshopsUse of patient workshops Create educational handouts Create educational handouts Education of staff on key areas Education of staff on key areas

Initial DataInitial Data

Evaluation of all cases seen by BH in Evaluation of all cases seen by BH in 9/059/05

123 pts with only 26 referred to 123 pts with only 26 referred to psychiatry (21.1%); referrals for psychiatry (21.1%); referrals for Bipolar, Psychotic Disorder, or Bipolar, Psychotic Disorder, or Dementia or failed 2 or more medsDementia or failed 2 or more meds

Workload comparison to traditional Workload comparison to traditional MH psychologist:MH psychologist:– 967 vs. 275 uniques967 vs. 275 uniques– 7736 vs. 1740 encounters7736 vs. 1740 encounters

Primary Care PsychologyPrimary Care Psychology

Lisa K. Kearney, Ph.D.Lisa K. Kearney, Ph.D.Primary Care PsychologistPrimary Care Psychologist

South Texas Veterans Health Care SystemSouth Texas Veterans Health Care System