Resolution on Psychologists in Integrated Primary Care and Specialty Health Settings

Adopted by Council of Representatives in August 2016.

Introduction

Children, adolescents and adults across the life span frequently face serious threats to their health and well-being. Psychologists have spent over five decades in integrated primary care and specialty health settings conducting research with and providing evidence-based professional services to a diverse array of patients, families, and hospitals. With ongoing health care reform in the United States, our public and private health systems are focused on improving population health through interprofessional teams to increase access to comprehensive physical and behavioral health care and prevention interventions; assessment of patient, provider and health system outcomes; as well as new service delivery, business and financing models to reduce costs. These changes are associated with both opportunities and challenges for psychologists across the career trajectory in and outside health settings.

As part of the American Psychological Association's strategic goal to "expand psychology's role in advancing health" (American Psychological Association [APA], 2009) and the APA Presidential Task Force on the Future of Psychology Practice Final Report (APA, 2009), this Resolution on Psychologists in Integrated Primary Care and Specialty Health Care Settings aims to encourage and support American Psychological Association policies and initiatives that advance evidence-based, interprofessional approaches to patient and family health.

WHEREAS children, adolescents, and adults of all ages frequently receive their physical and mental health care in primary care settings includingpediatrics, family medicine, general internal medicine, geriatric medicine, and obstetrics and gynecology (Coons, Morgenstern, Hoffman, Streipe, & Buch, 2004; Poleshuck & Woods, 2014; Roberts & Steele, 2009; Stancin & Perrin, 2014), and deal with complex psychosocial and behavioral health challenges when coping with serious illness treated in specialty medical departments such as cardiology, pulmonology; surgical, medical and radiation oncology; reproductive endocrinology; maternal fetal medicine; urology, and urogynecology; neurology and physical medicine and rehabilitation care; general and transplant surgery; endocrinology; orthopedics and sports medicine; gastroenterology; infectious disease; psychiatry; emergency medicine; palliative care, long-term care, as well as school, military, and correctional health care.

WHEREAS primary care is considered the "de facto" mental health system (Regier, Narrow, Rae, Manderschied, Locke, & Goodwin, 1993) where at least 60% of medical visits have psychosocial components; approximately 20% of primary care patients meet criteria for a diagnosis of depression, and roughly 15% have generalized anxiety (Robinson & Reiter, 2007); depression, anxiety, obesity and smoking are frequently initially treated in primary care settings in adult patients; and attention deficit disorder is typically treated in pediatric primary care.

WHEREAS depression causes more disability than heart disease or diabetes and is projected to become the single greatest cause of disability worldwide by 2030 (WHO, 2016); frequently co-occurs with and complicates chronic conditions such as cardiovascular disease, diabetes, obesity, asthma, chronic pain, epilepsy, HIV, and cancer (APA, 2014; Jensen & Turk, 2014; Sherr, 2011); and is associated with increased utilization of medical care (Simon, 2001), poor adherence to treatments for diabetes (McKellar, 2004), HIV (Gonzalez, J. S., Batchelder, A. W., Psaros, C., Safren, 2011), heart disease (Gehi, Haas, Pipkin, & Whooley, 2005; McGrady, McGinnis, Badenhop, Bentle, & Rajput, 2009), increased adverse events during drug treatment (Mitsikostas, Mantonakis, & Chalarakis, 2014), and increased risk of prescription opioid misuse (Grattan, Sullivan, Saunders, Campbell, & Von Korff, 2012).

WHEREAS the annual costs of treating health conditions such as hypertension, heart disease, diabetes, and asthma are significantly higher when patients have co-occurring mental health conditions such as depression and anxiety (Petterson, Phillips, Bazemore, Dodoo, Zhang, & Green, 2008).

WHEREAS anti-depressant (Mojtabai & Olfson, 2015), anxiolytic, stimulant, and sleep hypnotic medications are most frequently prescribed in primary and specialty care settings by professionals who are not mental health specialists.

WHEREAS behavioral factors such as tobacco and substance abuse, limited exercise or physical activity, poor nutrition, and risky sexual behaviors are associated with chronic physical conditions, such as heart and pulmonary disease, cancer, HIV and other infectious conditions; and these collectively account for 41% of mortality from leading causes of death in the United States (Mokdad, Marks, Stroup, Gerberding, 2004; Murray, 2013).

Gender, "At Risk" Populations, and Health Disparities in Primary Care and Specialty Health Settings

WHEREAS women across the life span have higher rates of routine clinical encounters in primary care settings (i.e., obstetrics and gynecology, family and internal medicine) and in specialty settings (Blackwell, Lucas, & Clarke, 2014), and report increased satisfaction with comprehensive, integrated health services in one location.

WHEREAS access to psychological services through the US Department of Veteran's Affairs (Kearney, Post, Pomerantz, & Zeiss, 2014) and US Department of Defense (Hunter, Goodie, & Dobmeyer, 2014) healthcare systems allows for primary care settings to provide behavioral healthcare to veterans, active duty, and retired service men and women and their families. Psychologists are routine members of the VA's Patient Aligned Care Teams dedicated to providing comprehensive, integrated health services.

WHEREAS underserved, uninsured, racially/ethnically diverse and immigrant children, adolescents, and adults receive primary and specialty care in Federally-Qualified Community Health Centers, through the Indian Health Service, school and prison-based health centers and other safety net health settings across the country where psychologists address mental health, health behavior, and substance abuse issues to reduce health disparities and improve population health; and provide linguistically and culturally appropriate assessment for diverse populations.

WHEREAS a higher percentage of individuals in rural America live below the poverty line, and they have less access to primary care, special medical services, mental health and substance abuse treatment. In addition, adults, adolescents, and children in rural areas receive less preventive care and have higher rates of all chronic diseases than individuals in urban environments (Agency for Healthcare Research and Quality [AHQR], 2004; Bailey, 2010).

WHEREAS adults with serious mental illness treated in the public health system on average have higher mortality rates than their age cohorts in the general population. This disproportionately higher mortality rate is related to a number of interacting factors such as suicide and injury, under-treatment of chronic physical conditions, and side effects of medications frequently used to treat psychotic conditions (Colton & Manderscheid, 2006; Parks, Svendsen, Singer, Foti, & Mauer, 2006; Eaton, Roth, Bruce, Cottler, Wu, Nestadt, Muñoz, 2013).

WHEREAS three quarters of a dults age 65+ have multiple chronic conditions (Anderson, 2010) and account for nearly 1/3 of physician visits (Cherry, Lucas, & Decker, 2010) and prefer psychology services integrated with primary care (Gum, Arean, Hunkeler, Tang, Katon, Hitchcock,...Unützer, 2006); and patient-centered, team-based, primary care is effective in the delivery of mental health and substance use services for many older adults (Institute of Medicine, 2012).

WHEREAS facilitating the involvement of same-sex partners in treatment, or intervening when medical staff mis-gender patients can be critical roles for psychologists in integrated primary care settings (Israel, Walther, Gortcheva, & Perry, 2001).

WHEREAS people with disabilities account for approximately 19% of the US population (Brault, 2012) and are prone to poorer health outcomes than individuals without disabilities (Horner-Johnson, Dobbertin, Lee, & Andresen, 2013); people with disabilities experience higher rates of obesity, cardiovascular disease, and diabetes than people without disabilities (Reichard, Stolzle, & Fox, 2011); and institutional and societal factors limit access to physical and behavioral health services (Johnson & Woll, 2003).

Patient and Health System Outcomes and Barriers to Care in Integrated Health Settings

WHEREAS research has demonstrated that the inclusion of psychological and behavioral health services in primary and specialty care settings is associated with a range of improved patient and health system outcomes. Primary care behavioral health interventions have been shown to: reduce symptoms, psychological distress and insomnia (Hunter et al., 2014); improve adherence to treatment recommendations (Katon, 2012); decrease emergency room visits and hospitalizations (Blount, Schoenbaum, Kathol, Rollman, Thomas, O’Donohue, et al., 2007); and result in a cost offset of 20-40% for primary care patients (Collins et al., 2010). In addition, psychological interventions are preferred to pharmacological interventions among older adults with depression, who have two times the number of primary care visits as middle-aged adults (Ashman, Talwalker, & Taylor, 2014; Gum et al., 2006). Furthermore, psychosocial and behavioral interventions in specialty health settings have been shown to improve patient outcomes in cardiology (Dunbar, Dougherty, Sears, Carroll, Goldstein, Mark,...Zeigler, 2012; Peterson & Kim, 2011), reproductive endocrinology (Frederiksen, Farver-Vestergaard, Skovgård, Ingerslev, & Zachariae, 2015), HIV, (Spies, Asmal, Seedat, 2013; Crepaz, 2008) and oncology (Andersen, Farrar, Golden-Kreutz, Glaser, Emery, Crespin, Carson, 2004; Jacobsen & Wagner, 2012).

WHEREAS research has demonstrated the utility and value of psychological and neuropsychological assessment for a broad range of health conditions. Evidence-based assessment plays a central role in the ongoing evaluation of affective, behavioral, cognitive, personality, and functional status; improvement or decline in relation to medical and behavioral health diagnoses and interventions; predicting surgical outcomes; and providing treatment recommendations to improve the quality of care and quality of life for patients (Celestin, Edwards, & Jamison, 2009; Carragee, Alamin, Miller, & Carragee, 2005; den Boer, Oostendorp, Beems, Munneke, Oerlemans, & Evers, 2006; Meyer, Finn, Eyde, Kay, Moreland, Dies, & Reed, 2001).

WHEREAS integrated services, such as pre-surgical psychological evaluations, pre-opioid therapy psychological evaluations, psychological evaluations for chronic pain, and psychological treatments for managing medical conditions, reduce health care costs and disability (Bruns, Mueller, & Warren, 2012).

WHEREAS some federal and state reimbursement regulations may compromise interprofessional approaches to mental health and substance abuse in primary care and specialty health settings and thus contribute to fragmented care, disparities in care, and reduced access to care.

Psychology Workforce in Integrated Care Settings

WHEREAS psychologists have routinely provided clinical services in pediatric, adult, and geriatric primary care; specialty medical practices; and other health settings for more than five decades with varied professional responsibilities including: consultation, screening, psychological and neuropsychological assessment; collaborative treatment with other health care professionals; quality improvement, program development and evaluation; interprofessional health provider and community education; health provider communications training and coaching; grant writing and research; patient and health system outcomes evaluation; as well as administrative and leadership roles.

WHEREAS psychologists working in pediatric, adult, and geriatric primary and specialty health settings have documented competencies necessary to provide evidence-based clinical and professional services, interprofessional education and research, and leadership (APA, 2008; APA, 2014; See APA Recognized Specialties and Proficiencies in Professional Psychology).

WHEREAS the American Board of Professional Psychology (ABPP) oversees 15 psychology specialties with four board certifications specifically related to the care of patients in health settings including: clinical health psychology, rehabilitation psychology, clinical neuropsychology, and geropsychology. Furthermore, a significant number of colleagues who are board certified in child and adolescent psychology and couple and family psychology work in integrated health care settings.

WHEREAS psychologists across the United States increasingly serve in leadership roles in academic health centers, community hospitals, and health systems in public and private sectors. Examples of administrative roles include: Deans of Medical Schools or Allied Health Schools, Vice or Associate Chairs of Family Medicine, Section Chiefs in Pediatrics, Directors of Integrated Behavioral Health, Chief Psychologists or Chiefs of Psychology Services, Directors of Behavioral Medicine, and Directors of Research Centers. In these leadership positions, psychologists advocate for the value of psychological research and services, a larger psychology workforce, increased access to psychological services, and appropriate clinical privileges at departmental and organizational levels. Nonetheless, psychologists working in academic health centers, hospitals, and health systems continue to face barriers to hospital staff appointments and clinical privileges and workforce development.

WHEREAS federal legislation (e.g., Patient Protection and Affordable Care Act; the Public Health Service Act for the National Health Service Corps Loan Repayment Program; Geriatric Workforce Enhancement Programs) includes psychologists in primary care practice; and loan re-payment is available for psychologists working in or with Medically Underserved Areas/Populations (MUA/P) or in outcome research in on Patient Centered Medical Homes (PCMH) to provide comprehensive, interprofessional and coordinated physical and behavioral health care to improve patient outcomes at lower costs. Nonetheless, systemic and local barriers often prevent psychologists from participating in Patient Centered Medical Homes, Accountable Care Organizations or other practice organizations to provide integrated care.

Workforce Development in Integrated Health Settings

WHEREAS there are an increasing number of positions for psychologists in pediatric, adult, and geriatric integrated primary care in public and private health systems, clinical, counseling and school psychology doctoral training programs and the current psychology workforce would consequently benefit from an expansion of training in service provision, interprofessional care, business operations, and/or research methods in primary care or specialty health settings.

WHEREAS, guidelines for interprofessional health provider education have been disseminated for the past several years by both federal agencies and health professions groups. Examples of publications from intra-organizational and interorganizational collaborations or health educators include: Core Competencies for Interprofessional Practice (Interprofessional Education Collaborative Expert Panel, 2011), Values Based Interprofessional Collaborative Practice: Working Together in Health Care (Thistlethwaite, 2012), Interprofessional Education: Definitions, Student Competencies, and Guidelines for Implementation in Pharmacy Education (Buring, Bhushan, Broeseker, Conway, Duncan-Hewitt, Hansen, Westberg, 2009), and the Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Entry-level Health Professional Degree (2010), among others. It is unclear, however, how many psychology doctoral programs are using interprofessional models to train their graduate students for clinical services or team science.

WHEREAS psychologists across the career trajectory are requesting information and training on competencies, clinical models, and business operations for individual and group practice in and outside of primary care and specialty health care settings (Coons et al, 2004).

WHEREAS the American Psychological Association does not currently have comprehensive data on the number of members in primary care or specialty health settings or information on their professional roles and responsibilities. This information would be useful for the development of collaborative relationships with other health professional organizations; for advocacy related to the inclusion of psychologists in integrated care settings, and for service for underserved populations in rural settings and other communities.

THEREFORE, BE IT RESOLVED that the American Psychological Association will encourage continued development and use of targeted communications, including social media, evidence-based articles and position papers, to disseminate research on the value of psychosocial and health behavior interventions in integrated health care settings to improve patient, clinician, health system, and population health outcomes; such messages will be targeted to health care thought leaders and systems designers, federal and state policy makers, professional organizations, health systems and foundations, health and science writers, and relevant consumer groups.

BE IT FURTHER RESOLVED that the American Psychological Association will continue to promote the inclusion of psychology and psychological science in integrated primary and specialty health care to improve patient, family, and population health across the lifespan through collaborations with influential health organizations federal agencies, and consumer groups.

BE IT FURTHER RESOLVED that the American Psychological Association will continue to promote the recommendations and findings from the Presidential Taskforce on Patient Centered Medical Homes (APA, 2014) through evidence-based articles, social media, and briefing papers on the value of including psychologists in Patient Centered Medical Homes for children, adolescents, and adults across the life span.

BE IT FURTHER RESOLVED that the American Psychological Association will continue to track and evaluate State Corporate Doctrine of Medicine laws regarding barriers to psychological assessment and intervention services in integrated health care settings.

BE IT FURTHER RESOLVED that the American Psychological Association will encourage the development and adoption of competencies and associated training materials for psychologists in primary and specialty health settings, such as those developed by the Inter-organizational Work Group on Primary Care Psychology Competencies (APA, 2015), and assist in the acquisition of these competencies through accreditation standards for doctoral training programs, internships, and post-doctoral fellowships.

BE IT FURTHER RESOLVED that the American Psychological Association will continue to disseminate information on competencies, optimal practice, and business models for individual and group practices providing integrated or collaborative care.

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