J Clin Psychol Med Settings (2009) 16:1–3 DOI 10.1007/s10880-009-9157-8

INTRODUCTION TO THE SPECIAL ISSUE

The Train is Leaving the Station: Is Psychology Aboard? Rodger Kessler Æ Barbara Cubic

Published online: 27 February 2009 Ó Springer Science+Business Media, LLC 2009

This special issue of the Journal of Clinical Psychology in Medical Settings (JCPMS) considers integrated care between psychology and primary care. This is not an altogether new subject, as individual journal papers and a range of books discussing aspects of the subject have been published for years. Strong advocates underscoring the importance of providing effective mental health services in primary care settings, such as Nicholas Cummings, William O’Donohue, Kirk Strosahl, Patricia Robinson, Andrew Pomerantz and Alexander Blount, have been trying to wake up the psychology community for years to the dilemmas created by two silos of health care. Despite previous writings on the subject we think this issue is unique for two reasons. The first is, the collection of papers represents a deconstruction of the construct of integrated care into its essential elements and then each paper addresses the key issues, such as clinical, operational, administrative, financial, training and research aspects to integrated care. The second, taken as a whole, the special issue explores whether psychology will play a meaningful role in the now rapid emergence of integrated care and we hope gives a call to action. The importance of integrated care has been increasingly embraced in the health care system. Whether a willingness to align psychology closer with medicine is growing within

R. Kessler (&) Department of Family Medicine, and the Center for Translational Science, University of Vermont College of Medicine, 371 Pearl Street Burlington, Burlington, VT 05401, USA e-mail: [email protected] B. Cubic Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA 23507, USA

psychology is an open question, but psychology has made some contributions. Championing psychological treatments of medical patients, the American Psychological Association was instrumental in the American Medical Association’s adoption of the Health and Behavior codes and Medicare reimbursement of these codes nationally. However, despite Medicare adoption of these codes, acceptance of the codes by other financial pay sources has been unequal and providing a convincing argument to financial entities to do so has been left to individual practitioners efforts at the local coverage levels (Kessler, 2008). There are multiple systematic reviews each concluding, with limitations, that collaborative primary care is effective. Such initiatives have been undertaken by such organizations as the Cochrane Collaboration and most recently the Agency for Health Care Research and Quality (Gilbody, Whitty, Grimshaw, & Thomas, 2003; Butler et al., 2008). The Substance Abuse Mental Health Services Administration (SAMHSA) in partnership with the Health Resources and Services Administration (HRSA) recently authored a publication entitled Integration of Mental Health/Substance Abuse and Primary Care advocating the financing of behavioral health in primary care and outlining a set of recommendations for doing so (Butler et al., 2008). Even more recently the World Health Organization published its 2008 World Report (http://www.who.int/whr/ 2008/en/) entitled Primary Health Care––Now More Than Ever, a call for collaborative primary care across the world. Since 2003 SAMHSA has been funding a grant program entitled Screening, Brief Intervention, Referral and Treatment SBIRT (http://sbirt.samhsa.gov/) each grant being 10? million dollars over 5 years, to provide substance use and identification services within primary care and other settings. In an economic climate in which meeting attendance is in retreat, there is an annual meeting of the

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Collaborative Family Health Association with collaborative care as its sole focus that has continued to grow with each successive meeting. Additionally, large scale organizations such as Kaiser Permanente, the United States Air Force and Navy, the Veteran’s Administration, and the Bureau of Primary Care have heavily invested in innovative models of integrated care. The list goes on, with organized psychology having made limited contributions with the exception of a few key players. It is far from too late for a significant psychological involvement. While systematic reviews support the concept of integrated care, they also point out major limitations in the data available for review. Translation of the large psychology, behavioral medicine, health psychology and primary care psychology efficacy literature into effectiveness in real world studies remains to be done. As the National Institute of Health shifts its focus towards translational science with the emerging Centers for Translational Science Awards, academic psychology has a great opportunity to participate in the emergence of interdisciplinary community based research designed to take our research findings and actively disseminate them in practice. In fact, in parallel to the writing of this introduction to the special issue the first author and his colleague Ben Miller, Psy.D. are involved in the establishment of the Collaborative Care Research Network, part of the National Research Network under the auspices of the American Academy of Family Practice. Collaborative practices and investigators are being recruited. This special issue of JCPMS is also an opportunity. It asks important questions that must be responded to for the field to progress. This issue was laid out to begin with papers focusing on conceptual issues in the field of integrated care, followed by a discussion of specific areas of application, and concluded by papers reviewing training models and philosophies necessary to create a workforce for integrated care. Opening the issue Kessler, Stafford and Messier identify the crucial issues that must be responded to for integrated care to make the leap from an interesting side issue into the mainstream of health care. They frame the nuts and bolts elements of creating a medical home for patients and provide a specific set of steps designed to respond to how mental health can be integrated into that home. As the special issue moves into addressing conceptual matters Peek describes the opportunities and challenges for integrated care created by the complexities of patient presentations. Miller, Mendenhall and Malik describe the dilemmas created by various terminologies used in the field of integrated care and recommend a standardized nomenclature. They then describe a model that deconstructs process metrics into factors/barriers and generalizes

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behavioral health provider roles into major categories to provide a framework to empirically discriminate between implementations across specific settings in order to allow the sustaining of successful integrated care initiatives. The papers by Cummings, O’Donohue and Cummings; Pomerantz, Corson and Detzer; and Robinson and Strosahl each provide a historical view of the development of integrated care and the barriers created by psychology’s inability to shift from traditional models of clinical service. These authors also underscore the many opportunities on the horizon, especially in terms of the dissemination of best practice models of integrated care. The next set of papers illustrates specialized ways in which medical and mental health conditions are being addressed in integrated care settings by psychologists. Korsen and Pietruszewski review programs which are demonstrating the sustainability of collaborative care models of depression. Knowles outlines the challenges related to communication in integrated care and ways to enhance appropriate sharing of information between psychologists and primary care providers. Murphy, Chabon, Delgado, Newville and Nicolson describe the Substance Abuse Consultation and Referral Service (SACRS) at Montefiore Medical Center (MMC) which has shown the value of a service dedicated to integrating screening, diagnosis, medical management of withdrawal, psychosocial assessment and intervention, and referral to the appropriate level of care for substance use related problems in a medical setting. And, Anstiss outlines the important role that motivational interviewing can play in integrated care to enhance adherence to medical regimens and inspire patients to address substance abuse, psychological concerns and medical issues. The special issue concludes with a set of papers addressing training. Each of these papers comments on the dilemmas created by educational models in psychology that graduate individuals who are often unprepared for providing services in medical settings, and almost always unaware of how to modify their mindset and skills to provide useful services in the rapid paced, primary care world. O’Donohue, Cummings and Cummings describe the successful doctoral and post graduate programs offered through University of Nevada-Reno, the most longstanding programs designed specifically to create psychologists for integrated care. An innovative new degree program for a doctoral in behavioral health at the University of Nevada-Reno is also described. Bluestein and Cubic outline a training program at the Eastern Virginia School of Medicine developed through Health Resources and Services Administration (HRSA) Graduate Psychology Education (GPE) grant funding that allows psychology interns to train side-by-side with family medicine residents in a variety of primary care settings.

J Clin Psychol Med Settings (2009) 16:1–3

The unique opportunities to serve as consultants and educators for family medicine residents by working on interdisciplinary family medicine treatment teams are outlined. Blount and Miller describe the pitfalls in utilizing clinicians from specialty mental health settings in primary care and the resulting program failures. In response to the current and even greater anticipated demand for mental health providers in primary care, these authors outline new initiatives that have emerged which attempt to provide training for the preexisting mental health workforce to enable their successful integration into primary care settings. And, last, but certainly not least, Ring’s paper on culturally responsive care provides insights into how psychology can help eliminate barriers to care by substantially increasing the number of trainees prepared to treat a diverse patient population. The common bond across all of the papers in this collection on integrated care is that each addresses in some way how to prepare a psychology workforce to handle key 21st century health issues. Unless that workforce is able to fully appreciate the interrelatedness of mental and physical health and develop ways to address health concerns in the

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most efficacious manner psychology will be riding in the integrated care caboose.

References Butler, M., Kane, R. L., McAlpine, D., Kathol, R. G., Fu, S. S., Hadorn, H., et al. (2008). Integration of mental health/substance abuse and primary care. Rockville, MD: Agency of Healthcare Research and Quality Publication 09-E003. Gilbody, S., Whitty, P., Grimshaw, J., & Thomas, R. (2003). Educational and organizational interventions to improve the management of depression in primary care. A systematic review. Journal of the American Medical Association, 289, 3145–3151. doi:10.1001/jama.289.23.3145. Kessler, R. (2008). Integration of care is about money too: The health and behavior codes as an element of a new financial paradigm. Families, Systems and Health, 26, 207–216. doi:10.1037/a001 1918. Substance Abuse Mental Health Services Administration. (2009). Screening, brief intervention, referral and treatment (SBIRT). Retrieved January 10, 2009, from http://sbirt.samhsa.gov/. World Health Organization (2008). 2008 world report: Primary health care––now more than ever. Retrieved January 10, 2009, from http://www.who.int/whr/2008/en/.

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