Primary Care Psychology

1. Primary Care Psychology Lisa K. Kearney, Ph.D. Primary Care Psychologist South Texas Veterans Health Care System

2. Models of Primary Care Psychology • Co-located Clinics Model: psychology services and medical in same building • Psychologist in Primary Care: provide traditional mental health services, but housed within primary care • Behavioral Health Consultant Model: fully integrated services for variety of mental and behavioral health problems • Staff Adviser Model: psychologist serves as consultant to PCPs alone (Gatchel & Oordt, 2003)

3. Behavioral Health Consultant Model • Provides services to broad range of patients, with and without official MH diagnoses • Primarily brief therapy model (1-4 sessions) • Provide services to targeted disorders (e.g., depression, diabetes, chronic pain) who are high-utilizers of clinic services • Advantages: serve more patients, greater access to psychologist, assists with psychiatry back log (Gatchel & Oordt, 2003; Rowan & Runyan, 2005)

4. Behavioral Health Consultant vs. Specialty Mental Health Clinic Models Differences fall in the following areas: • Primary goals • Appointment structure • Intervention structure • Intervention methods • Termination and follow-up • Referral structure • Primary information products (Runyan et al., 2003)

5. Behavioral Health Consultant Skills • Focused assessment • Time efficiency: 15-30 minute appts • Use of cognitive behavioral techniques • A stages of change model (Prochaska, DiClemente, & Norcross, 1992) • Appreciation for population health focus • Good communication with physicians and other staff members of the clinic (Gatchel & Oordt, 2003; Rowan & Runyan, 2005)

6. Behavioral Health Consultant Skills • Function as a team member • Respect for hierarchy of the system • Flexibility in scheduling • Understand medical conditions, procedures, medications • Help PCPs become comfortable treating pts with MH diagnoses; provide education (Bray et al., 2004; Gatchel & Oordt, 2003)

7. The Referral Process • Language in referral process (e.g., behavioral health vs. psychology) • Help pts understand behavioral health is part of primary care treatment • Explain connection between behavioral and physical health (e.g., diabetes and depression/stress, HTN and stress levels • Be first line referral for variety of problems • Allow opportunity for PCP to introduce you (Gatchel & Oordt, 2003; Haley et al., 2004)

8. Setting Up Shop • Build rapport with staff; reveal how BH can meet needs in primary care • “Psychotherapy ain’t enough” • Find specific need and help address it • Work as a team member • Market your services and be available • Learn primary care culture (e.g., clinic pace, how providers refer, feedback) (Gatchel & Oordt, 2003; Haley et al., 20054

9. Common Key Concerns • Diabetes • HTN and cardiovascular disease • Chronic pain • Sleep disturbance • Non-compliance • Depression, anxiety, and PTSD • Coping with MMP • Substance abuse and dependence

10. VA Setting Examples • Behavioral health orientation for initial intakes • Pts initially referred to orientation for overview of BH services and referral options • Pts complete 1 page intake form and brief depression screening • Follow-up individual phone calls made to set up plan of care

11. VA Setting Examples • Group therapy model • 5-6 groups run per week in primary care • Example groups: Diabetes Support, Mood Management Group, Chronic Pain, Healthy Living, Medical Problems Support, Trauma • Connections with psychiatry through a PharmD • Goal is to manage pts in primary care, assisted by Pharm D when necessary • Appropriate referrals to psychiatry: Bipolar, Schizophrenia, Psychotic Disorders, and non-responsive Depression after 2-3 initial trials of antidepressant in the clinic

12. VA Setting Examples • Interdisciplinary team approaches • Talk to PCPs about perception of large needs in clinic (e.g., non-compliance) • Collaborate with other professionals • Dietitian and nurses in the MOVE! Program • Creating healthy living programs (e.g., hypertension, diabetes, vascular risk reduction) which incorporate a team including a dietitian, PharmD, psychologist, and a nurse

13. VA Setting Examples • Assist with management of pts newly diagnosed with depression and placed on anti-depressant medication • Group co-led by physician and behavioral health consultant with 3 visits scheduled in 3 months after onset • Use of patient workshops • Create educational handouts • Education of staff on key areas

14. Initial Data • Evaluation of all cases seen by BH in 9/05 • 123 pts with only 26 referred to psychiatry (21.1%); referrals for Bipolar, Psychotic Disorder, or Dementia or failed 2 or more meds • Workload comparison to traditional MH psychologist: • 967 vs. 275 uniques • 7736 vs. 1740 encounters

15. Primary Care Psychology Lisa K. Kearney, Ph.D. Primary Care Psychologist South Texas Veterans Health Care System