A variety of promising models have demonstrated how to improve training in behavioral and emotional health promotion, risk prevention, and treatment. Six presenters at the workshop described examples of such models, with a particular emphasis on multigenerational approaches, evidence-based practices, the involvement of families from varied social demographic groups, interprofessional training, and team-based care.
IMPROVING PEDIATRIC AND ADOLESCENT BEHAVIORAL HEALTH SERVICES AND EDUCATION AT OHIO STATE UNIVERSITY
Primary care providers are in a unique position to screen, identify, and provide evidence-based management for behavioral health disorders, but many do not feel comfortable managing these issues, said Bernadette Melnyk, associate vice president for health promotion, university chief wellness officer, professor and dean in the College of Nursing, and professor in the College of Medicine at Ohio State University (OSU). The top three behavioral health conditions in children are ADHD, depression, and anxiety, explained Melnyk. “If we could get our primary care providers really good at just those three conditions in mild to moderate states, we could significantly improve outcomes in our pediatric and adolescent population,” she said.
The Keep Yourself Strong and Secure (KySS) Fellowship Program at
OSU provides access to behavioral health education for health care providers and health sciences students across the United States. It emphasizes screening, assessment, accurate identification, evidence-based management, and prevention. It also has skills-building components, because, as Melnyk said, “we know that information alone usually doesn’t translate to behavior change. People have to be given time to practice these skills.” The program is self-paced and consists of 14 online modules. A wide range of health care professionals can enroll in the program, including nurse practitioners, physicians, social workers, physician assistants, and other health-related professionals. All trainees in the program have a faculty mental health mentor who guides them during the course of the program.
Melnyk also described the OSU Total Health and Wellness Clinics, which are nurse practitioner-led interprofessional collaborative practice clinics that integrate primary care and mental health services to improve health outcomes in an underserved population in East Columbus and in a rural part of Ohio. The goals of the program are to increase the number of nurses and other health professionals skilled in interprofessional collaborative practice and to strengthen the capacity to improve health outcomes of high-risk patients across the lifespan. The program uses the TEAMcare model, which features a patient-centered focus, collaborative goal setting, practical care planning, and targeted multidisciplinary health care team management (Katon et al., 2010). All patients are screened for depressive and anxiety symptoms. Patients with elevated depressive and anxiety symptoms are given a thorough mental health assessment. They receive a seven-session manualized evidence-based cognitive behavioral therapy program, which is the gold standard first-line treatment for mild to moderate depression and anxiety, Melnyk said.
OSU is also working with Columbus schools to bring this evidence-based program to a high-risk population of youth. “We need to do more in our schools,” she said. “If we could just give every child and teen cognitive behavior skills-building coping skills as they are growing up as a preventive strategy, we might see much less serious mental illness.”
INTERPROFESSIONAL POSTDOCTORAL FELLOWSHIP TRAINING ON INTEGRATED HEALTH CARE AT THE UNIVERSITY OF ROCHESTER
As Melnyk observed, interprofessional approaches to education and training can help create an integrated pediatric primary care workforce. Susan McDaniel, Dr. Laurie Sands distinguished professor of psychiatry and family medicine, director of the Institute for the Family, and vice chair of the Department of Family Medicine at the University of Rochester School of Medicine, described one such approach. She discussed the university’s
Primary Care Family Psychology Postdoctoral Fellowship, which, along with the Academic Family Medicine Postdoctoral Fellowship, places fellows in family medicine and others in pediatrics.
The fellowship integrates several theories and their applications to improve the health outcomes of children and their families, including the biopsychosocial approach of George Engel, the family therapy approach of Lyman Wynne, and the community orientation of Robert Haggerty. Begun in the late 1980s, the fellowship encompasses psychology postdoctoral fellows, family medicine postdoctoral fellows, medical students, and marriage and family therapy students. The interprofessional fellowship model includes a family systems medicine seminar with the psychology and family medicine fellows and with the family medicine residents during the residents’ 5-month psychosocial rotation. It uses the text Family-Oriented Primary Care to ensure that fellows develop a shared mental model of biopsychosocial systems work (McDaniel et al., 2009). After the seminar each week, residents bring in families from their practice to work on assessment and interviewing skills with children and their families, with the seminar group participating from behind a one-way mirror. Throughout their 2 years of training, the psychology and family medicine fellows also participate in interprofessional teams, seeing patients in the clinic alongside the residents and faculty. Master’s students in marriage and family therapy have a practicum placement, gaining experience by seeing primary care patients for 200 hours. Fellows also undergo discipline-specific training to develop the competencies involved in becoming professionals in their fields.
Each June the program features a 5-day integrated health care and medical family therapy intensive that draws participants from all levels of experience, from students to faculty who run programs on integrated care. The meeting offers “knowledge, inspiration, and small groups that provide intensive learning, skill development, and consultation,” McDaniel observed.
Three outcomes from the fellows’ family therapy training are especially valued. The first is gaining excellent adult, couple, and family therapy skills along with child-focused family therapy skills. McDaniel said that she does not want her trainees to say, “I love working with the children, I just can’t stand working with their parents.” This statement, she said, “reveals a lack of understanding about how intertwined a child’s strengths and challenges are with those of his or her family and community.” The second outcome is the ability to apply family systems concepts and skills to facilitating team-based care. The third is to learn to supervise master’s-level clinicians and paraprofessionals and attend with medical students’ or residents’ patients. This model of integrated care has worked so well, she said, that it has been adapted to pediatrics, geriatrics, neurology, obstetrics and gynecology, and surgery.
McDaniel also described the pediatric family psychology fellowship program at Rochester General Hospital, which is part of the university’s Department of Pediatrics. Three psychology faculty and two psychology fellows work at the hospital with all the fellows, including those in pediatrics. These fellows participate in the same seminars and training along with those placed in family medicine. The family psychology fellows in pediatrics also facilitate two or three 30-minute seminars per week with the pediatric residents. The marriage and family therapy master’s students placed in pediatrics observe in the clinic for 18 hours to get some exposure to integrated pediatric care.
“Learning to think systemically and biopsychosocially and providing medical family therapy are complex skills to develop,” said McDaniel, and doing so requires time, support, and guidance (hence the 2-year fellowship, she pointed out). Faculty members work hard to model and discuss what modern dancer Twyla Tharp calls “the collaborative habit.” Fellows learn about increased self-awareness, moving from “me” to “we,” increasing each other’s contributions to the team, surfacing and managing conflict, learning the latest in team effectiveness research, and practicing mindfulness training.
Qualitative evaluations of the fellowship have been outstanding, McDaniel said, and more systematic studies back up these measures. A survey of 245 alumni of the pediatric residency over a 15-year period had a 71 percent response rate. The results showed a significant difference in comfort collaborating with behavioral health professionals for alumni who worked with psychology fellows in an integrated care practice as residents versus those with more traditional training. Pediatricians who trained with the psychology fellows also expressed greater comfort providing behavioral health care for their own patients.
A difficulty in scaling up this model is training pediatric faculty members to have strong collaborative family systems and psychosocial knowledge and skills, while also training psychology faculty members to have strong family systems and integrated primary care skills. A new off-the-shelf curriculum from American Psychology Association’s Division of Health Psychology provides an excellent introduction to integrated primary care for psychology faculty who do not have this skill set but understand that their students need this preparation, said McDaniel.
Cleveland is one of the nation’s poorest cities, with 58 percent of its children living in poverty, noted Terry Stancin, professor of pediatrics, psychiatry, and psychological sciences at Case Western Reserve University and
director of child and adolescent psychiatry and psychology and vice chair for research in psychiatry at the MetroHealth Medical Center. MetroHealth is the county’s safety net hospital, with more than 25 locations in the region. Its main campus is an academic medical center affiliated with Case Western Reserve University. Pediatrics is a relatively small part of the general health system, but it represents a large ambulatory practice, with over 100,000 annual visits per year. Most of the children served in the clinics are poor and insured by Medicaid.
Stancin described the Division of Child and Adolescent Psychiatry and Psychology as a “small but mighty team” consisting of five psychologists, two child psychiatrists, and three clinical social work therapists. However, it also has a growing number of psychology trainees who work to extend the influence of the division. Together, they handle more than 10,000 visits per year.
When Stancin arrived at MetroHealth in 1986, training grants were available to primary care programs to enhance the skills of pediatric residents to take better care of the psychosocial needs of children. Over the years, that model waxed and waned, with a more siloed approach taking effect after 1999. In 2011, a new effort was made to integrate behavioral health into primary care, and since 2013 this approach has taken off, Stancin said. Since then, the institution has developed a psychology residency program that was quickly accredited and has become fully integrated into its primary care clinic. The training model has four goals:
- Increase access to behavioral health care for children in poverty
- Train psychologists in integrated pediatric primary and specialty care settings
- Enhance the developmental and behavioral skills of pediatric residents
- Prepare interprofessional teams to collaborate effectively
Under the model, trainees are able to bill under the supervision of their trainers, which has gained the support of the administration. Training time is equally divided among primary care clinics, specialty care clinics, and ambulatory behavioral health clinics, providing a combination of experiences. Shared teaching time with pediatric residents enables trainees to learn together. Pediatricians mentor psychology trainees, while psychologists mentor pediatric residents. The program is built on competency expectations in a full range of service areas (Hoffses et al., 2016).
Tracking all clinical encounters psychology residents had in the primary care clinic for 6 months revealed 755 referrals for behavioral health consultations. Of those 755, 71 percent were billable encounters, and many of the rest were warm handoffs in which people were put in touch with follow-up care that may have led to billable encounters later. Of the 23 risk
assessments involving danger to self or others, interns were able to assess, stabilize, and send home all but two, whereas in the past all would have gone directly to the emergency room for a long evaluation that would not have been pleasant for the family and may have ended in hospitalization. “That alone was an important picture of our impact and increased accessibility,” said Stancin. In addition, the waiting list for behavioral health services was completely eliminated with the introduction of trainees in the primary care clinic.
A simulated clinic provided enhanced opportunities for interns and pediatric residents to learn. Psychology and pediatric trainees rotated through four simulations with actors portraying a parent of a 2-year-old with tantrums, a parent of a 13-year-old with diabetes, a 17-year-old with a history of suicidal ideation and depression, and a Spanish-speaking parent with a 12-year-old who has asthma. Faculty observed through one-way mirrors to inform the subsequent learning process. “It was a fascinating and powerful procedure,” Stancin said.
She drew five lessons from her experiences with MetroHealth. The first is that economic and leadership changes can dramatically affect training programs. Second, the ability to bill for trainee services has been critical to sustainability. Third, defining the roles of behavioral health providers can enable all members of a team to work at the top of their licenses. Fourth, cross-disciplinary teaching and mentorship have been important. And, fifth, defining meaningful and quality outcome measures, though difficult, can document effectiveness.
One caution she mentioned is whether the program is truly benefiting resident knowledge in behavioral health. “Some people are concerned that having ready access to a behavioral health professional has let some of the residents off the hook, so maybe they’re not learning all that they need to know about managing complex psychosocial conditions. We’re going to have to evaluate that and see,” she said.
Social workers have been partnering with physicians to address the social determinants of health since the 1800s, noted Lisa de Saxe Zerden, senior associate dean for master’s in social work education in the School of Social Work at the University of North Carolina at Chapel Hill. Born out of the social problems exacerbated by the industrial revolution of the 19th century, the profession of social work is today a major provider of behavioral health services in the United States, and the Bureau of Labor Statistics has predicted a 20 percent growth of social work jobs over the next decade (U.S. Department of Labor, Bureau of Labor Statistics, 2011).
Social workers understand integrated care, Zerden said. Theoretical underpinnings of the profession include a person-in-environment perspective, an emphasis on social determinants of health, a risk and resiliency framework, and a recognition of stages of change and therapeutic alliances. Social work practice relies on evidence-based interventions, assessment, brief treatment, clinical modalities, and care coordination, among many other skills, Zerden explained.
In 2014, the Health Resources and Service Administration (HRSA) awarded $26 million to 62 social work master’s programs to expand the behavioral health workforce, and another $54 million was awarded to community health centers to hire behavioral health professionals. The School of Social Work at the University of North Carolina at Chapel Hill received $2.2 million of this funding for two programs. UNC-PrimeCare, which was initiated under President Obama’s “Now Is the Time” initiative, enabled the training of 93 social workers to focus on the behavioral health challenges and issues of young adults. The project provides incentives to students to go into behavioral health work with a $10,000 1-year stipend, in addition to creating a learning community network within the School of Social Work, the university, and the community. Funding also went to a leadership program to train social workers who are involved in a social work master’s program and a public health degree. Some patient simulations have been video recorded to use for sustainability purposes once the grant ends.
After HRSA awarded this money, the Council on Social Work Education, which accredits professional schools, joined the Interprofessional Education Collaborative. “That’s huge,” said Zerden, “because that’s where the competencies for these different health disciplines start coming together and having some shared goals.” At the time of the workshop, Zerden and her colleagues were working with their grant officers to expand the grant so that macro-level social workers can work on community engagement, which would help incorporate prevention. They also were working to incorporate a class on prevention into the curriculum.
Several ongoing research projects are exploring how social workers can contribute to the improvement of behavioral health. A systematic review that eventually focused on 32 reports published between 2000 and 2016 looked at the role of social workers and integrated behavioral health care compared with routine or usual care. It found that social workers have three core functions: care managers, community engagement specialists, and behavioral health specialists and trainers. In all of the reports, the involvement of social workers was cost-neutral and improved behavioral health outcomes. A second study is examining 62 schools of social work to evaluate the functioning of social workers on integrated teams, though the database for this study is still being developed.
Zerden concluded with several challenges she has identified through her
work. One is to get others to understand the contributions of social workers to behavioral health. Social workers “sometimes talk about this among ourselves at our own professional conferences, and it’s nice to be part of these discussions in a cross-disciplinary and interprofessional way,” she said. Another challenge is that licensure regulations and scope of practice differ by state, and variability in titles, tasks, and settings makes these differences hard to capture. Resources vary from acute to community settings, as do reimbursement mechanisms for social work services. A mismatch also exists between federal funds to expand behavioral health providers and job availability. Nevertheless, Zerden concluded by pointing to the many opportunities for growth in interprofessional education and practice.
Cherokee Health Systems, a comprehensive community health care organization with 56 clinical sites in 15 counties in Tennessee, has had to embrace training as a way of staffing itself. It is both a federally qualified health center and a community mental health center, said Parinda Khatri, the organization’s chief clinical officer. “We exist for the safety net to provide care,” said Khatri. “We have a saying: ‘Cherokee goes where the grass is browner.’ We have gone wherever there is need.”
Founded in 1968, it grew rapidly beginning in 1978 when its current chief executive officer took over. In the early 1980s it expanded into behavioral health primary care. Seeing the same patients in medical care as in behavioral health services brought the two together. “When people ask about how this developed, I say, ‘Our patients showed us the way,’” she said. Now the organization sees more than 65,000 patients a year, with almost 16,000 new patients annually, and provides a wide array of clinical services. It emphasizes population-based care, since, as Khatri said, “for every one person who’s in [our offices], there are a hundred who aren’t.”
Telehealth has been one of the ways that Cherokee Health Systems has expanded access, with 40 percent of its psychiatric services being provided through telehealth. Through a telehealth system, pediatric nurse practitioners beam into schools in more rural areas to provide access to convenient acute care. Families are able to directly pick up prescriptions through e-prescribing.
Cherokee Health Systems has emphasized training because of the severe lack of health care providers for the safety net. “The pipeline [for such providers] is barely a pipe,” Khatri said. “It has all kinds of holes and rusted areas.” The organization serves as an Area Education Health Center for the region under a program established by Congress in 1971 and trains multiple professionals, including family and pediatric physicians, psychologists, and
social workers. It offers psychology internships and postdoctoral training. It also has training partnerships with five local academic institutions in the areas of family medicine, pediatric medicine, nursing, psychology, social work, nutrition, and pharmacy.
The organization refers to its health care approach as “behaviorally enhanced family health care.” Behaviorists are embedded in primary care clinics, and Cherokee provides a continuum of specialty behavioral health services. “That allows us to provide same-day, point-of-care access,” Khatri observed. “Nobody should have to wait even a day to see a development psychologist or behaviorist.” The organization emphasizes training in team-based care, since “a team of experts is not an expert team,” said Khatri. “It’s not just about being really good in your one area. It’s how do you be part of a team.”
The organization provides school-based health to 23 clinics, along with care coordination for children in the foster care system. It takes care of people who are migrants, refugees, or homeless, people “who are truly disenfranchised and vulnerable.” It also provides prenatal care, which has become much more pressing with the expansion of the opioid epidemic, Khatri said. Babies born with neonatal abstinence syndrome typically need one-on-one nursing care.
A tracking system has documented increased patient, family, and provider satisfaction; improved clinical outcomes; and improved health behavior change outcomes, which has allowed the organization to gain more resources to do better work for its patients. Another positive practice has been clinical immersion. “We have everyone shadow everyone on the team,” she said. “Our behaviorists shadow our primary care providers. Our medical providers shadow our behavioral providers. That’s been a very common theme, and combining that with mentorship is critical.”
Depending on the exact definition used, as many as 15 percent of children are affected by chronic illnesses, and the prevalence appears to be rising, observed Mary Ann McCabe, associate clinical professor of pediatrics at the George Washington University School of Medicine and an affiliate faculty member in applied developmental psychology at George Mason University. Examples include asthma (the most common illness), AIDS, cancer, cerebral palsy, congenital heart problems, cystic fibrosis, epilepsy, type 1 diabetes, and gastrointestinal conditions, such as Crohn’s disease, sickle cell anemia, and spina bifida. Chronic illnesses and medical treatments pose repeated and sometimes traumatic stress and interruptions to development. Some conditions and treatments are associated with cognitive
impairments, often to executive functioning. And psychological distress can and does impact health. Given these circumstances, rich opportunities exist for promoting behavioral health with these children and their families, McCabe observed.
All of the estimated 65 internship programs in pediatric psychology in the United States have some level of interdisciplinary team training with chronically ill children and families, McCabe observed. Postdoctoral fellowships also offer specialization with chronic illness. Two basic models inform this training. One is consultation or liaison with psychology or psychiatry, which was the first model to emerge and still exists in many major medical centers. The other is colocation, which is the model McCabe focused on in her presentation. Other health care disciplines commonly training alongside colocated psychologists include child life specialists, medical specialty fellows, nurses and nurse practitioners, nutritionists, pediatric residents, physical therapists, and social workers.
As an example of some of the knowledge competencies proposed for pediatric psychologists most relevant to chronically ill children and families, McCabe cited those developed by Palermo et al. (2014):
- Strong foundation in clinical child psychology, including an understanding of normative, adaptive, and maladaptive child emotional, cognitive, social, and behavioral development in the larger context of developmental expectations and caregiver behavior (i.e., family, schools, peers)
- Knowledge of biological, cognitive, social, affective, sociocultural, and life span developmental influences on children’s health and illness, including mechanistic and mediational pathways
- Understanding of pediatric acute and chronic illness, injury conditions, and medical management from the medical literature, including the effects of disease process and medical regimen on child emotional, cognitive, social, and behavioral development
- Knowledge of the role and effect of families on children’s health, and of health, illness, and medical management on family functioning
- Knowledge of the effect of socioeconomic factors on health and illness, including issues associated with access to care, diversity, and health disparities in children
- Understanding how other systems (e.g., school, health care, state and federal policies) affect pediatric health and illness and a child’s adaptation to illness
- Understanding the roles of other disciplines in health service delivery systems
- Knowledge of the transition of pediatric patients to adulthood and adult-oriented health care
She noted the same task force that produced these competencies also wrote that the future workforce will need “a new level of integration, communication, and shared decision making within and outside of a medical setting, [and] understanding interprofessional teams and team approaches to both maintenance of health and prevention of disease.”
McCabe suggested several mechanisms to achieve these competencies. Clinical rounds are often interdisciplinary with colocated psychologists. Psychosocial and behavioral rounds can focus specifically on psychosocial and behavioral health issues. Bereavement rounds can be helpful ways to process intense feelings and move on to caring for other children and families. Role playing can be “incredibly powerful,” McCabe said—for example, to help pediatric residents who have difficulty understanding why families are so upset. Consults with patients and other team members are a direct form of teamwork. Observations and modeling by psychologists can help other providers learn about behavioral health issues. Lectures and seminars are familiar, if not always the most effective teaching tool. The sharing of administrative responsibilities can help create a truly functioning team, and quality improvement activities can improve that functioning, she noted.
McCabe also discussed several innovations that can further workforce training. They include outreach to new populations, multidisciplinary inpatient or outpatient programs, automatic behavioral health consults and screening, quality improvement initiatives, and early exposure to the special issues facing children and families. As an example of the last item in this list, she briefly described a program in which medical students acted as big brothers/big sisters to cancer patients. “It was incredibly well received, and the medical students were wonderful and loved it for several years,” she recounted. However, when the medical student who started the program moved on to a residency, “it wasn’t sustainable, which is really unfortunate.”
A range of outcomes for integrated training with chronically ill children and families can be measured, including the number of consults, referrals for services, changes in the length of hospital stays or use of medications, changes in language or communications about behavioral health, graduates’ training practices and models of care, and qualitative feedback from families and professionals. For example, Maureen Monaghan in the Department of Endocrinology at Children’s National Health System has stated that qualitative interviews with medical providers using a psychosocial screening tool for depression have impacted their management of patients with diabetes, McCabe reported. The interviews allowed them to catch more patients at risk for behavioral health concerns and offer the provider the opportunity to ask more probing follow-up questions. However, McCabe
added, “we haven’t done a very good job yet of measuring the outcomes in training.”
Sustainability is a final issue. Consulting and liaison services can be supported through patient billing, which in turn can support behavioral health training across a hospital or health system. Colocation can be supported through medical specialty revenue and billing for behavioral health services. In particular, health and behavior codes can be used in the absence of a behavioral health diagnosis so that someone with a chronic illness or health condition can see a psychologist and the provider can be reimbursed. Grant funding, including for research, can augment salary support, and behavioral health research can drive colocation and integrated training opportunities. Finally, training in behavioral health can create an expectation for incorporating this aspect of care in all of one’s future positions.
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