Prior to beginning work on this be certain to have read all the required resources for this week I have attached them below with all there references as well.
The collaborative practice of clinicians across disciplines requires a shared language, appreciation of diagnostic and therapeutic paradigms, and recognition of appropriate roles within the
care team. This collaborative environment is at the heart of a
system that utilizes the skills and expertise of all its team members in appropriate and extended roles. This model of care delivery is often called integrated care (IC) or collaborative care (CC). Although this model is endorsed by many professional societies and agencies, the CC/IC care delivery model can fail due to multiple factors.
In your initial post, consider the clinical partnerships that result within the CC/IC delivery model. Integrating concepts developed from different content domains in psychology, address the following questions.
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- How might health care teams achieve therapeutic goals for individual clients?
- How does this support health literacy?
- What factors might lead to the failure of the CC/IC delivery model?
How might lack of acceptance of the value or viability of the CC/IC model by stakeholders, lack of awareness of the clinical competencies of various members of the team, barriers to
reimbursement for services, and lack of integration of support services within the practice cause a breakdown in efficacy?
- What supportive interventions within the CC/IC model address such issues?
In addition, consider how successful health care models assume an understanding of each profession’s competencies and responsibilities. For example, primary care providers (PCPs) are sometimes unaware of the abilities and practice scope of psychology professionals.
- Identify methods of targeted intervention and education for PCPs that might alleviate potential issues for the CC/IC model.
- Explain how the APA Ethical Code of Conduct can be used to guide decisions in these complex situations.
- Evaluate and comment on the potential work settings where you might find the CC/IC model. In what ways might this model provide more job satisfaction?
Two pages in length, APA style.
Auxier, A., Farley, T., & Seifert, K. (2011).
Establishing an integrated care practice in a community health center
Professional Psychology: Research and Practice, 42
(5), 391–397. doi:10.1037/a0024982
Funderburk, J. S., Fielder, R. L., DeMartini, K. S., & Flynn, C. A. (2012).
Integrating behavioral health services into a university health center: Patient and provider satisfaction
Families, Systems, & Health, 30
(2), 130–140. doi:10.1037/a0028378
Kelly, J. F., & Coons, H. L. (2012).
Integrated health care and professional psychology: Is the setting right for you?
Professional Psychology: Research and Practice, 43
(6), 586–595. Retrieved from
London, L. H., Watson, E. C., & Berger, J. (2013).
An integrated primary care approach to help children B-HIP!
Clinical Practice in Pediatric Psychology, 1
(2), 196–200. doi:10.1037/cpp0000014
Runyan, C. N. (2011).
Psychology can be indispensable to health care reform and the patient-centered medical home
Psychological Services, 8
(2), 53–68. doi:10.1037/a0023454
Soklaridis, S., Kelner, M., Love, R., & Cassidy, D.J. (2009).
Integrative health care in a hospital setting: Communication patterns between CAM and biomedical practitioners
Journal of Interprofessional Care, 23
(6), 655–667. Retrieved from https://library.ashford.edu/ezproxy.aspx?url=http%3A//search.ebscohost.com
Prior to beginning work on this be certain to have read all the required resources for this week I have attached them below with all there references as well.The collaborative practice of clinicians a
BRIEF REPORT An Integrated Primary Care Approach to Help Children B-HIP! Lorna H. London Rush-Copley Medical Center, Aurora, Illinois Erin C. Watson and Jared Berger Adler School of Professional Psychology, Chicago, Illinois This article outlines a collaborative health care initiative entitled “Be Happy, Involved, and Positive (B-HIP)”—a grant-funded program through the Illinois Children’s Health- care Foundation. The B-HIP program was developed in January 2009 at the Rush- Copley Medical Center to address the previously undiagnosed mental health care needs for pediatric patients in a primary care setting. This article seeks to illustrate how, through collaborative care, efforts are being made to assess and address the mental health care needs for pediatric patients, and is furthermore an attempt to share information about implementing a pediatric mental health screening for best practices of the proposed prevention program, “B-HIP.” The investigators applied the Pediatric Symptom Checklist (PSC) as a standard of care for identi ed pediatric patients. Along with anecdotal data of the B-HIP program, an outline of the theory, design, and implementation behind the program’s inception is presented. Keywords: primary care, family residency, pediatrics, integrated care, pediatric symptom checklist Medical residents, who are training to be- come independent practicing physicians, will often have patients who present with both medical and psychological illnesses. It is, therefore, increasingly important that they un- derstand ways to effectively assess and pro- vide basic care for these patients, and know when it is appropriate to refer these patients on for more in-depth mental health services. Primary care providers, who are a central part of health care for the majority of patients, are often the rst source of information and guid- ance for patients and their medical and per- sonal needs (Kelleher, Campo, & Gardner, 2006;McDaniel, Campbell, & Seaburn, 1995).More recently, studies have recommended the collaboration of mental health and pri- mary care to provide comprehensive care of pediatric populations with mental disorders, given the unique competencies professionals from these disciplines can offer (American Academy of Pediatrics, 2009;Kelleher et al., 2006). Health professionals in the realm of family medicine and pediatrics are at the fore- front of working with pediatric patients and their families. According to the literature, be- tween 10% and 21% of children who present to primary care of ces have mental health disorders that require treatment (Polaha, Dal- ton, & Allen, 2011). When available, mental health resources are often underused, and communication between providers is lacking (Wissow et al., 2008). Early diagnosis and mul- tidisciplinary management of children who need both medical and psychological management can lead to greater bene ts for children and their fam- ilies (McDaniel et al., 1995). The “Be Happy, Involved, and Positive (B-HIP)” program involves the practice of inte- grating medical and psychological services co- located in one setting to provide early identi – cation and treatment of pediatric mental health Lorna H. London, Family Medicine Residency Program, Rush-Copley Medical Center, Aurora, Illinois; Erin C. Wat- son and Jared Berger, Adler School of Professional Psy- chology, Chicago, IL. Correspondence concerning this article should be ad- dressed to Lorna H. London, PhD, Family Medicine Resi- dency Program, Rush-Copley Medical Center, 2000 Ogden Avenue, Aurora, IL 60504. E-mail:[email protected] rushcopley.com This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Clinical Practice in Pediatric Psychology © 2013 American Psychological Association 2013, Vol. 1, No. 2, 196 –2002169-4826/13/$12.00DOI: 10.1037/cpp0000014 196 problems. In light of the unique team composi- tion of the Rush-Copley’s Family Medicine Residency Program and in concurrence with the Medical Center’s mission to enhance and share strategies and educational tools, the authors aim to outline the theory, design, development, and implementation of our B-HIP program. Theory: Why Must We Build This Home? The B-HIP project was generously funded by the Illinois Children’s Healthcare Foundation and conducted in a Family Medicine Center and Residency Program located in a community hospital in a suburban region. The National Committee for Quality Assurance (NCQA) rec- ognizes the Family Medicine Center as a Pa- tient-Centered Medical Home (PCMH). The PCMH emphasizes individual, organizational, and systemic change, in addition to encouraging providers to participate in advocacy and policy endeavors to optimize primary care collabora- tion (Holtrop & Jordan, 2010). The goals of PCMHs are to integrate patients as active par- ticipants, integrate services and providers, offer the best available evidence-based and appropri- ate interventions, and achieve a comfortable and convenient coordination of treatment for the patient. The bene ts of mental health and medical care integration have been well documented. In the integrated care model, “providers support improved detection of behavioral health prob- lems through targeted or universal screening, focused assessment, brief interventions, and fol- low-up” (Rowan & Runyan, 2005, p. 11). Our tertiary integrated model positions all of our treatment team as collaborative providers in- cluding primary care physicians at the frontline, mental health providers supporting the primary care providers by bringing their expertise and support, and the patient and his or her commu- nity as collaborators in this population-based care approach (Rowan & Runyan, 2005). In addition to providing ongoing support for medical professionals, pediatric psychologists are well poised for a role within the integrated care team (Clay & Stern, 2005). They have an existing capacity to assess and provide treat- ment for children with Attention-de cit/ Hyperactivity-Disorder (ADHD), Anxiety, De- pression, and Autism Spectrum Disorders. They are able to provide psycho-education material tocolleagues and patients, and provide consulta- tion to improve patients’ care. As educators, pediatric psychologists can promote effective exchange of information through collaboration and coprecepting to improve medical residents’ con dence in identifying and treating pediatric mental health concerns (American Academy of Pediatrics, 2009). As evidenced by the B-HIP project, pediatric psychologists can write grants and initiate program development to bene t pe- diatric care. Design: Our Blueprint In an effort to achieve the goals outlined by the NCQA, the B-HIP project promotes the effective identi cation, coordination, and treat- ment of pediatric mental health problems to help children achieve an optimal state of phys- ical and emotional well-being. B-HIP has ve principal objectives: Curricular enhancements for primary care clinicians (PCCs) and mental health specialists to broaden skill sets to better assess the psycho- logical needs of children in the Family Medi- cine Center. Implementation of a universal mental health screening to promote early detection, prevention, and intervention among children and adolescents aged 5 to 17. The development and use of a tiered and individualized treatment based on the severity of symptoms and identi ed needs of patients, using evidence-based interventions and patient and family education. Utilization of case coordination to manage the needs of patients and families within the clinic and to facilitate linkage to community support services. Involvement of psychiatric consultation for patients diagnosed with disorders requiring psy- chotropic medication management and/or inpa- tient hospitalization. Development and Implementation: Building a Strong Foundation B-HIP focuses on training family medicine physicians in child development so that they may be better equipped to identify and assist with the treatment of childhood mental disor- ders. The B-HIP approach to enhancing the 197 HELPING CHILDREN B-HIP! This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. treatment of pediatric mental health involves the following four strategies. Education for Our Providers The rst step in enhancing the treatment of childhood mental disorders is educating our pri- mary care providers, particularly our family res- idents. Because family residents are often the rst point of contact for our patients, they are provided with the opportunity to screen for mental health issues and facilitate a discussion about treatment goals. Our pediatric psychologist contributed to ed- ucating our residents by offering weekly lec- tures to residents with topics includingCommu- nication with Families, ADHD School-Based Interventions, Human Development, Suicide Prevention,andBipolar Disorder in Children. Additionally, residents were required to at- tend the “B-HIP Connections Conference: Inte- grating Primary Care and Pediatric Mental Health,” where experts in mental and medical pediatric health presented on topics including the following:Adolescent Health Issues, ADHD Management in Primary Care,andBiopsycho- social Characteristics of Pediatric Obesity. PCCs and mental health specialists were re- quired to attend the sessions, and secondary providers were strongly encouraged to also attend. Lastly, our residents are observed by attend- ing medical faculty, pediatric psychologist, and child psychiatrist via the precepting process. Immediate feedback is given by attending phy- sicians’ pre-, during, and postvisit process. Most visits are also recorded via electronic video system and reviewed and evaluated by the pediatric psychologist. Finally, a consulting child psychiatrist is available for case discus- sion. To enhance the process for everyone, psy- chology practicum students are also given the opportunity to precept our family residents as they assess psychosocial symptoms and needs of our primary care pediatric patients. Screen Our Pediatric Patients Using Valid Measures B-HIP also strives to screen and detect men- tal health issues, so pediatric patients may re- ceive appropriate intervention at an early stage. Initially, the Pediatric Symptom Checklist(PSC) is used to assess pediatric patients that present with psychosocial issues, whether ob- served by the health care provider or reported by the patient and/or caregiver. The PSC is a 35-item questionnaire designed to improve the recognition and treatment of psychosocial prob- lems in children. Identi ed patients and care- givers were given the option to complete one of several versions of the form: the English or Spanish PSC parent form (PSC), the English or Spanish PSC-Youth Report (Y-PSC), or the pic- torial version (available in both English and Spanish). The Y-PSC can be administered to adolescents ages 11 and up. For children and adolescent ages 6 through 16, a cutoff score of 28 or higher indicates psychological impair- ment. For children ages 4 and 5, the PSC cutoff score is 24 or higher. The PSC is an empirically supported measure with 95% statistical validity (Navon, Nelson, Pagano, & Murphy, 2001). Im- portantly, the PSC tool allows us to screen both child and caregiver, broadening our conceptu- alization of health and demonstrating the impor- tance of collaborative care. Because the PSC is available in both Spanish and English, we are able to respond to the growing needs of the diversity of our patients. Our patients have mixed psychosocial condi- tions, including ADHD, Anxiety Disorder, De- pressive Disorder, Adjustment Disorder, Au- tism Spectrum Disorders, and V-Codes (e.g., relational or academic issues). Children who, based on their preliminary assessment, fall in the moderate to severe range of psychopathol- ogy are then assigned a mental health specialist. When necessary, the mental health specialist administers additional assessments and collab- orates with the primary care providers to de- velop an appropriate treatment plan. After the initial identi cation and assess- ment phase, treatments consist of empirically- based, individualized interventions, to try to address each child’s needs. Treatments in- clude a combination of individual, group, and/or commonly address bullying, con ict res- olution, time management, anger management, trauma/loss,living with ADHD, and self-esteem issues. There is no random assignment to treat- ment groups, nor is there withholding of treat- ment for any identi ed child. Fees associated with the operation of the program were initially covered by the grant. As the conclusion of the grant cycle has come to a close, psychology 198 LONDON, WATSON, AND BERGER This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. practicum students supervised by the pediatric psychologist continue services at no cost. Should the need arise for psychiatric care, the consulting child psychiatrist provides such ser- vices, and is reimbursed from the Family Med- icine Residency budget. Enhance Multidisciplinary Collaboration and Communication A key component of this program is the mul- tidisciplinary collaboration that is used to pro- vide assessment, education, and intervention. Our primary care providers consist of 12 resi- dents, four attending physicians, one pediatric psychologist, one consulting child psychiatrist, and four psychology practicum students. Throughout the last several years, we have also had two community licensed professional coun- selors and consulting community social work- ers. Because many of our patients and their families are Spanish-speaking, we have consis- tently had one or more Spanish-speaking mental health specialists. Collaboration between providers is facilitated through the educational components just dis- cussed, as well as on-site warm hand-offs, and electronically through the use of All- Scripts—an electronic program used by family physicians to enhance the delivery of integra- tive care. Warm hand-offs consist of a member of the clinical team being invited into the ex- amination room where a plan is coordinated for further care. Having the resident introduce the mental health specialist in a collaborative man- ner further assists the patient. This approach helps the patient understand the supplemental services available, increases compliance, and decreases the myths that often accompany clin- ical therapy (McDaniel et al., 1995). Importantly, we continue to nd new ways to address the barrier of a high turnover rate in trainees. Because our residents reside with us for three years and our psychology students for one year, we strive to develop a common mis- sion, appreciate respectful professional differ- ences, and promote a caring patient-centered community (McDaniel et al., 1995). Take It to the Community! This project coordinates mental health care and medical care, in the primary care setting,while allowing the health care team to also collaborate with schools and community-based organizations as needed. Importantly, the B- HIP project promotes collaboration beyond the professional interaction of medical and mental health professionals, to incorporate community members as part of the treatment team (McDan- iel et al., 1995). In an effort to provide ongoing comprehensive health care to pediatric patients, mental health specialists are able to provide school-based interventions at participating local school districts to monitor and ensure compli- ance of recommendations in alternative settings. In turn, schools act as a catalyst to minimize stigma associated with mental health concerns and maximize opportunity to serve as a com- munity partner. Open House: Final Thoughts and Preliminary Results To date, 625 pediatric patients have been screened and 110 have received clinical ser- vices. Preliminary data demonstrate positive outcomes regarding pediatric mental health screenings, utilization of outpatient counseling and psychotherapy services, and the effective- ness of working within the school– community system to enhance children’s medical and psy- chological well-being. The pediatric patients were almost equally male (49%) and female (51%), with a median age of 10 years. The patients self-identi ed as Hispanic (43%), Black (20%), White (20%), Biracial (5%), Asian (2%), or chose not to identify (10%). Pediatric patients’ visited the clinic mainly for school physicals (58%) or well-child visits (23%). In a matched comparison, youth re- ported signi cantly more symptomatology than their parents at initial screening. In general, parents rated male children with higher symp- tom scores than female children, and youth present for sick child visits rated their own symptomatology higher than other youth. Further data collection is necessary to dem- onstrate effectiveness and outcomes of the B-HIP project. Anecdotally it has been reported by our pa- tients that they bene t from receiving care in one location that can effectively coordinate ser- vices,reduce the obstacles in receiving treatment in a timely fashion, and promote early detection and intervention of mental health problems. By 199 HELPING CHILDREN B-HIP! This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. coordinating care with community-basedorgani- zations, we can provide comprehensive services to our youngest, and often most vulnerable pa- tients. To ensure that the mental health needs of our pediatric population are met, we continue to train our physician residents, to assist them in becoming more adept at assessing, diagnosing, and providing brief treatment for common psy- chiatric issues. We, as mental health specialists, create ongoing opportunities to break down the barriers of interdisciplinary collaboration. We have learned that even with the offer of free mental health services, offered at their medical home, there are still some barriers to overcome, including stigma of mental health services, environmental barriers (e.g., transpor- tation), bilingual services, and access to invalu- able team members (e.g., child psychiatrists, social workers). Additionally, parents who ini- tially express concern about their children’s emotional health are often delayed in seeking treatment, until matters reach a critical level. Prevention is still something that may not be seen as a priority for some of the participating families. Our future work will explore ways to minimize these barriers and increase opportuni- ties for continued interdisciplinary assessment and intervention. References American Academy of Pediatrics Committee on Psy- chosocial Aspects of Child and Family Health and Task Force on Mental Health. (2009). The future of pediatrics: Mental health competencies for pe- diatric primary care.Pediatrics, 124,410 – 421. doi:10.1542/peds.2009-1061 Clay, D. L., & Stern, M. (2005). Pediatric psychology in primary care. In L. C. James & R. A. Folen (Eds.),The primary care consultant: The next frontier for psychologists in hospitals and clinics(pp. 155–172). Washington, DC: American Psy- chological Association.doi:10.1037/10962-008 Holtrop, J. S., & Jordan, T. R. (2010). The patient- centered medical home and why it matters to health educators.Health Promotion Practice, 11, 622– 628.doi:10.1177/1524839910378485 Kelleher, K. J., Campo, J. V., & Gardner, W. P. (2006). Management of pediatric mental disorders in primary care: Where are we now and where are we going?Current Opinion in Pediatrics, 18, 649 – 653.doi:10.1097/MOP.0b013e3280106a76 McDaniel, S., Campbell, T. L., & Seaburn, D. B. (1995). Principles for collaboration between health and mental health providers in primary care.Fam- ily Systems Medicine, 13,283–298.doi:10.1037/ h0089075 Navon, M., Nelson, D., Pagano, M., & Murphy, M. (2001). Use of the pediatric symptom checklist in strategies to improve preventive behavioral health care.Psychiatric Services, 52,800 – 804.doi: 10.1176/appi.ps.52.6.800 Polaha, J., Dalton, W. T., & Allen, S. (2011). The prevalence of emotional and behavior problems in pediatric primary care serving rural children.Jour- nal of Pediatric Psychology, 36,652– 660.doi: 10.1093/jpepsy/jsq116 Rowan, A. B., & Runyan, C. N. (2005). A primer on the consultation model of primary care behavioral health integration. In L. C. James & R. A. Folen (Eds.),The primary care consultant: The next frontier for psychologists in hospital and clinics (pp. 9 –27). Washington, DC: American Psycho- logical Association.doi:10.1037/10962-001 Wissow, L. S., Gadomski, A., Roter, D., Larson, S., Brown, J., Zachary, C.,…Wang, M. C. (2008). Improving child and parent mental health in pri- mary care: A cluster-randomized trial of commu- nication skills training.Pediatrics, 121,266 –275. doi:10.1542/peds.2007-0418 Received February 14, 2013 Revision received March 6, 2013 Accepted March 10, 2013 200 LONDON, WATSON, AND BERGER This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Prior to beginning work on this be certain to have read all the required resources for this week I have attached them below with all there references as well.The collaborative practice of clinicians a
Integrated Health Care and Professional Psychology: Is the Setting Right for You? Jennifer F. Kelly Independent Practice, Atlanta, Georgia Helen L. Coons Independent Practice, Philadelphia, Pennsylvania Over the last decade, integrated care models have increased in both public and private sectors. This trend is especially apparent in primary care settings. Integrated care is designed to offer comprehensive and coordinated health services while addressing the economic realities and failures of the current health care system. Proposed integrated care models such as Accountable Care Organizations and Patient Centered Medical Homes include marked changes in health care delivery, financing, and reimbursement, which are designed to create a more cost-effective health system. This article provides an overview of integrated care to help practicing psychologists develop a better understanding of interprofessional health care and evaluate their interest in and readiness to provide professional services in health care. The advantages and challenges associated with integrated care will be provided. Keywords:clinical health psychology, integrated care, collaboration with physicians, professional issues, primary care The use of integrated care models has dramatically increased over the last decade in both public and private health care sectors. This trend is especially apparent in primary care settings, such as family practice and internal medicine, pediatrics, and women’s health (Trivedi & Grebla, 2011;Weisfeld, 2009), although inte- grated teams routinely provide care in specialty practices as well. This article will provide an overview of integrated care to help practicing psychologists develop a better understanding of inter- professional health care and evaluate their interest in and readiness to provide professional services in health care. Integrated care is in marked contrast to the more traditional and often fragmented approach to patient care, where providers acrossthe health disciplines operate on their own with consultative rela- tionships. Under this traditional silo approach, patient care is often compromised and usually costly. According to the Department of Health and Human Services, since the late 1990s, United States’ spending on health care increased at a faster rate of growth than the gross domestic product (GDP) and inflation (http://aspe.hhs.gov/ health/costgrowth, 2005). In 2004, a survey of American CEOs indicated that employee health care costs was the most prominent concern (Business Roundtable, 2004), and that many employers responded by requiring employees to increase their contribution or provided different forms of coverage. These changes consequently reduced the amount of household income available. Efforts to reform the American health care delivery system reflect the im- portance of improving the quality of care and reducing high costs associated with providing fragmented services (Amadeo, 2011; Patient Centered Primary Care Collaborative [PCPCC], 2011). In addition to financial costs, there is significant and important research on the human cost of the traditional health care approach. In the United States, it is estimated that over 130 million people have chronic health conditions and that 70% of all deaths are related to the chronic diseases (Loeppke, 2008). Effectively ad- dressing the challenges of increasing rates and disability associated with chronic conditions requires greater emphasis on the full continuum of prevention and basic primary care (Pelletier, Her- man, Metz, & Nelson, 2009). TheInstitute of Medicine (2001)defines integrated care as health care that is comprehensive, continuous, coordinated, and culturally competent and consumer centered. The organization, delivery, and management of services are brought together for the purpose of improving diagnosis, patient care, rehabilitation, and health promotion (Gröne & Garcia- Barbero, 2002). It is assumed that when services are integrated, there will be improved quality and efficiency of services.Kodner and Spreeuwenberg (2002)view the integration model as a step in Editor’s Note.This article is one of 11 in this special section on Visions for the Future of Professional Psychology.—MCR JENNIFER F. K ELLY received her PhD in clinical psychology from Florida State University. Board Certified in Clinical Health Psychology, she is the director of the Atlanta Center for Behavioral Medicine in Atlanta, Georgia. Her primary area of professional interest in research and clinical practice is health psychology, with particular interest in pain management, health disparities, and mental health advocacy. H ELEN L. C OONS received her PhD from Temple University, Philadelphia. She is a board certified clinical health psychologist; President and Clinical Director of Women’s Mental Health Associates—an independent practice that is colocated in women’s primary care and obstetrics and gynecology; and a Clinical Associate Professor of Psychiatry, Drexel University Col- lege of Medicine. Her professional interests include women’s health and mental health across the life span, behavioral health in primary care and specialty medical settings, continuing education, and advocacy. M IGUEL GALLARDO served as the action editor for this article. C ORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Jenni- fer F. Kelly, Atlanta Center for Behavioral Medicine, 2325 Log Cabin Drive, Ste. 105, Atlanta, GA 30080. E-mail:[email protected] Professional Psychology: Research and Practice© 2012 American Psychological Association 2012, Vol. 43, No. 6, 586 –5950735-7028/12/$12.00 DOI:10.1037/a0030090 586 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. the process of the health care deliverybecomingmore complete and comprehensive. Integrated care models are routinely used in a host of public and private health delivery systems. The Department of Veterans Af- fairs and the Department of Defense are national leaders in inte- grated care consultation and treatment models, team communica- tion, outcomes evaluation, and training (Trivedi & Grebla, 2011). In addition, Federally Qualified Health Centers in urban and rural communities and the Indian Health System have increasingly implemented integrated care models. Academic health centers routinely employ psychologists in primary and specialty care de- partments (Association of Psychologists in Academic Health Cen- ters, 2011). Kaiser Permanente and the Mayo Clinic are the two largest health care companies in the private sector that embrace the integrated model to patient care (Lawrence, 2005). Other managed care organizations as well as private insurance companies such as Blue Cross Blue Shield and Aetna appear to be actively position- ing their network providers to embrace this approach as well (Collaborative Family Healthcare Association, 2011;Patient Cen- tered Primary Care Collaborative, 2011). There is a growing body of knowledge that supports the clinical efficacy of integrative care practices. Research has evaluated phys- ical and mental health outcomes, as well as health care utilization (Pelletier, Herman, Metz, & Nelson, 2009). ThePatient Centered Primary Care Collaborative (2011)provides an excellent summary of the clinical and financial benefits of integrating behavioral health in Patient Centered Medical Homes (PCMHs; seewww .pcpcc.net). There are a broad range of benefits associated with integrating behavioral health care in primary care and specialty settings re- lated to decreasing the complexity of care while improving both access and satisfaction. First, mental health issues are routinely treated in primary care and specialty settings (Bray, Frank, McDaniel, & Heldring, 2004;James & Folen, 2005). In addition, in our busy world with competing responsibilities, “one stop” care is quite convenient for many women and men (Coons, Morgen- stern, Hoffman, Striepe, & Buch, 2004). One coordinated and efficient visit, for example, can readily include a routine check-up and HbA1C blood test for diabetes, a follow-up visit with the nutritionist to address appropriate food choices, and a brief session with a psychologist to identify strategies to improve adherence to medications and exercise.Individuals across ethnic groups and class are often reluctant to seek mental health treatment (Gary, 2005). However, when a patient is introduced to a psychologist as a “member of the team” by a provider with whom they already have a trusting relationship, they may be more receptive to a consultation in this setting compared with making an appointment with an unknown mental health provider at an unfamiliar location. When mental health, substance abuse and health psychology services are delivered in an integrated care setting, patients can consequently avoid the stigma all too often associated with traditional outpatient mental health/ psychiatric settings. Furthermore, integration of these services minimizes the lack of parity in insurance coverage for mental versus physical health services. When integrated health care teams are in the same community as patients, there are also often fewer geographic, cultural and linguistic barriers which further reduce health disparities in receiving mental health care (Coons et al., 2004). Differences Between Integrated Care and Multidisciplinary Care Historically, health care settings have used multidisciplinary models in contrast to integrated care teams. Multidisciplinary health settings are characterized by individuals from diverse health professions (e.g., psychologists, physicians, nurses, and physical therapists) who all bring their own expertise to patient care, col- laborate and communicate in a consultative model, but they may not necessarily work as a cohesive team. For example, multidis- ciplinary pain management programs often include pain manage- ment physicians such as anesthesiologists and physiatrists, physi- cal therapists, and psychologists working at the same facility. All the disciplines are present but they do not necessarily integrate their care. In contrast, integrated care models are characterized by interprofessional team collaboration and communication in all aspects of patient care, coordination, outcome evaluation, health profession training, and so forth. For excellent discussions of core team competencies for primary and behavioral health integration, seeInterprofessional Education Collaborative Expert Panel (2011) and Team-Based Competencies Conference Proceedings (2011), as well as the books listed inTable 1. Table 1 Useful Books On Psychologists in Integrated Primary Care Settings The Primary Care Toolkit: Practical Resources for the Integrated Behavioral Care Provider.Larry C. James, PhD Primary Care Psychology. Robert G. Frank, PhD, Susan H. McDaniel, PhD, James H. Bray, PhD, & Margaret Heldering, PhD Handbook of Primary Care Psychology.Leonard J. Haas, PhD Clinical Health Psychology and Primary Care: Practical Advice and Clinical Guidance for Successful Collaboration.Robert J. Gathchel, PhD, & Mark S. Oordt, PhD The Primary Care Consultant: The Next Frontier for Psychologists in Hospitals and Clinics.Larry C. James, PhD, & Raymond A. Folen, PhD Clinical Health Psychology in Medical Settings: A Practitioner’s Guidebook. Cynthia D. Belar, PhD, & William W. Deardorff, PhD Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention.Christopher L. Hunter, PhD, Jeffrey L. Goodie, PhD, Mark S. Oordt, PhD, & Anne C. Dobmeyer, PhD Health Care Ethics for Psychologists: A Casebook.Stephanie L. Hanson, PhD, Thomas R. Kerkhoff, PhD, & Shane S. Bush, PhD The Collaborative Psychotherapist: Creating Reciprocal Relationships with Medical Professionals.Nancy Breen Ruddy, PhD, Dorothy A. Borresen, PhD, & William B, Gunn, PhD Handbook of Cognitive Behavioral Approaches in Primary Care. Robert A. DiTomasso, PhD, Barbara A. Golden, PsyD, & Harry Morris, DO, MPH. Models of Collaboration.David B. Seaburn, Alan D. Lorenz, William B. Gunn, Jr., Barbara A. Gawinski, & Larry B. Mauksch. 587 INTEGRATED HEALH CARE AND PROFESSIONAL PSYCHOLOGY This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Differences Between Integrated Primary Care and Integrated Specialty Care The difference between primary and specialty care relates to the focus, time, and the scope of services provided. Delivering all the available evidence-based services can be a challenge to the pri- mary care provider, especially when the patients have severe, chronic, and persistent disorders. These patients will likely require consultation with the specialist (Wilson, 2008). Typically, in an environment where the provision of services are integrated, the primary care providers serve as the gatekeepers and are responsi- ble for the allocation of resources and controlling costs (Grumbach & Bodenheimer, 2002). The more the care is commingled between primary care clinicians and the specialists, there will be more of a need to develop strategies to coordinate the care (Peikes, Chen, Schore, & Brown, 2009;Schappert & Rechtsteiner, 2008). An example is a study conducted byLiss et al. (2011). They concluded that the high use of specialty care could adversely affect the ability of primary care providers to effectively coordinate care. They noted that the future studies should look at care coordination interventions that would allow for appropriate referrals for spe- cialty care without diminishing primary care providers’ ability to manage overall patient care. Accountable Care Organizations (ACOs) and PCMHs ACOs and PCMHs are examples of current efforts to greatly expand the use of integrated care models in the U.S. health care delivery system. These settings are designed to provide compre- hensive, patient-centered primary care services to patients, facili- tate partnerships between patients and providers and involve fam- ilies if appropriate, improve access to health care, ensure seamless coordination of clinical services with the continuum of care on site or through referrals assess health outcomes and care quality, and increase satisfaction and reduce costs (Allred, Wooten, & Kong, 2007;Berenson, Devers, & Burton, 2011;Homer, Klatka, & Romm, 2008;Schoen et al., 2007). Underlying the development of PCMHs and ACOs is the belief that more effective health care could be delivered if the interven- tion is better organized and coordinated (Betbeze, 2010). Accord- ing to theCenters for Medicare and Medicaid Services (2011), Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both deliv- ering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program (para 1). ACO programs offered by Medicare include Medicare Shared Savings Program, a fee for service program, Advance Payment Initiative and the Pioneer ACO Model which is a population based payment initiative for experienced providers. ACO are currently written into Federal Health Care legislation (i.e., the Affordable Care Act)with entirely different financial and reimbursement structures compared with the traditional fee for service cur- rently used by Medicare and Medicaid (Centers for Medicareand Medicaid Services, 2011). The entity or organization, not the individual providers, receives a capitation or a fee to take care of patients’ health care needs and functions under a pay for performance model, which includes financial penalties and re- wards. The premise is that the capitated system provides eco- nomic incentives to keep people healthy, as opposed to the fee-for-service model that needs to keep providing services for the ill to benefit economically. There are some concerns about this model of health care, in- cluding the fee schedule, which provides lower reimbursement than for traditional care (Mathews, 2012). It is not clear how psychology as a profession will fit into this model. While private insurance companies are developing and piloting PCMHs, many do not include psychologists in their new health delivery models. There are possible promising components of ACOs for psycholo- gists. For example, psychologists trained in integrated care are well trained to provide behavioral services and outcome evaluation in ACOs and PCMHs that have organizational structures and financial arrangements that emphasize prevention and mainte- nance care. PCMHs and ACOs reflect a dramatic paradigm shift in health care delivery, financing, and reimbursement. While it is not known what the time frame will be for full implementation of these models, health care will increasingly be delivered in integrated care settings in the public and private sector. Psychologists will need the fund of knowledge and clinical competencies to provide a host of psychological services within an interprofessional team under a different reimbursement structure (Coons, 2011;Rozen- sky, 2011,2012). Levels of Collaboration and Integration in Health Settings According toDoherty, McDaniel, and Baird (1996), while the goal of integrated care is ultimately to provide effective, seamless, coordinated care to patients across the life span and their families, levels of collaboration and integration in health settings vary greatly among psychologists and other health care providers.They describe five levels of collaboration and integration from none to off-site collaboration, colocation with collaboration but not integrated into the system, to fully integrated with systematic support. Most psychologists in independent or group practice have not been colocated or integrated into health settings, and often have little to no routine communication with referring health care providers (Ruddy, Borresen, & Gunn, 2008). Off- site collaboration with health providers involved in the care of mutual patients may include routine communication via phone, consult letter, and/or e-mail. More recently, psychologists in independent practice have started to colocate in medical set- tings in the private sector, although their services and roles are rarely fully integrated into the system (Coons & Gabis, 2010; Ruddy et al., 2008;Wender, Day, DiCaprio, & Un, 2011). Finally, psychologists may be fully integrated into the interprofessional team for patient assessment and treatment; communication during onsite patient encounters and through both electronic medical records (EMRs) and team meetings; program development and outcomes evaluation; health professional education; organizational leadership; and a host of other roles and responsibilities (James & Folen, 2005).Table 2summarizes the common roles and respon- 588 KELLY AND COONS This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. sibilities of psychologists in integrated health care settings and provides a comparison with traditional psychological services. Collaboration and Communication in Integrated Care Settings The models of mental health and behavioral health care in integrated care settings are quite different than traditional psy- chotherapy in outpatient or inpatient settings (James & Folen, 2005). Differences are apparent in the way referrals are made; approaches to assessment; the choice, implementation, and length of treatment modalities; communication with other pro- viders on the team; documentation options and details; and confidentiality among other issues (Hunter, Goodie, Oordt, & Dobmeyer, 2009). In integrated care settings, referrals and shared evaluation and treatment may take place with any mem- ber of the health care team. Referrals may come directly from physicians, nurse practitioners, physicians’ assistants, nurses, nutritionists, genetic counselors, physical therapists, social workers, medical assistants, and so forth. In some integrated settings, all patients are routinely seen by the psychologist as part of a comprehensive physical and psychosocial assessment. In Departments of Surgery, psychologists may see all patientswho are candidates for organ transplants or bariatric proce- dures. In Reproductive Endocrinology, psychologists may see any woman who wants to be an ovum (egg) donor. In other integrated practices, referrals are made on an “as needed” basis. Colleagues on the team may see the patient, couple or family with the psychologist, provide a brief introduction and do a “warm hand off” so that the psychologist continues the evalu- ation and immediately initiates treatment. For example, in in- tegrated primary care, the physician or nurse practitioner, phy- sician’s assistant or another provider may introduce a patient with stress related symptoms (e.g., headaches, gastrointestinal problems, initial and middle insomnia), and the psychologist would most likely immediately provide an initial assessment and start treatment instead of waiting to schedule another ap- pointment (Hunter et al., 2009;James & O’Donohue, 2009). In many integrated care settings, patients are routinely screened with validated assessment tools such as the Patient Health Ques- tionnaire (PHQ;Kroenke, Spitzer, & Williams, 2001) to assess for depression and anxiety disorders; alcohol screening tools such as the Alcohol Use Disorders Identification Test (AUDIT;Saunders, Aasland, Babor, de la Fuente, & Grant, 1993), and numerous other evidenced-based, problem-specific measures to screen for behav- Table 2 Comparison of Integrated Behavioral Health Care (IBHC) and Traditional, Nonintegrated Psychological Services Integrated behavioral health care (IBHC) Traditional, nonintegrated psychological services Level of collaboration Work collaboratively as a team Limited or no collaboration with referring health care provider Communication Communication during onsite patient encounters, through paper or electronic medical records, Vary from communication via phone to consultation letters and emails and team meetings Usually do not share records or send periodic updates Physical environment Located within primary care setting Independent or group practice located away from Multiple health care providers on site medical setting Space designed and overseen by practice, Solo or group practice hospital or health system May design on space Fast paced Assessment and Treatment Provide assessment and treatment while patient is on site Patient is given appointment based on opening on provider’s schedule Often use 5 A’s model to care: assess, advise, agree, assist, and arrange Patient seen for psychological evaluation, usually consisting of intake interview and testing. SBIRT approach to care: screen, brief intervention, refer to treatment Recommendations are based on evaluation results and the patient is scheduled for follow-up appointments Rapid assessment: Brief, problem focused 45- to 50-min sessions 15- to 30-min sessions Treatment may or may not be evidence based Number of sessions often limited Treatment to be evidence based Treatment and prevention focus Curbside consults with providers across health disciplines Crisis management sessions Refer for longer term care Clinical skills Competencies in health psychology and primary care work Expertise in health psychology preferred but not required Competencies to assess and treat patients from biopsychosocial perspective Knowledge in psychopharmacology and medication issues Competencies to work on interprofessional Knowledge in crisis management team Supervision skills Competencies in brief psychotherapy sessions aimed at treatment and prevention Knowledge of psychopharmacology and medication issues Knowledge in crisis management 589 INTEGRATED HEALH CARE AND PROFESSIONAL PSYCHOLOGY This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. ioral health issues and track clinical outcomes (Hunter et al., 2009; James & O’Donohue, 2009). While patients are routinely seen for the 45- to 50-min hour in traditional mental health settings, in integrated care settings, the treatment model is quite different. Often times, the teams use the 5A’s model to care or the Screen, Brief Intervention, and Refer for Treatment (SBIRT) approach to care. The 5A’s refer to assess, advise, agree, assist, and arrange. These models emphasize rapid assessment; brief, problem-focused psychological intervention; and referral as necessary (SAMHSA, 2012). Assessment and treat- ment sessions may last only 15 to 30 min for 3–5 sessions or just when the patient returns to follow-up with another member of the interprofessional team. In addition, other members of the team may conduct and document the follow-up. It has been estimated that primary care physicians prescribe 60% of psychotropic medications (Mark, Levit, & Buck, 2009; McGrath & Sammons, 2011), and 43% of patients that psycholo- gists treat take psychotropic medications (VandenBos & Williams, 2000). Psychologists are increasingly being consulted by primary care physicians on psychotropic medications, and it is believed that with increased training in psychopharmacology, psychologists will be of even greater value to the treatment team (McGrath, 2010; McGrath & Sammons, 2011). Integrated care settings frequently involve increased use of technology such as EMRs to facilitate clear and effective commu- nication with other members of the treatment team as well as outside collaborating providers. Psychologists in traditional prac- tice settings have been less likely to implement EMRs in general or with interoperability for several reasons, including the high cost associated with setting up the system. In addition, psychologists have not been included in the Medicare incentive program that would provide benefits to implement EMRs. The APA Practice Organization has been addressing this issue because of its impor- tance to the profession. ACOs and PCMHs emphasized in health care reform focus on interprofessional teams, prevention of disease, as well as outcome evaluation, such as improvement in health status, screening and prevention rates, patient satisfaction ratings and reduced costs. Consequently, psychologists in integrated care settings will have the opportunity to take leadership roles in team development; design, implementation, and evaluation of evidenced-based pre- vention programs; as well as outcome evaluation and health sys- tems research. Is Integrated Health Care a Good Professional Fit? If you are considering applying for a position as a psychologist in integrated care settings, engage in a careful self-assessment and self-study to make sure the professional setting is right for you and that you have the competencies to function effectively in a team- based health practice (Ruddy et al., 2008). Are you comfortable with differences in the culture of clinical medicine; differences in communication and confidentiality; shorter, problem-focused as- sessment and treatment; less control over when and where you see patients, couples. and families, and so forth? How will you feel if you are the only psychologist on site? Are you ready to work under a different payment structure? Do you have the clinical competen- cies necessary to work as a clinical health psychologist in inte-grated primary care or specialty health settings (Belar & Deardorff, 2009;Frank, McDaniel, Bray, & Heldring, 2004)? Culture and Language of Integrated Care Settings It is important to ask yourself whether you will enjoy a patient care setting that is problem focused with concrete, goal-driven recommendations. For example, when patients come with stress- related headaches and neck pain, assessment and treatment focuses on reducing symptoms (Arena & Blanchard, 2005;James & Folen, 2005;James & O’Donohue, 2009). Specific, action-oriented rec- ommendations are made, such as medications, cognitive– behavioral techniques, relaxation or mindfulness training, and/or a referral to physical therapy, and so forth. Discussion may or may not focus on underlying factors contributing to stress, and the patient may be referred to an outside mental health provider for ongoing treatment of complex psychosocial issues such as trauma, domestic violence, and ongoing caregiving challenges. Further- more, treatment and communication are problem focused to rap- idly reduce symptoms and improve well-being. The language of health settings is also remarkably different from mental health settings (Ruddy & Schroeder, 2004). Providers across disciplines typically speak to each other using technical words in a succinct manner with abbreviations and rapid commu- nication to the team and outside providers via the phone, e-mail, EMR, or dictations that are quickly disseminated (the same day or within a few days). Examples include using abbreviations such as “PRN” for “as-needed” and “po” for “by mouth.” In addition, communication with patients tends to be rather problem specific with concrete recommendations. Physical Environment in Integrated Care Settings It is important to ask whether you have a strong need to have control over your professional environment when working with patients. In addition, are you comfortable working with children and adults across the life span with acute, chronic, life threat- ening, and end stage physical conditions, including infectious diseases? In integrated health settings, you may see patients in examina- tion rooms instead of consultation rooms. You may have minimal input into how the office is set up or decorated, how treatments rooms will look, and so forth. Furthermore, health settings are fast paced and may be fairly noisy, depending on the practice location. Inpatient integrated care settings typically have bright lights, with routine messages on overhead speakers. In pediatric settings, you may hear children crying. These fast-paced environments are ex- citing for many, but can be stressful for other psychologists. Do You Have the Clinical Skills to Work in Integrated Health Settings? Working effectively in integrated care settings requires the fund of knowledge and clinical competencies necessary to provide high-quality, evidenced-based assessment, treatment, and preven- tion interventions within an interprofessional team (McDaniel, Hargrove, Belar, Schroeder, & Freeman, 2004). Core training in clinical health psychology; supervised experience in the specific integrated site; highly developed communication skills to work as 590 KELLY AND COONS This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. part of an interactive team with providers from varied disciplines; health and mental health outcomes assessment, and so forth are, at a minimum, essential as core training (Belar, 2011). It is also essential for psychologists to have the cultural competence neces- sary to work in both public and private integrated care settings. While core competencies in clinical health psychology are avail- able, many professional organizations developed competencies for interprofessional practice (Interprofessional Education Collabora- tive, 2011) and workforce development in primary and behavioral health care integration (American Psychological Association, 2011;SAMHSA-HRSA Center for Integrated Health Solutions, 2011). An increasing number of doctoral candidates participate in practicum and internships in integrated health settings. The Coun- cil of Clinical Health Psychology Training Programs (CCHPTP) has been providing opportunities to Directors of Clinical Training Programs to learn about curriculum in both clinical health psy- chology and integrated primary care. In contrast, psychologists in independent practice have fewer formal options to develop the competencies to provide services in integrated settings. Some individuals will choose to apply to a one or two year fellowship in integrated settings such as family practice, obstetrics and gynecol- ogy, pediatrics, neuropsychology, oncology, and so forth. While attending day-long continuing education workshops on integrated care are excellent opportunities for introductory training, they do not provide sufficient depth or onsite training to effectively work in these settings (Linton & Coons, 2011). While the certificate programs on integrated primary care do not typically require clinical supervision in the practice settings, some psychologists have arranged to shadow colleagues on a limited or regular basis to learn about brief models of assessment and treatment, interpro- fessional team communication, and documentation, among other roles and responsibilities.Bray (2004)andBray et al. (2004) provide comprehensive information on training opportunities in integrated and primary care. In addition, students can check the Association of Psychology Postdoctoral and Internship Centers (APPIC) directory to locate internships and postdoctoral programs with primary care experiences. Making the Transition to Integrated Health Settings Psychologists who are serious about making the transition to integrated settings are encouraged to engage in a formal self- assessment (Ruddy & Schroeder, 2004) and self-study over a year or two to obtain the necessary competencies to function effectively and contribute to interprofessional team care in this practice envi- ronment. If you are new to the health setting, you will likely need to establish competencies in both clinical health psychology and integrated primary or specialty care so that you can deliver evidenced-based services as part of an interprofessional team (Be- lar & Deardorff, 2009). Day-long continuing education workshops and ongoing certificate programs in integrated primary care are available in person and on line (Blount, 2011). In addition, contact colleagues in integrated health settings to discuss the possibility of shadowing them (Linton & Coons, 2011), and perhaps establishing a formal supervisory relationship for six months to a year. If you are considering colocation or integrating your work in a health setting, establish a formal contract with the medical practice or parent organization (Coons & Gabis, 2010). Psychologists haveestablished various agreements with providers and/or organiza- tions. For example, some individuals become formal employees of the practice while others are independent contractors. In both of these employment models, integration is more likely with shared use of patient records, fee schedule and billing of services. A number of psychologists have been paid by foundation grants to provide services on site. Some early career psychologists are also employed by and serve on integrated care teams in Federally Qualified Health Centers and receive loan repayment (Graduate Psychology Education Program, 2012). A small but growing number of psychologists are colocating in primary care settings but are self-employed or work for a mental health group (Coons, 2011;Ruddy et al., 2008;Wender et al., 2011). Irrespective of the employment or independent model, it is essential to clarify expectations of the providers and administrative staff, secure a contract, and collaboratively develop the agreement. At the very minimum, the contract should address the following: roles and responsibilities; the time frame spent on site; where patients will be seen; whether you will be able to chart in the practice’s paper or EMR; who will do billing; access to computers, Internet and copy machines; property and malpractice insurance; details related to signage, public relations/advertising and propri- etary issues; and the terms of the agreement (Coons & Gabis, 2010). Furthermore, if you are colocating but are either self- employed or employed by another organization (but not the med- ical practice), the contract should include formal lease arrange- ments and cost of the space, as well as all the issues listed above. In addition, the contract should include grievances processes and the quality assurance or evaluative requirements. It is important to note that contractual and payment issues for psychologists working on integrated care teams in ACOs and PCMHs will differ from the arrangements for psychologists who are integrated or colocated in health settings with different fiscal structures. ACOs and PCMHs will have different financing and reimbursement structures because care for individuals is capitated. States also differ in regards to whether psychologists can partner with physicians to contractually establish interprofessional prac- tices. For example, in Washington State, psychologists may estab- lish practice entities with physician partners while in other states, this arrangement is illegal (Anton, 2012). Obtaining legal counsel from a health law attorney is essential if you are considering the colocation model or partnership in an integrated care practice. Ethical Considerations Integrated care is an exciting and rewarding environment to provide evidence-based professional services to diverse children and adults with complicated and interacting physical, mental health and psychosocial issues. Core competencies also include understanding the complex ethical issues which can emerge in health settings when caring for patients as part of an interprofes- sional team, including providers from a range of health disciplines. In addition to understanding the often complex ethical issues in integrated care settings, the psychologist must know how to ad- dress these matters in practice with other providers. First and foremost, the psychologist must have knowledge and training in clinical health psychology and in integrated care. Ac- cording to Principle 2.01 of the APA Ethics Code (American Psychological Association [APA], 2010), psychologists should 591 INTEGRATED HEALH CARE AND PROFESSIONAL PSYCHOLOGY This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. only provide services “within the boundaries of their competence, based on education, training, supervised experience, consultation, study or personal experience” (p. 5). If they plan to work within this new area, they must obtain the necessary training, consulta- tion, or supervised experience. As discussed earlier in this article, the psychologist should consider in depth continuing education and supervised experience in health care settings, especially in integrated primary and specialty care. The training should also include working with interprofessional teams and knowledge of psychopharmacology. Psychologists in integrated health care set- tings are routinely approached about various medications, in par- ticular psychotropic medications. Unless the psychologist is prac- ticing in a state with prescription privileges or within the Department of Defense areas that allow psychologists to prescribe, they should acknowledge the limits of their practice (Haas & DeGruy, 2004;Papas, Belar, & Rozensky, 2004;Tovian, 2006). For our psychology workforce to be fully prepared to respond to changes in health care delivery, training in integrated primary care needs to be part of the core training in graduate programs, intern- ships and during the postdoctoral fellowships. In addition, creden- tialing in the health setting will become increasing important as ACOs and PCMHs focus on providing evidenced based care with measurable outcomes. Psychologists should consequently seri- ously consider board certification (Kaslow, Graves, & Smith, 2012) in clinical health psychology (Tovian, Rozensky, & Sweet, 2003), and possibly in the future, in integrated primary care (Coons, 2011). Another key ethical consideration in integrated care settings involves confidentiality. Providers across the health professions have different expectations and experiences around private health and mental health information (Ruddy & Schroeder, 2004). It is well known that there is not the same degree of confidentiality when working in a medical facility as one would have in an independent practice facility (Robinson & Baker, 2006). Numer- ous health care providers will have access to the health records, including physicians, nurses, and office staff. This is even more evident now with the use of EMRs. Furthermore, in some health systems, patient portals allow adults to access portions of their own health records (University of Pennsylvania Health System, 2011). Psychologists should strive to adhere to the APA Record Keeping Guidelines (American Psychological Association, 2007), which also addresses EMRs. According to the Guidelines, electronic records should be created and maintained in a way that will protect their security and confidentiality, as well as appropriate access, and they should be compliant with ethical and legal requirements. Psychologists need to become aware of the unique aspects of electronic record keeping in their particular integrated practice settings. The possible limits of confidentiality, methods of han- dling release of information requests, charting or electronic data storage practices, consultation, and team meeting practices should be presented to the patient at the outset of treatment, and ideally, should be presented in written and oral form. Another ethical consideration relates to informed consent and patient autonomy. Specifically, there may be situations when a patient is required to be evaluated or treated by a psychologist before they receive certain forms of medical care, such as medi- cations and certain procedures. For example, adults requesting bariatric surgery or the spinal cord stimulator device typically undergo a required psychological evaluation. The patient may beresistant to participate in such services but feels they are being forced to do so in order to receive the desired treatment (Taylor, 2001). Not only does this create an ethical dilemma for psychol- ogists in integrated care settings, but it also can impact psycho- logical intervention. According to Code 3.10 of the APA Code of Ethical Principles (American Psychological Association, 2010), it will be important for the clinician to obtain the informed consent of the patient using language that the patient can understand, and the consent needs to be appropriately documented. The principle of beneficence requires that a psychological com- ponent is offered if it is deemed to be an appropriate and positive treatment for the patient, but when a patient feels coercion to treatment, it can violate patient autonomy. The psychologist work- ing in the integrated care setting needs to work cooperatively and jointly with members of the treatment team to ensure autonomous consent. In addition, the psychologist should explore these possi- ble concerns with patients. Finally, termination of services may pose a challenge in inte- grated care settings. There may be times when termination of services is a decision that is influenced by factors outside of the psychologist’s control, such as when the physician may decide to no longer treat the patient because of adherence related issues (e.g., repeated no shows for appointments). Code 10.10 of the APA code of Ethical Principles notes that “Except where precluded by the actions of clients/patients or third party payers, prior to termination psychologists provide pretermination counseling and suggests al- ternative service providers as appropriate” (American Psycholog- ical Association, 2010, p. 13). If this situation were to arise, psychologists in integrated care settings need to work with their interprofessional team to ensure that patients or families have appropriate referrals for mental health, substance abuse and/or health psychology services. Summary As health care reforms are implemented across both public and private health systems, and the integrated care model becomes more common for the delivery of mental health, substance abuse, and health psychology services, the future of traditional small and independent mental health practice becomes unclear (Coons, 2011). Some psychologists will no doubt continue to provide fee-for-service mental health care to some sectors of the popula- tion. In addition, psychologists with specialty practices (e.g., fo- rensic psychology and executive coaching, etc.) are likely to continue to work in their private models, although others, such as some sports psychologists, may be employed by orthopedics/ sports medicine settings (Hays, 2012). Working in an integrated care setting can be an extremely satisfying professional and personal experience. In both primary care and specialty settings, psychologists typically provide con- sultation and treatment on an impressive range of physical, mental health, substance abuse, psychosocial, health behavior, and other complex issues. Often times, problems are interacting, and require careful differential diagnostic skills and flexible, multimodal treat- ment approaches. In addition, care may be focused on children, teens, and adults across the life span, and diverse families coping with a host of challenges. Evaluation, consultation, and brief treatment are also provided in the context of the interprofessional care team. The fast-paced work setting consequently allows for 592 KELLY AND COONS This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. rapid intervention and is far less isolating than traditional psychol- ogy practices. Integrated settings are defined by the diverse range of health providers with the shared goals of evidenced based, collaborative and effective care. With proposed Federal and State changes in the delivery, financing, and payment of health care, as well as private and public sector shifts to comprehensive care models, more children and adults will be receiving their care in integrated settings. A portion of psychologists are already well positioned in these practices as key members of effective and efficient interprofessional health care teams. We need, however, to greatly expand our workforce credentialed for work in primary care (Belar, 2011;Rozensky, 2011) and specialty settings, as well as our advocacy efforts at the Federal, State, local, and private insurance company level to ensure that we are included in the broad range of integrated medical practices for the decades to come. Al- though there may be challenges associated with the integrated care model to health care, it clearly has numerous advantages, such as providing a more coordinated and less fragmented approach to patient care. The data underscore that this practice approach is being em- braced by public and private organizations. It is up to the individual practitioner to determine if it is the right approach and professional home for them. References Allred, N. J., Wooten, K. G., & Kong, Y. (2007). 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Miller, PhD,Department of Psychology, SUNY-Binghamton ●Journal of Experimental Psychology: Applied(http://www.apa.org/pubs/journals/xap/),Neil Brewer, PhD, School of Psychology, Flinders University ●Neuropsychology(http://www.apa.org/pubs/journals/neu/),Gregory G. Brown, PhD, ABPP, UCSD School of Medicine and Veterans Affairs San Diego Healthcare System ●Psychological Methods(http://www.apa.org/pubs/journals/met/),Lisa L. Harlow, PhD,De- partment of Psychology, University of Rhode Island Electronic manuscript submission:As of January 1, 2013, manuscripts should be submitted electronically to the new editors via the journal’s Manuscript Submission Portal (see the website listed above with each journal title). Current editors Anthony Dickinson, PhD, Wendy A. Rogers, PhD, Stephen M. Rao, PhD, and Mark Appelbaum, PhD, will receive and consider new manuscripts through December 31, 2012. 595 INTEGRATED HEALH CARE AND PROFESSIONAL PSYCHOLOGY This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.