By: Dina Goldstein Silverman, PhD
Cooper University Health Care
I am a residency-trained health psychologist, currently employed at a major university hospital. As such, I work side by side with a vibrant and diverse multidisciplinary treatment team and frequently have to reach across the aisles to mental health colleagues in other disciplines (e.g., psychiatrists, social workers, and advanced practice nurses) as well as non-psychiatry physicians, physician assistants, nurses, physical and occupational therapists, speech pathologists, dietitians, and hospital administrators. At Cooper University Health Care, our motto is, “One Team. One Purpose.” This is a great guidepost for those of us vested in integrated health care. We all work hard to benefit our patients – their improved physical health and their behavioral health, well-being, and interpersonal growth. However, my colleagues employed in more traditional psychotherapy settings occasionally express their concerns that in integrated care settings, shorter session times and session limits may preclude patients from receiving the depth of psychotherapy that they may accrue in a typical psychotherapy setting, that of a 50-minute hour, every week. In this article, I will address the benefits of integrated behavioral health and highlight how this model results in more efficient and effective delivery of mental health treatment, facilitating access to care for all patients, including those who may have long-standing barriers to accessing traditional psychotherapy.
Primary care medicine has been the leading provider of mental health services in the United States for decades (Jacobs, Brieler, Salas, Betancourt, & Cronholm, 2018). Research suggests that in the past two decades, psychologists have been playing an increasingly larger role in primary care settings (Robinson, & Strosahl, 2009). At the same time, primary care medical settings have begun to transition from a strictly biomedical model to an increasingly holistic, biopsychosocial perspective (Bluestein, & Cubic, 2009). In fact, family medicine residency programs have increasingly employed psychologists as core faculty involved in training resident physicians in assessment and treatment of anxiety and depression, as well as providing them with tools to increase medication adherence, compliance with appointments and cessation of harmful behaviors by teaching residents motivational interviewing and equipping them with rudimentary counseling strategies (Jacobs, Brieler, Salas, Betancourt, & Cronholm, 2018). Psychologists have also been able to educate family medicine residents in family systems theories, helping them provide culturally competent care geared towards the benefit of the patient and the patient’s family. At the same time, behavioral health integration, a system of involving mental health professionals, including psychiatrists, psychologists, licensed clinical social workers, nurses, etc. in primary care clinics, has repeatedly been shown to improve patient satisfaction, reduce costs, improve social function for patients with depression, and increase access to care for vulnerable populations that traditionally struggle with limited resources, low socioeconomic status, and being underinsured or uninsured (Fisher, & Dickinson, 2014; Sadock, Perrin, Grinnell, Rybarczyk, & Auerbach, 2017; Solberg, Crain, Maciosek, et al., 2015; Woltmann, Grogan-Kaylor, Perron, George, Kilbourne, et al., 2012). The seminal study by Katon et al. addressed the evidence for clinical effectiveness of primary care integration in the treatment of depression extensively, spurring the growing trend and increased interest in this mode of practice. Both Dr. Katon, Dr. Blount, and their teams have written watershed books summarizing the current research on the best practices in integrated care, its clinical effectiveness, cost effectiveness, and legislative information on implementation and payment structures of this form of care (Blount, 2019; Ratzliff, Unutzer, Katon, & Stephens, 2016).
In fact, behavioral health integration often allows primary care clinics to function as a gateway to mental health services. For instance, African Americans are more likely to seek mental health treatment from a primary care provider than from a mental health provider, and behavioral health integration can help provide continuity of services for this population and many others that for reasons of racism, historical abuses towards People of Color in the mental health system, financial concerns, and societal stigma may not seek traditional mental health services (Nilsson, Berkel, & Chong, 2019; Snowden, & Pingitore, 2002). The three primary models of behavioral health integration include collaboration, colocation, and full integration. In a collaborative model, the primary care office and the mental health provider are located in different locations and communicate with one another with varying degrees. In a collocated model, there is physical proximity and different care structures, and in a fully integrated model, care delivered in intentional team care with warm handoffs, shared records and multidisciplinary care coordination (Heath, Wise Romero, & Reynolds, 2013).
In a warm handoff scenario, a primary care provider may notice an elevation on the PHQ-9, a depression screening tool of a new patient, or an existing patient may complain of worsening anxiety, family problems, or concerns stemming from a recent adverse event, ranging from a motor vehicle accident that left that patient with an exaggerated startle response, tachycardia, nightmares, early insomnia and racing thoughts, or a work stressor that left the patient perseverating about their work performance. With the psychologist located in the same office, the physician has an opportunity to offer psychological services in-house, bring the psychologist into the exam room with the patient’s consent and have the patient be further evaluated to assess the extent of depressive or anxious symptoms. If the patient has time at that visit, the psychologist may then spend time meeting with the patient in an adjoining office and addressing the patient’s acute concerns. This may be teaching the patient diaphragmatic breathing, progressive muscle relaxation and guided imagery, providing the patient with psychoeducation about sleep hygiene, or engaging the patient in motivational interviewing to resolve the patient’s ambivalence about quitting smoking, arriving to the appointment in a timely fashion, or taking medication. The visit may be a one-time information session or a consultation leading to a brief therapeutic relationship that takes place on the same day and in the same space as the patient’s follow-up primary care visit. The advantages to the patient are manifold: reduced time off work, reduced transportation costs, a reduction in perceived stigma of mental health services, and direct access to a mental health provider.
Subsequent sessions are typically set up in the same office space, and they are approached from an evidence-based standpoint – in some cases, the sessions focus on addressing symptoms of depression or anxiety, and in other cases, adjustment to chronic illness, substance misuse or abuse and binge eating, or grief and coping with significant life stressors. There are certainly quite a few instances when what had begun as a brief consultation leads down the road to a traditional psychotherapeutic relationship. However, there are also cases when that brief relationship is sufficient to address the patient and the doctor’s concerns for the time being, although the patient may choose to follow up with the psychologist intermittently, or the psychologist may periodically reach out to check in with the patient. Another advantage to behavioral health integration is the presence of electronic medical records. As a psychologist supporting a large bariatric surgery practice with three surgeons, five advanced practice nurses, two physician assistants, four dietitians, and multiple nurses, I rely heavily on our shared electronic medical records for information on our shared patients. Electronic medical records allow me to communicate in real time with the rest of the bariatric team about my interactions with patients, provide feedback to the team, ask the team questions, and communicate patient concerns. I am also able to help advocate on behalf of the patients. At our monthly multidisciplinary team meetings, the entire team sits down to discuss the pre-operative patients that we have concerns about from surgical, nutritional, and psychological standpoints, as well as our post-operative patients that may struggle with weight regain or emotional eating, disordered eating behaviors, depressive symptoms, family problems, or any other concerns. Working in the trenches, side by side with the team, allows me to target concerns quickly and assist the patient in reaching the patient’s goals while also supporting the team’s goals in taking care of our patients. For my own personal benefit, I enjoy the ability to learn not only from my patients and psychologist colleagues, but from the physicians, advanced practice providers, dietitians, nurses, therapists, and other medical professionals I work with and gain insights, perspectives, and knowledge that further my skill development as a psychologist.
Dina Goldstein Silverman, PhD, is a licensed psychologist in New Jersey and Pennsylvania and Assistant Professor of Psychiatry and Psychology at Cooper University Health Care and Cooper Medical School of Rowan University. Her functions at Cooper include conducting pre-operative bariatric evaluations and pre- and post-operative psychotherapy with patients enrolled in the Cooper Center for Metabolic and Bariatric Surgery, as well as psychotherapy and psychological evaluations with other outpatient populations with co-morbid medical and mental health conditions. She is also involved in developing a comprehensive outpatient behavioral support program for bariatric patients. She teaches didactics in evidence-based psychotherapies and provides individual supervision to psychiatry residents, medical students, and psychology post-doctoral residents in clinical health psychology. Dr. Goldstein Silverman received her education at the University of Texas at Austin, Teachers College, Columbia University and Temple University, and she completed her internship at the Trenton Psychiatric Hospital, and her post-doctoral residency in clinical health psychology at the VA Connecticut Health Care System. She has presented on various topics in health psychology regionally and nationally and has co-authored several publications in peer-reviewed journals. In her spare time, she loves to hang out with her husband and children, travel, cook, bake, and volunteer with her synagogue. She lives in the “Jersey-delphia” area of southern New Jersey.
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