Bridging the Gap Between Medicine and Psychology:The Nemours Primary Care Psychology Experience

Roger Harrison, Ph.D., Pediatric Psychologist

duPont Hospital for ChildrenClinical Assistant Professor of Psychology

Jefferson Medical CollegeKristin Cupo, M.A.,

Psy.D. StudentImmaculata University

Session # 2October 28, 20112:30 PM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources• Despite increased responsibilities placed on primary care, staff have typically not received

comprehensive training concerning psychosocial problems, which include basic scientific knowledge of etiology, assessment, and treatment (Tynan, 2004)

• Research indicates that a substantial proportion of the population seeking mental health services first turn to primary care providers. (McMenamy & Perrin, 2002)

• The need is out there BUT more training and research is needed!

• McDaniel, Belar, Schroeder, Hargrove, and Freeman (2002) provide tips to establish a training curriculum for psychologists in primary care:

– Increase the knowledge base about the benefits of mental health services in primary care– Increase the number of psychology faculty members who have direct experience in primary care setting– Psychology students need an interdisciplinary practica experience in multiple health care settings as well as courses

in health care ethics and health care policy– Increase in federal funds to support previous points

Objectives1. Describe the key contributors of the interdisciplinary collaborative team

at Nemours Pediatrics

1. List the challenges of implementing an interdisciplinary collaborative team in the community setting

1. Describe the benefits of technological advances in communication systems between professionals (e.g., EPIC, COAST system)

1. Identify the pros and cons of integrating student training programs in primary care offices

Expected Outcome

• Explore the collaborative healthcare approach adapted at Nemours Pediatrics

• Discuss the challenges and benefits of integrating a collaborative healthcare approach in a primary care setting

• Propose ways to integrate this approach into other primary care settings

Today we will:

Nemours Pediatrics• Nemours operates 10 Primary Care Clinic sites throughout the

State of Delaware• Primary Care Initiative places psychologists/trainees in 5 sites• Clinics serve a wide variety of patient populations, vast

cultural and socio-economic diversity• Primary Care Initiative is supported by Health Resources and

Services Administration (HRSA) Graduate Psychology Education Program (GPEP) Grant (D40HP19633-01-00)

Nemours Pediatrics: Jessup Street

Who We Are

• The Medical Staff– 4 Pediatricians – 8 Pediatric Resident Physicians– 2 rotating medical students– 5 nurses

• The Psychology Staff– 2 Psychologists– 1 rotating Psychology fellow– 1 rotating Psychology intern– 1 rotating Psychology extern

• The Support Staff– 1 Office Manager– 3 Support Staff

•Primarily low income African American in Wilmington, DE•19.4% non-Hispanic White•Serves 5,500 patients, averaging 1,150 visits per month•Insurance mix: 87% Medicaid, 13% Commercial•Median income in zip code (2010 Census): $36,000•Psychology show rates 61.46%

Who We Serve

Hurdles: Community Challenges in Wilmington

• Socio-economic – Unemployment much higher than national average for Black families

• >20% in Wilmington– Families often move frequently, phone numbers are frequently changed– Disproportionate rate of single-parent families, multiple caregiver families,

kinship care• Educational

– DE graduation rate of 68% is lower than the national graduation rate of 71%– Rate for AA students is <50% in Wilmington, DE

• Mental health access– Very few choices for mental health service

• Two large community mental health agencies• Many established community mental health providers move away from

accepting any insurance– Services are inappropriate for families we serve

• Some families report feeling unvalued, receiving impersonal care– Clinics do not promote ongoing care for families with multiple risk factors

• Fee for no-show • No reschedule policy

Medical Team

• Convenient hours including weekend sick visits

• 24-hour medical advice phone line for patients and families

• Primary care for all children, newborns through teens

• Care for minor illnesses • Routine well-child care• Immunizations • Hearing and vision screening • School/sports physicals • Laboratory services including blood tests • Asthma and bronchiolitis treatment • ADHD/ADD treatment • Treatment for behavioral problems • Nutrition counseling

Psychology Team

• Very wide range of referral concerns

• Consultation with families• Brief intervention• Brief assessment• Education and consultation with

primary providers• Consultation with schools and

other agencies

• Time spent each week consulting between disciplines

• Pediatricians , Psychologists, Residents, and students rotate in offering weekly formal didactic seminars

• Psychologists frequently called into doctor visits• Rotating medical students sit in on selected initial

consultation and follow-up therapy visit

Collaborative Experience: Education and Consultation

Innovations in Communication Technology: EPIC

• Electronic Medical Record (EMR)• Carries all pertinent patient information

– HIPAA: Certain professions have limited access – We are working to grant physicians access to

psychology notes

• Easy access to show rates• Provide review of previously received services

Innovations in Communication Technology: ADHD Coast System

• Component of EMR that allows parents and teacher to complete Vanderbilt Scales online

• Reduces the chance of lost paperwork• Aids in accurate diagnosis of child • Provides baseline measure for child who does

not meet diagnosis

Hurdles: Student Training Programs

Pros• Eager to work with any

population• State of the art educational

experiences• Broad knowledge of

multiple treatment approaches

Cons• COST!• Billing• Time to supervise• Rotating schedules of

students impedes continuity of care

Where Do We Go From Here?At Jessup Street• Conduct preliminary research on

impact of Primary Care Initiative • Social Work Position to be

added• Create MH packets to be

handed out to families with information on:– Educational resources– Community resources– Psychoeducational material on

various diagnoses – Accommodations– Emergency Numbers

Other Primary Care Clinics

• Lessen the stigma of mental health care in the primary care setting– More exposure during

training– More research!– If it is not possible to have

mental health providers on sight, pair with a psychology practice

Learning Assessment

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!