primary care psychology november 28, 2006 melissa stern presentation created by laura williams
TRANSCRIPT
Primary Care Psychology
November 28, 2006Melissa Stern
Presentation Created by Laura Williams
REMINDER
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Presentation Outline
Why primary care psychology? Barriers to primary care psychology Models of psychological practice in primary care Pediatric psychology in primary care Training issues in primary care psychology
What is Primary Care?
Primary Care:– First-contact care– Continuous – Comprehensive– Coordinative – Continuing responsibility– Personalized care
(Bray, et al., 2004)
Includes family physicians, general internal medicine physicians, and pediatricians
Primary Care Practice
Short office visits Average = 14 minutes for pediatric visits
Priority is physical health Inadequate training on psychosocial issues
– Why is this even important? Physicians may feel uncomfortable bringing up
psychological issues Patients may feel uncomfortable
(Black & Nabors, 2004; Ferris, et al., 1998; Perrin, 1999)
Primary Care Psychology
“the provision of health and mental health services that includes the prevention of disease and the promotion of healthy behaviors in individuals, families, and communities”
(Bray, et al., 2004, p. 8)
Changing role of psychology as a mental health profession to a health profession
Why is psychology important in primary care?
1. Behavioral health factors
7 of the top 10 health risk factors are lifestyle or behavior factors (VandenBos, et al., 1991)
60% of visits to primary care involve behavioral health issues (Cummings, Cummings, & Johnson, 1997)
100% of medical visits involve a psychological or behavioral component (Belar, 1996)
Why is psychology important in primary care?
2. Mental health factors
28% of Americans have a mental disorder– Only ½ of those receive treatment– ½ of those treated receive treatment only through
primary care providers– ADHD is one example!!
20-25% of patients in primary care have a mental disorder (Spitzer, et al., 1995)
Pediatric Psychology & PC
40-80% of parents have questions about their child’s behavior or development (Young, et al., 1998)
11-20% of children in primary care settings have mental disorders (Costello, 1989)
½ of parents have psychosocial concerns at well-child visits (Sharp, et al., 1992)
Pediatric Psychology & PC
Pediatric PC presents a variety of special opportunities for psychologists to intervene
Well Child visits– After immunizations, parents rated developmental and behavior
concerns (e.g., eating habits, school issues, child safety) as the most impt. issues in WC visits (Busey, Schum, & Meurer, 2002)
Patients with Chronic Conditions “High users” of PC
– Not completely accounted for by health status– Psychosocial concerns of child– Parent adjustment: parent stress and efficacy
(Janicke & Finney, 2001 & 2003)
Psychosocial Issues in Pediatric PC
The “hidden morbidity” CBCL given to pediatric PC patients; 25% had
elevated scores Gave DISC to patients with elevated scores and a
random sample of non-elevated patients PCP diagnosed emotional/behavioral problems in 6%
of patients, while 12% of patients were diagnosed based on the DISC
83% of patients with an emotional/behavioral problem were NOT diagnosed by PCP (Costello, 1988)
Identification of Psychosocial Issues in PC
Identification of Ψ problems in PC has increased In 1979: 6.8% identified with Ψ problems In 1996: 18.7% with Ψ problems Largest increases in:
– Attention problems (1.4% to 9.2%)– Emotional problems (.2% to 3.6%)
Medication, counseling, and referrals for Ψ problems also increased Paralleled increases in single-parent families and Medicaid
enrollment Why?
(Kelleher, et al., 2000)
Referral of Pediatric PC Patients
Child Behavior Study 1994-1997– Sampled 400 PCP and 21,000 patients (aged 4-15 yrs)
Of patients with a new Ψ problem presenting in PC (approx 4,000 patients), 76% were not referred
– 46% could be managed by PCP– 35% were already receiving additional services– 15% self-limiting problem
(Rushton, Bruckman, & Kelleher, 2002)
(Rushton, Bruckman, & Kelleher, 2002)
Referral of Pediatric PC Patients
When PCPs identified a Ψ problem, what did they do?– 39% “watchful waiting”/no treatment– 33% PCP counseling– 18% PCP counseling + medication– 10% medication alone– 16% referral for additional services
Most often referred to a psychologist vs. psychiatrist 25% of PCPs reported that Ψ services were available within their
offices at least 1x/week Only 61% of patients given a referral actually initiated services
(Rushton, Bruckman, & Kelleher, 2002)– What’s happening with the other 40%?!?!
Role of Primary Care Psychologists
Assessment of psychosocial or behavioral symptoms
Mood-related symptoms Child behavior problems
Psychosocial management of acute and chronic health conditions
Adherence to physician recommendations Pain management Coping with stressful medical procedures
Role of Primary Care Psychologists
Collaboration with other primary care providers Consulting with physicians, nurses, and other health care
providers
Identification of appropriate experts for referrals Referring patients for additional psychological services
(Bray, et al., 2004; McDaniel, et al., 2002)
Barriers to Psychological Services in Primary Care
Practical issues Time and space
Ethical issues Informed consent Confidentiality
Insurance payment New CPT codes = reimbursement?? Research is needed
Education and training of graduate students(Black & Nabors, 2004; Perrin, 1999; Schroeder, 1999)
Models of Collaboration
1. Psychologist as a tertiary provider
– Traditional model– Physician refers patients with emotional or
behavioral problems – Psychologist is located in separate practice– Empirically validated treatments– Example: UF Psychology Clinic
Models of Collaboration
2. Psychologist as a consultant
– Physician assumes primary responsibility Psychologist provides consultation
– Multidisciplinary teams in medical centers– Example: Schroeder at UNC-CH
Private pediatrics practice Brief parent meetings Consultations with physicians/nurses Telephone consults Parent groups
Models of Collaboration
3. Psychologist as interdisciplinary team member
– Physicians and psychologists share responsibility for patient care
– Billing is done as a team– Managed care has made this model more obsolete– Example: special populations (e.g., diabetes,
failure to thrive, developmental disabilities)
Models of Collaboration
4. Psychologist as community collaborator
– focused on community rather than individuals– leads to programs implemented on a community level – prevention programs– Example: NRBHC
(Black & Nabors, 2004; Drotar, 1995)
Diagnostic & Statistical Manual for Primary Care (DSM-PC):
Child & Adolescent Version
Coding system for the recognition and treatment of common behavioral and developmental symptoms in primary care
Developed by American Academy of Pediatrics, Society of Pediatric Psychology, and others
2 Core Areas: Situations & Child Manifestations
(Drotar, 1999)
Diagnostic & Statistical Manual for Primary Care (DSM-PC):
Child & Adolescent Version
1. Situations Describe and evaluate impact of stressful
situations that can impact children’s mental health Similar to psychosocial or environmental factors
coded on Axis IV
(Drotar, 1999)
Diagnostic & Statistical Manual for Primary Care (DSM-PC):
Child & Adolescent Version
1. Situations (12)
Challenges to Primary Support GroupChanges in CaregivingOther Functional Change in FamilyEducational ChallengesHousing ChallengesEconomic ChallengesHealth-Related Situations
Diagnostic & Statistical Manual for Primary Care (DSM-PC):
Child & Adolescent Version
2. Child Manifestations (10)– Symptoms organized into behavioral
clusters– Allow physicians to consider:
Severity of presenting problem Common developmental presentations Differential diagnosis
Diagnostic & Statistical Manual for Primary Care (DSM-PC):
Child & Adolescent Version
2. Child Manifestations
Developmental Competency
Impulsive/Hyperactive or Inattentive Behavior
Negative/Antisocial Behavior
Emotions and Mood
Illness-Related Behavior
Diagnostic & Statistical Manual for Primary Care (DSM-PC):
Child & Adolescent Version
Problem Severity:
1. Developmental Variations• Behaviors may raise concern but are within range of typical
for the child’s age
2. Problems• Disrupt child’s functioning but do not warrant a DSM-IV
diagnosis
3. Disorders
Diagnostic & Statistical Manual for Primary Care (DSM-PC):
Child & Adolescent Version
Barriers for the use of DSM-PC: Training of pediatricians and/or psychologists More user friendly Very little research Time consuming Use of DSM-PC has not led to improvements in
reimbursement rates
Practicing Primary Care Psychology
Time management– 20-30 min for assessment and recommendations– Framework for assessment/intervention
1. Introductions & informed consent
2. Identify referral question/presenting problem
3. Symptoms
4. Functional impairment
5. Summarize/Conceptualize problem
6. Collaborate on behavior change plan/recommendations
Practicing Primary Care Psychology
Use of relationship-building strategies– Frequent empathetic statements are not necessary– Implied relationship due to the physician-patient
relationship that already exists– Norm within primary care is “get to the problem”
quickly– Summary statement implies understanding of the
patient’s problem
Practicing Primary Care Psychology
Selection of appropriate intervention– Use of interventions designed to facilitate small
changes – Use of psychoeducational material– Avoid using the same strategy for every patient
(e.g., a depressed patient may benefit from increased enjoyable activities or reduction in negative thinking)
Practicing Primary Care Psychology
Inappropriate level of care– Primary care interventions should be tried before
referring for outside mental health services (in most cases)
Overdocumentation– No need for lengthy background information– Notes should be < 1 page
Practicing Primary Care Psychology
Importance of feedback to the physician– In medical settings, physician’s are accustomed
to receiving succinct, same-day feedback– Interruptions are common in medical settings– Importance of providing feedback to physician
about how to address behavioral concerns
Primary Care Psychology
Given managed care restrictions on physician’s time and the prevalence of behavioral and mental health factors in primary care, psychologists can play a vital role
There are several different models of collaboration between primary care providers and psychologists
Pediatric psychologists can help address parent’s behavior and developmental concerns in primary care– DSM-PC
Primary Care Psychology
The practice of primary psychology differs in many ways from the traditional practice of psychology in mental health clinics
Significant barriers exist for the successful provision of psychological services in primary care
Future directions in primary care psychology include: improved education/training, more reimbursement for services, research documenting the efficacy/effectiveness of primary care interventions