integrated health care

Inter-professional Training in Family-Centered Integrated Healthcare for the

Underserved Population of Children:Organizational/Implementation Issues

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Integrated Health Care

Family Systems

Cultural Competence

Presenters Cindy Carlson, Ph.D. Margie

Gurley Seay Professor and Department Chair The University of Texas at Austin

Jane Ripperger-Suhler, M.D. Program Director, Child and Adolescent Psychiatry University of Texas Southwestern at Seton Family of Hospitals, Austin

Jane Gray, Ph.D. Psychologist & Director of Psychology Training, Texas Child Study Center Director of Behavioral Health Texas Center for the Prevention and Treatment of Childhood Obesity

Greg Jensen, LCSW Vice-President of Behavioral Health Lone Star Circle of Care

Elizabeth Minne, Ph.D.Psychologist, Lone Star Circle of Care Referral Center at Crockett High School

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Learning Objectives

Articulate the relationship between inter-professional training and integrated health care delivery.

List three reasons children’s services should be family-centered, culturally/linguistically competent, and integrated.

Identify three barriers and three solutions to inter-professional training implementation.

Provide two examples of how evaluation data informorganizational/implementation issues.

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UT Graduate Psychology Education (UT-GPE) Program

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Goal: Foster interdisciplinary teamwork in the provision of evidence-based, culturally & linguistically competent, family-centered treatment of children.

How? Trainees (doctoral psychology students) participate in interdisciplinary training with psychiatrists and other health professionals, including seminar participation, clinical service delivery, and field placements at integrated health care sites that permit collaboration.

(HRSA Award: D40HP19644/Graduate Psychology Education Programs. Project director: C.Carlson)

Key Elements of UT-GPEP

Trainee Preferred Criteria Spanish-speaking Ethnic minority Clinical, Counseling, or

School Psychology (doctoral only)

Interest in serving children & families

Doctoral level 2-4th year of training

Training Requirements 2 years sequential Initial year evidence-based

practice in Texas Child Study Center

2nd year FQHC or FQHC-like setting

Engagement in research Engagement in policy

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Training in Family-Centered Care

Training Goals

Systems theory

The family health and illness cycle

Family functioning and child health

Family-centered care principles

Family assessment methods

Evidence-based family intervention and parent training

Training Modalities

Interdisciplinary seminar

Individual and group supervision

Training experiences in family assessment, family therapy, and family-centered care

Family case study presentations

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Training in Integrated Health Care

Training Goals

Models of integrated health care

How to integrate physical and behavioral health

Barriers to implementation

Knowledge of integrated health care initiatives across the nation

Training Modalities


Training experiences in integrated health care settings/FQHCs

Policy involvement

Site visits

Research

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Training in Culturally and Linguistically Competent Care

Training Goals

Role of culture and language in the delivery of services

Emphasis on Spanish-speaking and Latino families

Development of knowledge, skills, and awareness in providing care for diverse populations

Understanding of health disparities among children

Training Modalities


Bilingual/multicultural supervision

Training experiences in settings serving diverse populations

Research

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Why Inter-professional Education (IPE) is Essential

Integrated health care places patients, families, and communities at the center of health care provision served by point-of-delivery teams of professionals.

Inter-professional education is recommended to

Reduce ignorance of roles and duties Reduce professional prejudices Increase understanding & knowledge Increase team-work & collaborative skill

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The Ideal:Keys to success in IPE

Early exposure Learn about colleagues’ professional culture Spend time in classroom and socially Learn about own professional culture and be able to

articulate this to others Recognize own biases and assumptions Leadership from each culture: teaching and learning Enthusiastic and skilled facilitators

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The Reality:Challenges and Barriers in IPE

Few models exist that are accepted and operationalized successfully

Logistical barriers semester length grading requirements practice style

Profession-centrism and social identity theory

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The Reality: Predictions about IPE prior to implementation Integration would be challenging Differences in background, approach, value systems Prejudice about “the other” Fragile identities: uncertainty and insecurity about identity as

members of one’s professional group and tendency to over-differentiate groups to consolidate identity

We will need to address the cultures of the professional groups Integrating across professions may

help them understand cultural barriers with patients (clients) introduce new ideas for working styles enhance their ability to work with other disciplines as well

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The Reality: Taking the Plunge in Year One

Met together in two hour blocks

On “psychiatry turf”

Instructors came from psychiatry, public health, business, counseling psychology, and school psychology backgrounds

None from within employed clinical faculty of psychiatry or from clinical psychology faculty

New roles and new professional partnerships

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The Reality: Mistakes in Year One

I did not attend lectures so no “parent” representative for psychiatry

Attempts to address interprofessional cultural differences came late in the year

Expectations of teachers for group function further sequestered groups because it did not match the groups’ expectations

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The Reality: Corrections in Year Two and Outcomes

Corrections Child psychiatry at every class (almost) Compared training backgrounds in first session Presented expectation of group project early (family therapy together)

Outcomes More engagement of all groups inter-professionally in discussion Only one dyad attempted and presented conjoint family therapy experience

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The Reality: New Challenges in Year Three

Larger and more diverse group

More formal structure Some participants getting credit/grades Semester requirement

All participants do not work in clinic together

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Brainstorming Solutions for IPE

Every situation will present its own challenges but some seem to be universal Identity issues Learning/teaching styles Goal differences

How do we transcend identity and prejudice issues to facilitate teamwork?

How do we provide learning opportunities that match expected styles?

How do we encourage collaboration in diverse groups who have different goals and motivations?

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Importance of Family-centered Collaborative Care

Families increasingly involved in care as medicine advances

Complexity of medical plans puts demand on families

Psychosocial issues at the family level are related to higher healthcare costs

Family system is relevant in health behaviors

Family-centered collaborative care acknowledges ecosystemic view Provider is part of the ecosystem

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The Ideal:Family Centered Collaborative Care

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Partnership between patients, families, and healthcare professionals

Collaboration among disciplines Medicine, nursing, behavioral health, among others

Inclusion of family as crucial part of team

Biopsychosocial model with equal importance of each element

The Training Setting

Mental health collaboration between University of Texas and Dell Children’s Medical Center Trainees providing therapy services Outpatient clinic: collaboration between psychology and

psychiatry Children’s Hospital

• Trainees embedded within interdisciplinary teams of pediatric subspecialty services (oncology, obesity)

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The Reality: Successes in Family Centered Care

Parents engaged as collaborators in treatment

Assessment of family system, including strengths

Many examples of effective collaboration among disciplines

Multiple disciplines of mental health within teams

Trainees display high skill level in collaborative behaviors

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The Reality: Challenges and Barriers in Family Centered Care

Setting

Collaboration across disciplines Awareness of roles and skills Overlap in content and techniques Financial support for time spent on collaboration

Limited availability of bilingual supervision on site

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The Reality: Challenges and Barriers in Family Centered Care

Communication systems/EMR

Billing and diagnosis

Challenges to family therapy efforts Referral challenges Availability of family members Supervision

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Brainstorming Solutions for Family Centered Care

How do we create more effective collaboration across disciplines?

How do we successfully implement family therapy within these types of settings?

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Importance of training in FQHCs

An Institute of Medicine report in 2005 concluded that the only way to achieve true quality (and equality) in the health care system is to integrate primary care with mental health care and substance abuse services.

(Institute of Medicine, “Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series”, November 1, 2005.)

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The Ideal: Training in FQHCs

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Providing holistic care by diagnosing and treating physical AND mental conditions … together

Training in BH & medical clinics

Program development

Interdisciplinary training

Embedding BH students in

medical clinics

Managing technology

The Reality: Challenges and Barriers to Training in FQHCs

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•Lack of Clarity re: Value Added

•Financial Impact of Trainees•Ability to bill

•Demand for training slots

•Service Delivery vs. Academic Culture

The Reality: Challenges and Barriers to Training in FQHCs

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Brainstorming solutions for training in FQHCs

What is the value-added to FQHCs to have trainees?

Partial Answers:1. Recruitment and retention2. Expanding access3. Professional development for staff4. Interdisciplinary student training 5. Program development6. Research

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Importance of cultural and linguistic competence (CLC) in collaborative care

There is a growing presence of diverse ethnic/cultural groups in society. Latinos comprise one of the fastest growing minority groups.

Health care providers are increasingly challenged to address the needs of a linguistically and culturally diverse clientele.

Providers and trainees in agencies that cater to underserved populations are especially likely to interact frequently with diverse groups.

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The Ideal: CLC in Collaborative Care

The training agency must uphold the delivery of culturally competent care as a core value.

Effective multicultural training: Providing trainees exposure to a diverse client group, including minority clients

Effective multicultural training: Opportunities to train with ethnically diverse faculty

Culturally Competent Supervision: Establishing a broad definition of culture and appreciating the

heterogeneity within a cultural group. Encouraging self-awareness in supervision. The value of bilingual supervision.

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The Reality: Challenges and Barriers in CLC in Collaborative Care

Recruiting clinicians and trainees from diverse backgrounds can be tricky.

Lack of bilingual clinicians makes it difficult to serve non-English speakers.

Cultural competence training for staff: Budget and time constraints.

Overcoming barriers to accessibility of services for underserved populations.

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The Reality: Challenges and Barriers in CLC in Collaborative Care

Issues in providing culturally competent supervision: Lack of bilingual supervisors places limits on the linguistic

development of trainees. Supervisors often do not get guidance on how to be a

culturally competent supervisor.

Supervision: Making incorrect assumptions about the type of training experiences that minority students desire.

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Brainstorming solutions for CLC in Collaborative Care

How might a healthcare agency go about demonstrating a core value in culturally competent care?

How do we become more accessible and connected to the communities we serve?

How do we enhance cultural competency in the healthcare setting?

What are some areas for growth in providing multicultural supervision of trainees?

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Keith Research & Evaluation, LLCwww.keithresearch.com

First Year (Cohort 1): Psychiatry Residents (8), Doctoral Psychology Interns (2), and GPEP Trainees (3 Spanish-speaking)

Second Year (Cohort 2): Psychiatry Residents (3), Doctoral Psychology Interns (2), and GPEP trainees (2 Spanish-speaking)

Evaluation Methods:

Data Collection: Outcomes (pre- mid-course, post surveys) + feedback (mid-course, end of course)

Observations: beginning, core areas, and closure

Survey development: peer review & number of items

Data analysis and reflections

Mid-course (formative results) influence on training

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Keith Research & Evaluation

Seminar evaluation results - Year 1

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Seminar evaluation results – Year 1Areas for improvement

Several participants reported that the multicultural content was too focused on Spanish-speaking/Hispanic populations (however, the grant goal was to focus on these populations)There were varying reactions to course content and expectations, with some participants feeling the reading load was too heavy or repeated information that they had learned previouslyOverall, not all participants seemed to be aware of the goals of the seminar or how it fit into their training programInter-professional collaboration was difficult to accomplish

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Year 2 Modifications based on evaluation results

Site visits to integrated health care settings were added to seminar in order to address comfort with these settingsAll training directors and seminar instructors attended the first class in order to ensure “buy-in” from attendees and explain the goals of the course within their training programOverview of the grant program was more formalized in the first class in order to clarify seminar focus and goalsA collaborative project (case study) was added to increase inter-professional collaboration between psychology and psychiatry

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Seminar evaluation results – Year 2

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Qualitative evaluation results - Year 2

“Buy-in” from participants was reflected in increased participation within seminar and increased cohesion among seminar participants

Case study collaboration faced logistical barriers in terms of finding cases, though participants did work at collaboration and some were able to present cases to the class

Attendance requirements were different for different training programs due to scheduling constraints - this was an evaluation challenge and led to different levels of exposure to course topics among course participants

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Using evaluation results to inform course developmentWhat evaluation results from Year 2 are targets for improvement in Year 3?

What can be changed in Year 3 to improve participants’ abilities in the multicultural/ cultural competencies area?

Given the logistical challenge of completing the case study assignment, how else can the goal of increasing inter-professional collaboration be addressed?

How can scheduling challenges across training programs be addressed?

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Questions?,

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integrated health care

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