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Primary Care Psychology

Primary Care Psychology. November 28, 2006 Melissa Stern. Presentation Created by Laura Williams. REMINDER. OUR LAST EXAM IS NEXT WEEK!!

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Primary Care Psychology

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  1. Primary Care Psychology November 28, 2006 Melissa Stern Presentation Created by Laura Williams

  2. REMINDER • OUR LAST EXAM IS NEXT WEEK!! • We will have you fill out instructor/course evaluations FIRST (as Gregg and I can’t be in the room) and administer the exam AFTER the evaluations are completed. • So, please plan to be here for more than an hour!

  3. 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

  4. 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

  5. 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)

  6. 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

  7. Why is psychology important in primary care? • 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)

  8. 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)

  9. 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)

  10. 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)

  11. 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)

  12. Identification of Psychosocial Issues in PC • Identification of Ψ problems in PC has increased • In 1979: 6.8% identified with Ψproblems • 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)

  13. 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)

  14. (Rushton, Bruckman, & Kelleher, 2002)

  15. 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%?!?!

  16. 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

  17. 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)

  18. 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)

  19. Models of Collaboration • 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

  20. Models of Collaboration • 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

  21. Models of Collaboration • 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)

  22. Models of Collaboration • 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)

  23. 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)

  24. 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)

  25. Diagnostic & Statistical Manual for Primary Care (DSM-PC):Child & Adolescent Version • Situations (12) Challenges to Primary Support Group Changes in Caregiving Other Functional Change in Family Educational Challenges Housing Challenges Economic Challenges Health-Related Situations

  26. Diagnostic & Statistical Manual for Primary Care (DSM-PC):Child & Adolescent Version Child Manifestations (10) Symptoms organized into behavioral clusters Allow physicians to consider: Severity of presenting problem Common developmental presentations Differential diagnosis

  27. Diagnostic & Statistical Manual for Primary Care (DSM-PC):Child & Adolescent Version • Child Manifestations Developmental Competency Impulsive/Hyperactive or Inattentive Behavior Negative/Antisocial Behavior Emotions and Mood Illness-Related Behavior

  28. Diagnostic & Statistical Manual for Primary Care (DSM-PC):Child & Adolescent Version Problem Severity: • Developmental Variations • Behaviors may raise concern but are within range of typical for the child’s age • Problems • Disrupt child’s functioning but do not warrant a DSM-IV diagnosis • Disorders

  29. 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

  30. Practicing Primary Care Psychology • Time management • 20-30 min for assessment and recommendations • Framework for assessment/intervention • Introductions & informed consent • Identify referral question/presenting problem • Symptoms • Functional impairment • Summarize/Conceptualize problem • Collaborate on behavior change plan/recommendations

  31. 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

  32. 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)

  33. 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

  34. 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

  35. 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

  36. 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

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