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Amber A. Hewitt Ph.D.

The Role of Psychologists in Integrated Primary Care

A pediatric health psychologist shares her perspective

The health care reform debate has dominated media and water cooler conversations for the past several months. As a congressional fellow working on health policy in the United States Senate, my days are filled with meetings about how the current law, the Patient Protection and Affordable Care Act (ACA), impacts various patient and provider groups. Most conversations center around Medicaid, Planned Parenthood, reproductive rights, preexisting conditions, and essential health benefits. Last week marked a significant pivot in health care discourse when the “repeal and replace” measure failed to pass in the U.S. Senate. This post highlights one of the lesser-known ACA provisions, the patient-centered medical home (PCMH), which has a direct impact on mental health care delivery and outcomes.

The PCMH is one of several integrated care models implemented in both civilian and military health systems. In practice, the PCMH can look differently but shares a set of principles (“Patient-Centered Medical Homes,” 2010). For example, the primary care provider is responsible for coordinating a patient’s overall health care. Also, treatment is centered on the patient and his or her family while the health team utilizes electronic health records for coordination and follow-up.

The ACA created the Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS) which tests innovative payment and service delivery models such as PCMHs. According to the National Institute of Mental Health (NIMH), "combining mental health services/expertise with primary care can reduce costs, increase the quality of care, and, ultimately, save lives" ("Integrated Care," 2017). However, the success of this model is up against a fragmented U.S. health care system (“Patient-Centered Medical Homes,” 2010).

I reached out to Dr. Corinn Elmore, a pediatric health psychologist at a large military hospital, to get a better idea of what it’s like as a psychologist working in a PCMH.

Describe your role and responsibilities at the medical center? What is your title?

“I work as a pediatric health psychologist integrated into a pediatric primary care facility in a large military hospital. My patient population includes child and adolescent military dependents. I serve as a consultant on a multidisciplinary team that may include physicians, nurses, and allied health staff and provides brief evidence-based interventions to patients. Common presenting problems include ADHD management, toileting, anxiety, feeding, and behavioral aspects of managing chronic illness. Since this is a new service and field, a large portion of my time has been devoted to developing the service and providing education to medical staff, and understanding the needs of our particular clinic.”

How did you become interested in integrated behavioral care?

“In addition to my doctorate in clinical psychology, I have a master’s degree in family therapy and was always interested in how to join with large systems to affect change. On internship, my specialty area was integrated behavioral health where I helped to establish an integrated primary care program. I fell in love with the opportunities for innovation and the ability to work with a diverse patient population."

What do you like the most about your job?

“Since I am the first psychologist in this role where I work, I was able to lead the establishment of the service and was able to tailor it to the needs of the clinic. I appreciate the autonomy as well as being able to provide an accurate representation of psychology to patients and medical providers. Further, I often get to treat patients who would not seek care through traditional behavioral health avenues, which makes the work especially meaningful.”

What is the role of psychology and psychologists in the medical home model?

“Psychology fits very well into the PCMH model because most of the patients in primary care report some type of behavioral issue during their medical visit, yet many are unable to access care due to stigma, insurance issues, transportation barriers, etc. Having psychology integrated into the medical home makes the services more accessible and reduces overall health costs related to work absences, managing chronic illness, and hospitalizations.”

How do you respond to the critique that behavioral health should not be integrated with primary care? Do those concerns resonate with your experience?

“The critique I most often hear is not that behavioral health shouldn’t be integrated with primary care, as much as the question of how feasible is it to integrate these services into a medical clinic setting taking into account financial and physical barriers. While these concerns are not completely invalid, research does show that healthcare costs are actually reduced over time with behavioral management of chronic illnesses. As the field continues to grow, it will be helpful to have a body of literature on the efficacy and effectiveness of behavioral health integration.”

What are some of the challenges related to integrating behavioral health into patient-centered medical homes?

“One of the major challenges with behavioral health in many PCMHs is insurance reimbursement. In many settings, patients are billed separately for the behavioral health and medical appointments even when the care is co-located. In addition, a psychologist cannot see as many patients as PCPs [due to differences in our treatment paradigms]. So the psychologist will never generate enough money from direct care to support their position, and PCMH leadership often has to pay for the psychologist’s salary if they think the service is beneficial. Another challenge is the difference in culture and perception related to the identity and role of the psychologist. In integrated primary care, psychologists act as consultants and do not provide traditional talk therapy in the way that specialty behavioral health does. Often, medical providers require education to fully understand this distinction. Thankfully, in the military system where I work, all services are covered by insurance and specialty behavioral health services are also available, so patients are not hindered by these barriers."

References

https://www.nimh.nih.gov/health/topics/integrated-care/index.shtml
http://www.apa.org/news/press/releases/2017/01/medical-homes.aspx
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=25
http://www.healthcareitnews.com/news/military-redefines-medical-home-mo…

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About the Author

Amber A. Hewitt, Ph.D., a counseling psychologist specializing in adolescent well-being and resilience, is adjunct faculty at Simmons College and American University.

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