Integrated Health Care

1. Inter-professional Training in Family-Centered Integrated Healthcare for the Underserved Population of Children: Organizational/Implementation Issues Integrated Health Care Family Systems Cultural Competence

2. 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

3. 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 inform organizational/implementation issues.

4. UT Graduate Psychology Education (UT-GPE) Program • 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)

5. Key Elements of UT-GPEP Trainee Preferred Criteria 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 • Spanish-speaking • Ethnic minority • Clinical, Counseling, or School Psychology (doctoral only) • Interest in serving children & families • Doctoral level • 2-4th year of training

6. Training in Family-Centered Care Training Goals Training Modalities Interdisciplinary seminar Individual and group supervision Training experiences in family assessment, family therapy, and family-centered care Family case study presentations • 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

7. Training in Integrated Health Care Training Goals Training Modalities Interdisciplinary seminar Training experiences in integrated health care settings/FQHCs Policy involvement Site visits Research • Models of integrated health care • How to integrate physical and behavioral health • Barriers to implementation • Knowledge of integrated health care initiatives across the nation

8. Training in Culturally and Linguistically Competent Care Training Goals Training Modalities Interdisciplinary seminar Bilingual/multicultural supervision Training experiences in settings serving diverse populations Research • 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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?

18. 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

19. The Ideal:Family Centered Collaborative Care • 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

20. 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)

21. 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

22. 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

23. 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

24. 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?

25. 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.)

26. The Ideal: Training in FQHCs Providing holistic care by diagnosing and treating physical AND mental conditions … together Training in BH & medical clinics Embedding BH students in medical clinics Interdisciplinary training Managing technology Program development

27. The Reality: Challenges and Barriers to Training in FQHCs • Lack of Clarity re: Value Added • Financial Impact of Trainees • Ability to bill • Demand for training slots • Service Delivery vs. Academic Culture

28. The Reality: Challenges and Barriers to Training in FQHCs

29. Brainstorming solutions for training in FQHCs What is the value-added to FQHCs to have trainees? Partial Answers: • Recruitment and retention • Expanding access • Professional development for staff • Interdisciplinary student training • Program development • Research

30. 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.

31. 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.

32. 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.

33. 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.

34. 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?

35. Keith Research & Evaluation, LLCwww.keithresearch.com Keith Research & Evaluation 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

36. Seminar evaluation results - Year 1 Keith Research & Evaluation

37. Seminar evaluation results – Year 1Areas for improvement Keith Research & Evaluation 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 previously Overall, not all participants seemed to be aware of the goals of the seminar or how it fit into their training program Inter-professional collaboration was difficult to accomplish

38. Year 2 Modifications based on evaluation results Keith Research & Evaluation Site visits to integrated health care settings were added to seminar in order to address comfort with these settings All 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 program Overview of the grant program was more formalized in the first class in order to clarify seminar focus and goals A collaborative project (case study) was added to increase inter-professional collaboration between psychology and psychiatry

39. Seminar evaluation results – Year 2 Keith Research & Evaluation

40. Qualitative evaluation results - Year 2 Keith Research & Evaluation “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

41. Using evaluation results to inform course development Keith Research & Evaluation What 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?

42. Questions? ,