Focus on Integrative and Collaborative Care

The collaborative practice of clinicians across disciplines requires a shared language, appreciation of diagnostic and therapeutic paradigms, and recognition of appropriate roles within the health care team.  This collaborative environment is at the heart of a health care 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. 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(1)How might health care teams achieve therapeutic goals for individual clients?(2)How does this support health literacy?(3)What factors might lead to the failure of the CC/IC delivery model?(4)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 financial reimbursement for services, and lack of integration of support services within the practice cause a breakdown in efficacy?(5)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. Address the following questions(1)Identify methods of targeted intervention and education for PCPs that might alleviate potential issues for the CC/IC model(2)Explain how the APA Ethical Code of Conduct can be used to guide decisions in these complex situations(3)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? 

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. https://doi.org/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. https://doi.org/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. https://doi.org/10.1037/a0030090

Runyan, C. N. (2011). Psychology can be indispensable to health care reform and the patient-centered medical home. Psychological Services, 8(2), 53–68. https://doi.org/10.1037/a0023454

Soklaridis S, Kelner M, Love RL, & Cassidy JD. (2009). Integrative health care in a hospital setting: communication patterns between CAM and biomedical practitioners. Journal of Interprofessional Care, 23(6), 655–667. https://doi.org/10.3109/13561820902886287

Integrative health care in a hospital setting:
Communication patterns between CAM and biomedical
practitioners

SOPHIE SOKLARIDIS
1
, MERRIJOY KELNER

2
, RHONDA L. LOVE

2
, &

J. DAVID CASSIDY
1,3

1
Centre of Research Expertise in Improved Disability Outcomes (CREIDO), University Health

Network, Rehabilitation Solutions, Toronto Western Hospital,
2
University of Toronto, and

3
Department

of Public Health Sciences, University of Toronto, Toronto, Ontario, Canada

Abstract
Research in the area of collaboration between complementary and alternative medicine (CAM) and
biomedical practitioners often describes their relationships as fraught with power struggles. This paper
explores communication among the various stakeholders at an integrative health clinic for artists
located in a university hospital. Qualitative research methods were used, in-depth interviews and semi-
structured focus groups, to facilitate the gathering of information about patterns of communication
among stakeholders involved at the clinic. The findings describe the challenges to communication and
integration at the clinic. The lack of communication is described as a scheduling issue, or lack of
consistent presence of CAM practitioners, and a lack of formal methods of communication (patient
charting). The consequences of these gaps were felt mostly by the CAM practitioners, as their scope of
practice was not well understood by other practitioners. CAM practitioners stated that this had a direct
effect on their confidence levels. CAM practitioners were relegated to the periphery of the hospital in
their role as part-time, contract employees. Their lack of consistent presence at the clinic lead to a lack
of understanding of their scope of practice, hence, a lack of referrals from other health-care
practitioners, particularly those who were biomedically-oriented.

Keywords: Integrative health care, Collaboration, complementary and alternative medicine,
biomedicine, hospital

Introduction

Research suggests that people who consult a complementary and alternative medicine

(CAM) practitioner are more likely than those who do not to have a regular physician, to

have seen a specialist in the past year, to have had 10 or more physician visits in that time,

Correspondence: Dr Sophie Soklaridis, PhD, Centre of Research Expertise in Improved Disability Outcomes (CREIDO),

University Health Network, Rehabilitation Solutions, Toronto Western Hospital, 399 Bathurst Street West, 4-144 Fell Pavillion,

Toronto, Ontario, M5T 2S8, Canada. Tel: þ1 416 603 5800 ext. 5308. E-mail: sophie.soklaridis@uhnresearch.ca

Journal of Interprofessional Care,

November 2009; 23(6): 655–667

ISSN 1356-1820 print/ISSN 1469-9567 online � 2009 Informa UK Ltd.
DOI: 10.3109/13561820902886287

and to have had their blood pressure checked in the preceding two years (Zollman &

Vickers, 1999). These findings imply that people who make heavy use of CAM regarded

their CAM practitioner as an adjunct to their physician.

Integrative health care (IHC) has become a term to describe the combination of CAM

practitioners and biomedical (conventional medicine) practitioners working together to

provide patient care. In this article, we use the term ‘‘integrative’’ as opposed to

‘‘integrated’’ because the former suggests a process that we believe is more representative

of what is happening at the clinic we studied, while the latter suggests an endpoint or that

integration has already occurred.

In response to patient demand for IHC, hospitals are increasingly interested in providing

IHC to patients. For example, a survey to determine the extent of integration of

complementary therapies in critical care units in North and South Thames Regional Health

Authorities in the Greater London area indicated that of the 51.1% of critical care units that

claimed to provide complementary therapies, only 7% provided interventions on a routine,

systematic basis. The general explanation for not providing complementary therapies was

‘‘lack of time and knowledge’’ (Hayes & Cox, 1999).

Although such journals as the British Medical Journal report that CAM is on the rise

worldwide (Thompson & Feder, 2005), the increased acceptance of CAM by the public

does not indicate that communication between health-care practitioners is satisfactory. The

mere coexistence of different modalities does not produce an integrative system of care, and

combining approaches may not work synergistically.

Research in the area of collaboration between CAM and biomedical practitioners in

hospitals often describes their relationships as fraught with power struggles (Shuval et al.,

2002) and entrenched in the medical hierarchy of the health professions (Hollenberg, 2006).

This article explores how CAM and biomedical practitioners at an integrative health clinic

for artists located in a large, urban, academic hospital in Canada perceive the level and type

of communication with one another, the hospital administrators, the Foundation members,

and with the artist clients.

There are few examples of co-existing biomedical and CAM approaches of health care,

especially in a hospital setting. The clinic we studied is an occupational health-care clinic

for professional working artists: a unique centre, it offers both biomedical and CAM

approaches of health care to clients in a hospital setting. Disciplines at the clinic include

chiropractic, massage therapy, osteopathy, naturopathy, physiotherapy, psychotherapy,

medicine, and nursing. Two of the publicly funded biomedical practitioners are full-time,

salaried employees of the hospital. All of the CAM practitioners and two of the non-

publicly funded biomedical practitioners have private practices outside the clinic. They

provide their services to the clinic on a fee-for-services basis. The clinic relies

on aggressive fundraising to subsidize these activities. Thus, the number of fundraising

dollars is linked to the number of hours each practitioner is provided by the Artists’

Foundation.

The purpose in conducting this research was twofold. First, we wanted to see how IHC

was working in practice. We examined the mechanisms of communication and the levels of

collaboration among the practitioners, artists, hospital administrators and Foundation

members. Second, to discover how integrative health care might work within a hospital

setting, we explored how the organizational structures of the hospital and the Foundation

influenced the development of IHC at the clinic. This research was deemed important and

thus supported by both the hospital administration (responsible for the daily operations of

the clinic), and the Foundation (responsible for fundraising to pay for the CAM services and

subsidy program for artists).

656 S. Soklaridis et al.

Methodology

We used both in-depth individual interviews and semi-structured focus groups to

understand the social and physical setting of the clinic, including internalized notions of

norms, traditions, roles, and values that were held by the respondents at the clinic. First,

individual in-depth interviews were conducted with each of the ten health-care practitioners

at the clinic. The purpose of conducting individual interviews was to obtain information that

might not initially have been shared in a focus group format among the various practitioners.

It was particularly important to conduct individual interviews with practitioners to obtain

information, including minority or ‘‘silent majority’’ viewpoints, regarding communication

and integration among the practitioners at the clinic. There was representation from the

following health professions: chiropractic, massage therapy, medicine, naturopathy, nursing,

osteopathy, physiotherapy, and psychotherapy.

Second, four semi-structured, qualitative focus groups were convened with a total of 26

key informants with clients of the clinic (n¼8), hospital administrators (n¼5), board
members (n¼8), and practitioners working at the clinic (n¼5). The purpose of conducting
focus groups was to move beyond the level of the individual and examine knowledge that

was shared among group members. Of the ten health-care practitioners (BIO and CAM)

interviewed initially, five were available to attend the focus group. We were interested in

observing how these practitioners interacted with one another within the focus group setting.

In addition, we wanted to further explore respondents’ opinions and experiences through

group discussion that moved beyond our preliminary analysis of statements during the

individual interviews. With the exception of the practitioners, we assumed that the other

groups shared a common identity, which would not have prevented them from publicly

sharing their opinions, stories and beliefs. Thus, the use of focus groups was deemed to be a

more appropriate data collection tool than individual interviews. The artist group (A)

included representation from dance, visual arts, actors, and writers. The hospital

administrators group (HA) included those who were previously or currently involved with

operational aspects of the clinic. The Foundation board members (BM) group is a volunteer

group comprised of artists and business people who provide a link to the artistic community

and work with the hospital on artists’ health issues. One of the mandates of the Foundation

is to assist professional Canadian artists with financial support to be applied towards the cost

of CAM treatments at the clinic, which are not otherwise covered by the provincial health

plan. There was representation from artists, practitioners, educators, legal and business

professionals in the focus groups.

The study involved purposeful sampling (Patton, 2002), the rationale of which is to select

information-rich cases whose study will illuminate the research questions under study

(Morse & Field, 1995).

Separate guides were constructed for the individual interviews with practitioners and for

each of the four focus group sessions. Although each guide was different, the following

questions were posed to elicit views on IHC, collaboration and communication:

(1) How do practitioners, hospital administrators, artists, and Foundation members

understand and define integrative health care?

(2) How are epistemological differences between practitioners resolved when biomedical

and CAM approaches to health care co-exist?

(3) What are the informal and formal mechanisms for communication between and

among the practitioners, artists, hospital administrators and Foundation members

involved with the clinic?

Integrative health care in a hospital setting 657

(4) How do practitioners, artists, hospital administrators, and Foundation members

describe their everyday interactions with one another?

(5) What social, economic, and hospital policies/politics influence the level of integrative

health care at the clinic?

(6) How do issues of sustainability, funding, and the subsidy program affect the

integration of health care services and delivery at the clinic?

The transcripts from the individual interviews and focus groups were analyzed using a

constant comparative approach (Brown, Weston, & Steward, 1995). A coding scheme was

developed (SS, MJK, RL) using an iterative approach. SS performed the initial open-coding

of the interviews and focus groups. Codes were compared and contrasted (SS, MJK and

RL) to develop a finalized coding scheme. Once a satisfactory level of agreement over the

coding scheme was reached, it was then applied to each interview and focus group

transcript. According to Glaser and Strauss (1967), ‘‘no one kind of data on a category or

technique for data collection is necessarily appropriate. Different kinds of data give the

analyst different views of vantage points from which to understand a category and develop its

properties’’ (p. 5). The consistency we found in overall patterns of data from the two

different methods, and our explanations for any differences in data, contributed significantly

to the overall credibility of the findings. A qualitative computer software package,

NVIVO
TM

(Nvivo, 2002), was used to store and organize the various codes derived from

the data. The software allows each code or theme to be stored and then organized into larger

categories as the research proceeds.

Ethics approval from the university and the hospital ethics review board was obtained for

the study.

Results

This article explores communication among the various stakeholders at the clinic. It is

divided into four sections. The first section examines communication patterns. The second

section describes the mechanisms for communication among the stakeholders of the clinic,

both formal and informal. The third section illustrates some of the consequences of a lack of

communication between these groups. The fourth section offers some of the potential

solutions, as described by the respondents of this study.

In this paper, we focus on the data collected for communication among the practitioners.

As a result, some of the data from the other focus groups is only given consideration insofar

as it relates to communication between practitioners. The voices of the hospital

administrators and board members are given priority in another publication that examines

how the organizational structure of the clinic affects integration (Soklaridis, Kelner, Love, &

Cassidy, 2009).

Communication patterns

The practitioners described three challenges to communication and hence integration at the

clinic. First and foremost, the overall consensus was that there is little everyday interaction,

posing a major challenge to communication and integration. In fact, a few respondents

stated that they had never met one another. Most biomedical practitioners at the clinic

stated that they had met each other. For example, the physician, nurse practitioner, and the

physiotherapists had met and on varying occasions worked together. However, meetings

with CAM practitioners were not nearly as frequent. This, according to both the CAM and

658 S. Soklaridis et al.

biomedical practitioners, made integration difficult – if not impossible – to achieve. One

biomedical practitioner observed that, in general, her interactions with some practitioners

were few and far between:

BIO 4: Even though we are all on board I still haven’t met everybody, so it is hard to feel

like we are integrated in some way when we don’t even know one another. We have not

even had a conversation with some of the individuals.

Second, scheduling served as both an enabler and a barrier to communication and

integration. For example, the few interactions that had occurred did so when the

practitioners occupied the ‘‘same space at the same time’’. At the time of the study,

the biomedical practitioners worked in or had access to the clinic more often than any of the

CAM practitioners. Two of them were permanent, full-time employees of the hospital and

one was contracted to work for three days a week at the clinic. The CAM practitioners were

all contract, fee for service, employees and worked at the clinic from four hours (or less) a

week to one day a week. Five of the six CAM practitioners who worked four hours a week or

less said it was very difficult, if not impossible, to interact with other practitioners during

their shift. A CAM practitioner said:

CAM 4: It is hard to parachute in and parachute out. . . . It is hard to feel the community

when I am there [half a day, once a week], and I think I am the only one there . . .

sometimes I see someone else float in and out, but it’s not as if we chat.

Secondly, there was little consensus among the respondents on the current state of teamwork

and the direction of communication. Issues regarding how information was passed along, by

whom, and when, was identified by most of the respondents as problematic. Most of the

practitioners at the clinic deemed that a certain level of teamwork was necessary for patient

care. A few practitioners said that teamwork was an important part of integrative health care

because it meant familiarity among practitioners, which ultimately had benefits for the patient/

client. As a CAM practitioner said to a biomedical practitioner in the focus group:

CAM 4: But also to me the team aspect does benefit the patient in the sense that there is

the potentiality there so that if they needed to see a physician, if the physician they are

seeing is someone who knows me, who knows my work, who knows the preparation they

are getting the benefit of that even if they only see you once.

The third facet of communication was the direction of that communication. For instance,

communication was often facilitated through the patient/client, who was described as the

vehicle for information-sharing among their colleagues. Such a method of communication

was not seen as an optimal way to obtain information regarding patient care, since patients

were thought to interpret therapies and the outcome of their therapies differently than

intended. On the other hand, several CAM and biomedical practitioners, for financial

reasons, chose to communicate with one other instead of making referrals, which seemed to

run contrary to the premise of the clinic as an integrated. At the clinic, patients were

provided with a subsidy for therapies not covered by the provincial health plan. However,

having to work within the subsidy allowance, one biomedical practitioner stated:

BIO 3: I can go and talk to [CAM 2] and say, ‘‘what can you recommend?’’ And in that

way they [the patients] don’t necessarily have to see him, because . . . the integration is

Integrative health care in a hospital setting 659

there, the only thing that is harder is the price. It is still expensive [for the patient] to get

these other modalities, so even if we have subsidies it is still an expense. . .

Mechanisms for interaction

Two types of communication at the clinic were described, informal and formal.

Informal types of communication included hallway consultations, quick telephone calls,

e-mails, and even sticky-notes posted by health-care practitioners to the patient charts.

Formal types of communication included documenting patient visits, diagnosis, and

recommendations in a patient chart, and staff meetings. The practitioners described both

types of communication as dependent on a shared language.

Most of the practitioners agreed that they did not often talk about patients and when they

did, communication between them was very informal. This kind of communication is

illustrated here:

BIO 2: Occasionally we talk about patients but that is only about 10 percent of the time.

So I know, I guess I know, I have spoken to people but I think it is mostly talking to people

in the hallway.

For formal communications, clinic practitioners generally use standard tools such as

charting. Common in most health-care settings, patient charting involves the process of

entering diagnostic, prescriptive, progress or other notes regarding the patient, which are

then kept in a main patient file. However, charting took on different meanings when CAM

and biomedical practitioners used the same patient file.

The chart, in essence, was deemed by the majority of practitioners at the clinic as an

ineffective communication tool. Issues emerged that were common to most practices, such

as unruly handwriting, and when CAM and biomedical practitioners used one chart, issues

of language and style also created some difficulty.

During the focus group a CAM practitioner described her inability to read a patient chart

due to messy handwriting:

CAM 4: And also something that I was experiencing was not being able to read peoples

handwriting very well on our charts. And I use the charts a lot . . .

A biomedical practitioner said he was frustrated with the lack of systematic charting, and

therefore he did not read the patient charts:

BIO 2: We could do a whole other focus group just on the charts you know what I am

saying . . . I don’t even read, I barely read charts that’s terrible to say but there is no

systematic charting, because we have never come to conclusion or consensus how

we are really going to chart, is it going to be done by professions, or are we just going to

doodle along . . . and then the reality is that there is also a whole vocabulary and

nomenclature and a way of charting that physiotherapists use, that I need to be educated

about.

The issue of biomedical language in particular was discussed during the focus group with

the practitioners at the clinic. One CAM practitioner explained how difficult it was to

understand some of the acronyms that the other biomedical practitioners seemed to take for

granted:

660 S. Soklaridis et al.

CAM 4: I am going to get her [biomedical practitioner] to tell me . . . what she is doing

and to learn what she means by ‘‘SOT’’?

BIO 4: Yeah, but that is standardized charting formula.

CAM 4: Yeah . . . well that is sort of a medical convention, yes it is but if you are not part of a

medical model, and this is the issue here for us is that we have to figure out a way to include

every one and to make sure that we don’t get caught up in the medical model because we are

trying to do something innovative here . . .

Consequences of minimal interactions

A formalized structure of communication had not been established, creating a lack of

communication and integration. As a consequence, the majority of respondents felt there

were disadvantages to practitioners’ work environments and personal growth. Firstly, they

believed this situation perpetuated a lack of understanding regarding the scope of practice of

each practitioner. In turn this led to a lack of referrals for those who were least understood

(in this case, the CAM practitioners at the clinic). Secondly, the limited communication and

integration inhibited the establishment and nourishment of practitioner confidence. Thirdly,

the lack of communication and integration among the various stakeholders continued to

limit and keep practitioners at the clinic disconnected from the larger hospital and

community resources. We will now elaborate each of these points in turn:

Not knowing other practitioners’ scope of practice had a direct effect on referral patterns.

The majority of practitioners (both CAM and biomedical) said that they would not refer

their patients to a therapy or modality that they did not understand. For example, one

biomedical practitioner stated that unless a patient requested it, she would not refer to a

modality that she was unfamiliar with. We asked the CAM practitioners, who were least

likely to get referrals, about the referral process and their perceptions of why other

practitioners were not referring patients to them. They attributed the lack of referrals to the

(mostly) biomedical practitioners’ lack of understanding of their scope of practice:

CAM 6: I don’t think that most people know what osteopathy is, so how are they going to

refer to an osteopath when they don’t even understand what the difference is between

osteopathy and maybe physio. . . . So that’s part of the barrier too with these alternative

therapies coming in.

Several practitioners said that they wanted to learn and better understand how each

practitioner’s scope of practice related to their own and how they could support each other

in providing better patient care. With regards to supporting each other in their practice, a

CAM practitioner stated:

CAM 4: I need to understand what the other practitioner is doing because a lot of them do

refer to me or the patients themselves self refer for [health service], so I need to be able to

be supportive around their Naturopathy or their psychotherapy or their osteopathy or their

physiotherapy so I need to be able to understand that.

Second, and linked to providing support to one another, was the concept of practitioner

confidence. The idea of practitioner confidence was not a question in the interview guide

and if it did not emerge organically from the interviews or focus groups, the question was not

directly asked. However, most of the CAM practitioners said that communication and

Integrative health care in a hospital setting 661

integration among the different therapies and modalities could increase practitioner

confidence and help them grow as practitioners. Conversely, the biomedical practitioners

did not discuss the link between integration and practitioner confidence.

CAM 3: I think the over all confidence level of the practitioners, all of us medical and

alternative, would increase if we had a format to talk openly about what we are thinking

what we are struggling with what we are not sure about in a forum where there are people

of different mindsets and different lens that they are looking through. I think that would

be exciting and would build the confidence level that I could easily go and ask and not feel

like I was in jeopardy in any way or so but that would take time and some familiarization.

Another CAM practitioner hypothesized that an element of self-consciousness occurs

when one is not familiar with the scope of practice of other practitioner in the clinic:

CAM 2: I think the practitioners suspect that there is something I could do naturally, but

they haven’t conferred with the case so they are reluctant right and they don’t want to be

embarrassed.

Another CAM practitioner said that increased practitioner confidence was linked to not

assuming ownership of patients; explaining this, she stated:

CAM 1: So I think there has got to be a lot of respect and personal confidence that there is

not that ownership of the patient, and it [IHC] really is for the good of the patient. And I

think it really it’s that thing that really needs to be reminded [to practitioners] because,

yeah, there is overlap.

The majority of clinic practitioners said that a lack of communication and integration,

coupled with the clinic’s unique location (in a hospital), meant that they felt isolated. They

did not know if there was a network that could be tapped into, and they described feeling like

the larger hospital community was completely unaware of their presence. According to all of

the CAM practitioners, the sense of not knowing what was available, or even what they could

ask for, had implications in their everyday practice. A few of the CAM practitioners said that

were not aware of what they were entitled to ask for from the hospital administrators or

board. One of them stated:

CAM 6: Maybe, and knowing what we can ask for, is it feasible for me to say, ‘‘I want

these couple of posters up in the room’’, ‘‘I would like a spine a model of a spine’’, ‘‘I

would like this anatomy book that has these pictures because when I talk to people about

what there injury is I refer to these diagrams’’. . . you know things I use often in my

treatment. I don’t know if it is feasible for them to provide me with this stuff or not.

Improving communication and integration

Respondents were asked to reflect on what they believed would assist in improving

communication and integration. One overarching theme emerged from the interview and

focus group data; having face-to-face and/or virtual team meetings. In addition, the

respondents said that e-mail exchanges and electronic technology could help facilitate some

of the current issues in communicating and charting.

662 S. Soklaridis et al.

The majority of practitioners strongly believed in the benefits of staff meetings. Although

most said that they believed meetings, especially ones without pay, were not convenient to

attend. None of the CAM practitioners were permanent employees of the hospital; they were

hired as contract, fee-for-services, part-time employees; all of them described this as a

limiting factor for integrative health care. For example, attending meetings or anything

outside of patient care at the clinic was unpaid. However, they generally stated that

importance of these meetings often outweighed the barriers of convenience and money. As

one CAM practitioner explained:

CAM 1: Let’s just have it out – it is not convenient, but it is essential so something needs

to happen. . . .

As opposed to in-person meetings, one of the biomedical practitioners suggested the clinic

embrace technology and explore the possibility of holding virtual meetings:

BIO 1: I think the other thing I would like to see is us being a little more proactive around

complex patient care planning, and complex case conferences, and we may not be able to

do it in person but maybe we need to start having some kind of chat rooms or some kind

of secure interactive e-mail thing where we can start to do some of this.

The majority of board members agreed that both virtual meetings and electronic records

would provide channels for communication between health-care practitioners. As one board

member explained:

BM 4: There needs to be electronics, they have to, if they can’t all meet in person, they

have to somehow [meet virtually] . . .

E-mail could be useful not only between practitioners at the clinic, but also for keeping the

lines of communication open between health-care practitioners and artists. Artists in the

focus group discussed using e-mail and other features of the Internet as a method of being

kept informed about their care. One artist said e-mail could be used for follow-up:

A 1: Or even for patients who have not been there for a while, to just pop out an e-mail to

find out how they are doing as a forum for feedback. [The hospital] does tend to treat the

ailment rather then the patient. And the [clinic] seems to be trying very hard to treat the

patient rather then the ailment, so in a way, using technological tools like the Internet and

e-mail probably would be helpful.

According to the majority of practitioners at the clinic, electronic health records would not

address the issue of biomedical language; however, it would make reading the charts easier.

A biomedical practitioner suggested colour-coding each modality as a method of making the

chart more accessible to all practitioners, so when practitioners opened the chart they could

identify right away who this patient is seeing. As one biomedical practitioner in the focus

group suggested:

BIO 2: We all make decisions for the sheets that we should use – it is just that we honestly

haven’t. Different colours for instance, if naturopathy would use yellow, and physiotherapy

would use red or orange so you know it would be a nice easy way I could say ‘‘oh, yellow

sheet there,’’ she’s seeing naturopathy – as I said we haven’t come to that.

Integrative health care in a hospital setting 663

Discussion

For some practitioners, a lack of basic CAM knowledge may have affected their viewpoint.

For example, if they did not know what osteopathy was, they probably could not express a

view about its effects. In addition, for many biomedical health care practitioners, the chief

reported impediment to a change in attitude towards IHC was a perceived lack of quality

research in CAM (Bower, 1998). Research publication bias against CAM, dearth of research

fundings, and the challenges of research design inherent to some CAM modalities have

contributed to this lack of quality and quantity in published research (Kaptchuck & Miller,

2005; Verhoef, Vanderheyden, Dryden, Mallory, & Ware, 2006).

Gaining knowledge in CAM is challenging as few medical residencies require or even

offer rotations in CAM, and very few published curriculum guidelines and course

evaluations exist (Kligler, Gordon, Stuart, & Sierpina, 2000). Although reliable and timely

publications about CAM and IHC are becoming more common, they are still not widely

accessible. In our study, the majority of respondents described how a lack of knowledge,

when they were not familiar with the scope of practice of other practitioners, led to feelings

of self-consciousness and defensiveness. The results of this research are congruent with

other studies in the organizational theory literature that examine the defensive patterns that

individuals adopt when operating in groups. For example, in a survey of 569 managers,

Mulvey, Veiga, and Elsass (1996) found that 61% of respondents listed lack of confidence to

contribute as a cause for limiting their involvement in team discussions. The findings

suggest that the threat of embarrassment or appearing incompetent weighed heavily on most

of the practitioners at the clinic. A lack of understanding of each others’ scope of practice

could create embarrassment or potential conflict if an inappropriate referral was made, and

so as a defence mechanism, the majority of practitioners avoided the issue: they simply did

not refer to practitioners they were unfamiliar with.

Individuals engage in knowledge sharing and creative problem solving only when they

have already established a language in which they can combine and exchange their existing

knowledge (Leonard-Barton, 1998). Developing a dialogue between CAM and biomedical

practitioners is a neglected topic in the literature, even though such dialogue is essential to

the process of integration. The findings suggest that commonality of understanding

language should be the initial focus of improving communication between biomedical and

CAM practitioners. Most respondents, particularly the practitioners, were quite clear on the

importance of ‘‘speaking the same language,’’ whether it was between the board members

and the hospital administrators or between the practitioners at the clinic. For example,

CAM practitioners discussed the challenges they faced when trying to understand

the biomedical language in patients’ charts. It could even be argued that the continued

use of biomedical language for patient charting is a defence mechanism used to maintain

biomedical control over patients (Larson, 1980).

To assist with this challenge, several articles about CAM education and training for

practitioners have policy recommendations to overcome the barriers of language. For

example, the White House Commission on Alternative and Complementary Medicine

(WHCCAMP, 2002) proposed that parallel training be provided to CAM practitioners to

ensure that they receive education and training programs that encompass the basic

elements of biomedical science and conventional health-care relevant to and consistent

with their scope of practice. Such training, it is believed, will improve communication

between biomedical and CAM practitioners. However, what the WHCCAMP commis-

sion failed to understand is that making CAM practitioners responsible for attaining

fluency in biomedical language would have the result of co-opting CAM, rather than

664 S. Soklaridis et al.

increasing communication and fostering integration. As one of the CAM practitioners

discussed in the focus group, the clinic is trying to create something unique, whereby all

practitioners become familiar with each other’s disciplines – including language – so as to

improve integration of care, interdisciplinary respect, and communication in the care of

patients/clients.

Several respondents believed that communication among practitioners through the

patient chart could be useful if the charts were electronically based and if the information on

them was organized systematically. Electronic medical records do not have many of the

problems associated with paper-based records. For example, handwriting is not a problem

with most electronic records. However, electronic records are not automatically more

comprehensible (Rose, 1998). For electronic records to be useful at the clinic there would

need to be a systematic way of charting patient information across the various disciplines.

The findings suggest that creating an integrative clinic requires an organizational structure

that supports this type of integrative care. At the time of this research, opportunities did not

exist for creating a shared vision of health care that permitted each practitioner to contribute

his or her particular knowledge and skills within the context of an integrative team approach

to health care. However, the very fact that this multi-disciplinary group of practitioners was

working in a common setting is important and should not be overlooked. To a certain

extent, co-location of practitioners is an example of integration by association. Even without

formal arrangements, co-location can lead to familiarity and exchange between practi-

tioners. There is some evidence that regular face-to-face contact between health-care

practitioners can facilitate a greater level of integration and offers practitioners a greater

opportunity to learn from each other (Axelsson & Axelsson, 2006; Bradley et al., 2008).

Although several practitioners referred to themselves as a ‘‘team’’, this term was mostly used

when referring to the fact that they were co-located. It seems that the term ‘‘group work’’ may

better apply to what is actually happening at the clinic. A group is defined as a number of people

or things located, gathered, or classed together (Barber, 2004). Implicit in this definition is the

assumption that in groups, members maintain their individual roles, but are collected together.

When grouped, the participants accept they are within their own professional identity and

contribute from their own role and background. Therefore, it is co-location or a common

identity that defines the group. However, the intragroup process as a result of this co-location is

not defined. Given the definition of group here, the health-care practitioners at the clinic can be

thought of as a group. As discussed above, they have aspects that qualify them as a

multidisciplinary team, but they also have aspects of a group because they mainly function as

individuals in parallel practice. For example, the outcomes of psychotherapy are not dependent

on the physiotherapist completing particular tasks in a given time frame. In groups, people do

not have to work together; they just have to inform each other about what they are doing when it

is deemed appropriate. Although there is evidence emerging that teams are effective vehicles,

little has been done to establish why a team (and which version of team structure) might be the

most appropriate for the given circumstance.

Given the organizational structure of the clinic, it may be unrealistic to expect health-care

practitioners to adopt a team approach. The expectations of an IHC team may be inappropriate

when the tasks, for whatever reason, do not lend themselves to a collective approach. For

example, scheduling was both an enabler and barrier to communication and integration. The

majority of respondents agreed that the current staffing structure at the clinic was not

conducive to interactions between any practitioners, particularly the CAM practitioners, as

they were the ones with the fewest working hours at the clinic. Shuval, Mizrachi, and

Smetannikov (2002) would propose that the findings suggest a dual process of simultaneous

acceptance and marginalization of CAM practitioners who work in biomedical institutions.

Integrative health care in a hospital setting 665

The CAM practitioners did work at the clinic, however they were not considered regular staff,

and they did not have the same advantages as the two biomedical practitioners who were full-

time, salaried staff members at the hospital. In theory, the salaried practitioners had more

opportunity to attend meetings, rounds, and other hospital benefits that were not extended to

the part-time, non-salaried CAM biomedical practitioners at the clinic.

The implications of our findings suggest that it is important to consider how sporadic

interactions can pose a major challenge to collaboration and integration. This could explain

why practitioners perceived their work environment and personal growth to be disconnected

and disadvantaged. The findings suggest that improvements in communication, collabora-

tion and a supportive organizational setting can be used to move IHC forward, and that each

stakeholder, as an individual and within a group, has a key role to play. These findings could

contribute to the development of IHC strategies and best practice models required for those

working with populations with specific needs.

The study was limited in its scale. Caution is duly noted, as for all qualitative studies,

that the findings are context bound and thus not widely generalizable. The nature of this

research was descriptive and exploratory, and thus cannot provide definitive conclusions.

However, the findings support the perceived importance of improving communication

between biomedical and CAM practitioners for patient-centred care. Given the current

momentum for teamwork, collaborative practice and group practice in healthcare, further

research is warranted in the area of improving communication, collaboration, and

integration.

These findings have been presented to both the hospital administrators and the

Foundation board, and are now being used as a guide to facilitate opportunities for

integrating CAM practitioners into the hospital setting. The Foundation board has since

raised money to bring the CAM practitioners in for regular clinic team meetings. The

hospital administration has accepted the need for more organizational support for the clinic,

and is taking steps to integrate CAM services into the clinic by re-examining CAM and its

use, appropriateness, and relation to regulatory and hospital policy.

Conclusion

We conclude that a lack of communication and integration, whether it was between the

CAM and biomedical practitioners or among the CAM practitioners, was seen as

contributing to a lack of understanding regarding scope of practice and how to integrate

the various practitioners, particularly CAM. This parallels the current biomedically-

dominant Canadian health-care system, even though some CAM practitioners appear to be

gaining a slow, yet significant change in status.

This research further suggests that in Canada’s public health-care system, the exclusion of

CAM from public funds, when the goal is integration, does not support IHC’s development.

Even though the current Canadian health-care system was designed to provide universal and

equitable access to health care for all Canadians, this system currently applies only to the

provision of medical, hospital, and laboratory services. It could be argued that the public

health care system is not financially sustainable, and therefore it is inappropriate to add

therapies (both biomedical and CAM) that are perceived to be unproven to an already

overburdened publicly funded system. On the other hand, it could also be argued that the

current system has been designed to perpetuate the interest of key stakeholders, such as

medical practitioners and pharmaceutical manufacturers. In some ways, the existing system

of health care is the antithesis of collaboration and teamwork. Thus, the creation of

successful IHC may necessitate a major change in the current system of health care.

666 S. Soklaridis et al.

Acknowledgements

We would like to thank the respondents who were interviewed and acknowledge the

financial assistance of the Artists’ Health Centre Foundation that supported this research.

We would also like to thank the external reviewers for their helpful feedback, which

strengthened our manuscript.

Declaration of interest: The authors report no conflicts of interest. The authors alone are

responsible for the content and writing of the paper.

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Integrative health care in a hospital setting 667

http://www.whccamp.hhs.gov/fr4.html

Psychology Can Be Indispensable to Health Care Reform and the
Patient-Centered Medical Home

Christine N. Runya

n

University of Massachusetts Medical School

The Patient Protection and Affordable Care Act (PPACA) was passed into legislation in
March 2010, making health care reform a reality. Perhaps the most well-developed model
of primary care that aligns with the PPACA’s agenda is the patient-centered medical home
(PCMH). Integrated care, as defined by collaborative care between mental health and
primary care providers and systems, will undoubtedly play a critical role in the success of
the PCMH. The role of psychology and integrated care in the PCMH as well as training
implications for psychologists are discussed. This article is intended to challenge ou

r

discipline to embrace psychology as a health care profession that must prepare for and
solidify its added value in the health care delivery models of the future. Requisite skill sets
for primary care psychologists and existing training opportunities are presented. Finally,
possible mechanisms for training psychologists in integrated care and the professional roles
primary care psychologists can expect to fill are proposed.

Keywords: integrated primary care, patient-centered medical home, health care reform, psychol-
ogy training

The United States has finally exhausted the
luxury of time and endless debate about how to
reform health care. The Patient Protection and
Affordable Care Act (PPACA) was signed into
law in March 2010, representing the result of
highly contentious and laborious deliberation
on health care reform. Infused with ideas and
funding for pilot programs and demonstration
projects, the PPACA is a complex assortment of
policies and finance reform that seeks to contain
costs, improve access to high-quality health
care, and expand insurance coverage. Consider-
able funding is allocated for research and clin-
ical demonstration projects to elucidate effec-
tive and efficient models of health care that
include prevention, health care maintenance,
acute care, and chronic illness management.
Parallel to the enactment of the PPACA, the
patient-centered medical home (PCMH) was

gathering steam as one of the most widely ac-
cepted health care delivery models for high-
quality, cost-effective primary health care (Na-
tional Committee for Quality Assurance, 2009).
If the PCMH is widely implemented, behavioral
health will no longer be an afterthought in rou-
tine health care. Not a moment too soon, the
dawning of the age of integrated health care is
upon us. This article, a summary of the keynote
address from the annual midwinter National
Council of Schools of Professional Psychology
conference held in Orlando, Florida, in Febru-
ary 2010, addresses the core components of
integration, supported by available evidence,
along with the rationale for integrated care in
the PCMH, from various perspectives. The ra-
tionale will challenge the field of clinical psy-
chology to embrace and prepare our workforce
for this reality. The second portion of this article
describes core competencies for integrated
health care practitioners and briefly identifies
current training programs and emerging trends
for training primary care psychologists. The
workforce shortage for integrated care provid-
ers and potential means to shrink this gap are
discussed. Finally, suggestions for how to cre-
ate and sustain training initiatives at the predoc-
toral level and possible professional roles for
primary care psychologists are offered.

This article is based on two presentations given at the
midwinter conference for the National Council of Schools
of Professional Psychology in February 2010.

Correspondence concerning this article should be ad-
dressed to Christine N. Runyan, University of Massachu-
setts Medical School, Department of Family Medicine and
Community Health, Hahnemann Family Health Center, 279
Lincoln Street, Worcester, MA 01605. E-mail: christine
.runyan@umassmemorial.org

Psychological Services © 2011 American Psychological Association
2011, Vol. 8, No. 2, 53– 68 1541-1559/11/$12.00 DOI: 10.1037/a0023454

53

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Health Care Reform and Integrated Care

In addition to increasing health care coverage
for Americans and improving the quality of
health care, cost containment is inarguably the
primary impetus for health care reform. Propor-
tionately, the United States spends more on
health care as a percentage of the gross national
product compared with other developed coun-
tries for astoundingly worse global health out-
comes, including much higher rates of infant
mortality and lower projected life expectancies
(World Health Organization, 2008). Medicare,
the largest single health insurer in the United
States, provides coverage for people 65 and
older and for people under 65 with certain qual-
ifying disabilities. The financial welfare of the
Medicare system is bleak, and projected costs
are not sustainable without substantial modifi-
cations in the program or the number of covered
lives. As was true in 2008, the Medicare Hos-
pital Insurance Trust Fund paid out more in
2009 in hospital benefits and other expenditures
than it received in taxes and other dedicated
revenues (Social Security and Medicare Boards
of Trustees, 2009).

The Medicare Supplementary Medical Insur-
ance Trust Fund, which pays doctors’ bills and
other outpatient expenses, and Medicare Part D,
which pays for access to prescription drug cov-
erage, are both projected to remain adequately
financed into the indefinite future because cur-
rent law automatically provides financing each
year to meet next year’s expected costs. How-
ever, expected steep cost increases will result in
substantial increases in Medicare beneficiary
premium charges at a rate that exceeds any
expected income increases for this population.
That is, a much larger proportion of their (often
fixed) incomes will have to be allocated for
health care premiums, a solution that is hotly
debated and understandably not well received
by Medicare beneficiaries.

Similarly, private health insurance is becom-
ing increasingly cost-prohibitive. Employers,
particularly small business owners, are increas-
ingly unable to offer health care coverage as a
benefit for employees. Health care premiums
increased 114% between 1999 and 2007,
whereas earnings over this same time period
increased only 27% (Robert Wood Johnson
Foundation, 2009). Although many tout medi-
cal malpractice payouts as the primary explana-

tion for excessive health care costs, the actual
driver appears to be expensive, highly sophisti-
cated technology accounting for an estimated
two thirds of health care spending growth
(Ginsburg, 2008). Changing demographics in
the United States, worsening health risk behav-
iors, and increased prevalence of chronic dis-
eases are also undoubtedly contributing to ex-
cess costs. As previously noted, we are paying
more and more for health care without any
notable improvements in quality of care—an
outcome that would not be tolerated or sustain-
able in any other American industry. Health
care reform legislation must be simultaneously
corrective on costs as well as improve access to
high-quality care.

One of the essential ingredients of cost-
effective, high-quality health care delivery sys-
tems includes a holistic perspective on disease
and wellness, as well as a consideration of the
social context in which health behaviors— both
good and bad—are adopted and maintained.
These concepts represent the fundamental as-
sumptions underlying the PCMH. Primary care
is the largest platform for health care delivery;
however, it will remain an incomplete solution
to comprehensive, biopsychosocially informed
and delivered health care without adequately
trained and competent providers to offer these
services. Positioning behavioral health provid-
ers where people routinely access care (e.g.,
primary care clinics, emergency rooms) offers
one avenue for increasing penetration into the
population by identifying and addressing be-
havioral health needs (i.e., integrated care). Of
note, ample research suggests that many pa-
tients are receptive to receiving psychological
assessment and intervention in primary care
clinics (Lester, Tritter, and Sorohan, 2005). The
PCMH model recognizes the vast unmet need
for behavioral health care in primary care and
advocates a central role for a variety of collab-
orative providers, including mental health spe-
cialists. Other arguments make a compelling
case for integrating care as well, but health care
reform and, specifically, primary care reform
through the adoption of the PCMH hold sub-
stantial promise for taking this vision into a
reality.

Adopting this perspective requires a philo-
sophical stretch for clinical psychology as a
discipline, which has generally functioned
within a specialty model of health care delivery.

54 RUNYAN

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Similar to other types of medical specialties,
clinical psychology services have largely
tended toward a narrow focus on emotional and
behavioral factors (i.e., above the neck). More-
over, psychological services often require prior
authorizations from insurance companies and
offer a restricted range of covered services, sim-
ilar to other types of specialty health care. Op-
erationally, psychology has embraced this
model by using diagnostic-oriented, reduction-
ist, and time-limited services that focus on the
individual seeking care for relatively uncom-
mon events. Most of our research is also exclu-
sionary and aimed at identifying the best inter-
ventions for psychiatric diagnoses meeting
Diagnostic and Statistical Manual of Mental
Disorders (4th ed., text rev.) criteria. Moreover,
in funded, large-scale clinical research trials,
patients with various comorbidities are usually
screened out to ensure a diagnostically pure
sample. This research agenda has undoubtedly
yielded credible data to support specific psycho-
logical interventions. However, even an inter-
vention with a moderate or high rate of success
will have a limited impact on the population’s
well-being because it is tied to a service model
that is highly selective. That is, the overall im-
pact of any intervention, or of health care as a
whole, depends not only on effectiveness but
also on the degree to which such interventio

ns

can penetrate into the population of interest
(i.e., Impact � Effectiveness � Penetration;
Rose, 1992).

A contrast to this existing model is a slightly
more global but still clinic-based model of ser-
vice delivery. It is a problem-oriented model
(i.e., specific diagnosis is less relevant than the
problem and symptoms) based on continuity of
care and service delivery for symptoms that
may not meet conventional diagnostic thresh-
olds and can be understood within the context of
the family and community. As a description,
this encapsulates a primary care perspective of
health care delivery. Although our discipline
has not had a psychological equivalent of pri-
mary care to date, integrated care, embedded
within the PCMH, offers such a model.

The Patient-Centered Medical Home

The PCMH is an approach to providing com-
prehensive primary care for children, youth, and
adults. Patients are cared for by a physician who

leads a medical team and coordinates all aspects
of preventive, acute, and chronic care needs of
patients using the best available evidence and
appropriate technology (National Committee
for Quality Assurance, 2009). The American
Academy of Pediatrics, the American Academy
of Family Practice, the American Osteopathic
Association, and the American College of Phy-
sicians have developed the following joint prin-
ciples to describe the characteristics of the
PCMH (March 2007; excerpted from the Pa-
tient-Centered Primary Care Collaborative web-
site: http://www.pcpcc.net/behavioral-health):

• Personal physician: Each patient has an
ongoing relationship with a personal physician
trained to provide first contact, continuous, and
comprehensive care.

• Physician-directed medical practice: The
personal physician leads a team of individuals at
the practice level who collectively take respon-
sibility for the ongoing care of patients.

• Whole-person orientation: The personal
physician is responsible for providing for all the
patient’s health care needs or taking responsi-
bility for appropriately arranging care with
other qualified professionals. This includes care
for all stages of life, acute care, chronic care,
preventive services, and end-of-life care.

• Care is coordinated or integrated across all
elements of the complex health care system
(e.g., subspecialty care, hospitals, home health
agencies, nursing homes) and the patient’s
community (e.g., family, public and private
community-based services). Care is facilitated
by registries, information technology, health in-
formation exchange, and other means to assure
that patients get the indicated care when and
where they need and want it in a culturally and
linguistically appropriate manner.

• Quality and safety are hallmarks of the
medical home (selected elements):

—Practices advocate for their patients to
support the attainment of optimal, patient-
centered outcomes that are defined by a
care-planning process driven by a compas-
sionate, robust partnership between physi-
cians, patients, and the patient’s family.

—Evidence-based medicine and clinical
decision support tools guide decision mak-
ing.

55PSYCHOLOGY IN PRIMARY CARE PCMHS

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—Patients actively participate in decision
making, and feedback is sought to ensure
that patients’ expectations are being met.

—Information technology is used appro-
priately to support optimal patient care,
performance measurement, patient educa-
tion, and enhanced communication.

• Enhanced access to care is available
through systems such as open scheduling, ex-
panded hours, and new options for communica-
tion between patients, their personal physician,
and practice staff.

• Payment appropriately recognizes the
added value provided to patients who have a
PCMH. The payment structure should

—reflect the value of physician and non-
physician staff patient-centered care man-
agement work that falls outside the face-
to-face visit;

—pay for services associated with coordi-
nation of care both within a given practice
and between consultants, ancillary provid-
ers, and community resources;

—support adoption and use of health in-
formation technology for quality improve-
ment;

—support provision of enhanced commu-
nication access such as secure e-mail and
telephone consultation;

—recognize the value of physician work
associated with remote monitoring of clin-
ical data using technology;

—allow for separate fee-for-service pay-
ments for face-to-face visits;

—recognize case mix differences in the
patient population being treated within the
practice;

—allow physicians to share in savings
from reduced hospitalizations associated
with physician-guided care management in
the office setting; and

—allow for additional payments for
achieving measurable and continuous
quality improvements.

Although behavioral health integration was
not explicitly included in the original PCMH
principles, the spirit of the biopsychosocial

model (Engel, 1977) in primary care is evident.
There have been numerous pundits advocating
for the explicit inclusion of behavioral health,
including the Behavioral Health Task Force of
the Patient-Centered Primary Care Collabora-
tive (PCPCC), whose member organizations are
listed in Table 1. The PCPCC, developed to
advance the PCMH, is a coalition of more than
600 members, including major employers, con-
sumer groups, patient quality organizations,
health plans, labor unions, hospitals, and clini-
cians. The Task Force is working tirelessly to
promote the absolute necessity of behavioral
health, including prevention, tobacco cessation,
substance abuse and mental health services, in
order to fulfill the PCMH vision of whole per-
son orientation and team approach to care
(http://www.pcpcc.net/behavioral-health). In
practice, it is hard to imagine a primary care
practice being an effective PCMH without inte-
grated behavioral health services. Of note, the
American Academy of Family Practice Board
Chairman Ted Epperly recently gave an inter-
view entitled “How Health Care Reform Could
End the Stepchild Status of Primary and Behav-
ioral Health Care,” in which he argued for how
the PCMH can serve as the bridge between the
historical silos of medicine, mental health, and
substance abuse services (Behavioral Health
Central, 2010).

The two specific core principles of the PCMH
most central to the inclusion of behavioral health
are whole-person orientation and integrated ser-
vice delivery. Integrated service delivery models
use a team-based approach to care for all patients
and the full range of patient needs, including emo-
tional and behavioral needs, as well as problems
of living that routinely surface in primary care
settings. A whole-person orientation implies that
primary care will have the capacity to identify and
address physical health care needs as well as men-
tal health needs, such as depression and anxiety;
behavioral medicine needs, such as chronic illness
management and chronic pain; and preventive
medicine needs, such as tobacco use, obesity,
health risk behaviors, and medical nonadherence.
Well-functioning team-based care would involve
providers and staff actively communicating col-
laboratively to ensure that patients experience ho-
listic, nonfragmented, and comprehensive health
care encompassing the full spectrum of needs
ranging from preventive services to chronic dis-
ease management.

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Recently, the National Committee for Quality
Assurance published updates to the PCMH stan-
dards. These changes unambiguously recognize
the dynamic interdigitation among emotional, be-
havioral, and physical health. Although much of
our existing language hamstrings us into discuss-
ing these as distinct entities, the recognition that
overall health status is a fluid compilation of all of
these components is unmistakable in the new stan-
dards. The proposed standards incorporate other

new concepts and have been reorganized through
consolidation or retirement of components. The
draft standards include:

• Provide access and continuity,
• Identify and manage patient populations,
• Plan and manage care,
• Support self-management,
• Track and coordinate care, and
• Improve performance measurement and

quality.

Table 1
Patient-Centered Primary Care Collaborative Behavioral Health Task Force Participating Organizations
and Individuals

Access Psychiatry LLC Alere American Academy of Family Physicians
American Academy of Pediatrics American College of Physicians American Osteopathic Association
American Psychiatric Association Association of Medical

Education and Research in
Substance Abuse

Baylor College of Medicine

Blue Cross and Blue Shield
Association

Blue Cross and Blue Shield of
California

Blue Cross Blue Shield of Michigan

Blue Cross Blue Shield of Tennessee ClinicNet Collaborative Health Solutions LLC
Colorado Behavioral Healthcare

Council
Colorado Clinical Guidelines

Collaborative
Empire Blue Cross Blue Shield

Family Medicine at University of
California, San Diego

GlaxoSmithKline Health2Resources

IBM Johnson & Johnson Kaiser Permanente
McKesson Merck National Business Group on Health
National Council for Community

Behavioral Healthcare
Novartis Pfizer

Sanofi-aventis St. Mary’s Hospital Thomson Reuters
TransforMed Ultrais University of Massachusetts Memorial

Health Care
University of Colorado Denver

School of Medicine
Academy of Psychosomatic

Medicine
Agency for Healthcare Research and

Quality
American Psychological Association American Society of Addiction

Medicine
Boehringer Ingelheim

Campaign for Mental Health Reform Commission on Accreditation
of Rehabilitation Facilities

Cartesian Solutions LLC

Integrated Primary Care SIG,
Society of Behavioral Medicine

Dartmouth Medical School George Washington University Medical
Center, Center for Integrated
Behavioral Health Policy

Goal QPC Healthspring Institute for Clinical Systems
Improvement

Integrated Benefits Institute James Barr, MD, Central New
Jersey Medical Home
Network

Lilly

Marillac Clinic, Colorado Medfusion Morehouse School of Medicine
National Association of State Mental

Health Directors
National Naval Medical Center Presbyterian Healthcare Services

Rush University Medical Center Substance Abuse and Mental
Health Services
Administration

Sentara

Takeda Thomas Group University of Cincinnati
University of Pittsburgh Medical

Center
University of Rochester

Medical Center
University of Vermont College of

Medicine
University of Washington Utah Health Science Center Value Options

Source. http://www.pcpcc.net/content/pcpcc-behavioral-health-taskforce-participating-organizations-and-individuals

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With regard to behavioral health, the new stan-
dards propose that primary care include: (a) a
comprehensive assessment including substance
abuse, health behaviors, and depression screen-
ing with a standardized tool; (b) that one of the
three clinically important conditions identified
by the practice must be a condition related to
unhealthy behaviors (e.g., obesity) or a mental
health or substance abuse condition; and (c

)

tracking referrals and coordinating care with
external mental health and substance abuse pro-
viders.

The Economic Rationale

Annual medical expenses among those who
suffer from both chronic medical and behavioral
health conditions cost roughly 46% more than
those with only a chronic medical condition
(Unützer et al., 2009). Moreover, of the top-five
conditions driving overall costs (including uti-
lization costs, lost work-related productivity,
and pharmacy costs), clinical depression tops
the list (Murray & Lopez, 1997). Particularly
for recognizing and treating depression in pri-
mary care, numerous studies to date have dem-
onstrated both cost-effectiveness and cost-offset
when behavioral health care is integrated into
primary care settings (Von Korff et al., 1998).
Studies have also documented improvements in
medical costs when behavioral health treatment
is provided for a variety of illnesses. For exam-
ple, in a meta-analysis of 91 studies, Chiles,
Lambert, and Hatch (1999) found that medical
utilization decreased 15.7% for those with a
mental health condition who received behav-
ioral health care, whereas it increased 12.3% for
those who did not. No well-controlled studies to
date have demonstrated the cost advantages of
placing primary care services within specialty
mental health clinics, although the lack of evi-
dence is primarily a function of the lack of
rigorous studies as opposed to any evidence to
the contrary. An exhaustive list of the studies
exploring the economics of integrated health
care will not be reviewed; however, interested
readers are referred to an article by Blount et al.
(2007).

The economics of improving primary care
services can also help make a case for behav-
ioral health integration. There is evidence that
the overall costs of health care among Medicare
beneficiaries tends to decrease as a function of

the density of primary care providers in any
geographical area according to Medicare
Claims Data (Baicker & Chandra, 2004). That
is, the more primary care providers there are in
any area, the lower the overall costs of health
care per person. One possible explanation for
this is that fewer persons are referred to spe-
cialty services, which often involve expensive
and sophisticated technology for diagnostics
and interventions. Moreover, the relationship
between quality indicators and numbers of pri-
mary care practitioners also trends fairly lin-
early and suggests that increasing the number of
primary care providers improves standardized
indicators for quality of care among Medicare
beneficiaries. In fact, there is evidence to sug-
gest a 5% decrease in mortality for every 20%
increase in primary care physicians, whereas
this same study reported a 2% increase in mor-
tality per every 8% increase in specialist physi-
cians (Shi et al., 2003). Unfortunately, in Amer-
ica, about 70% of physicians are subspecialists
and only 30% are in primary care; in the past
decade, nearly 90% of medical school graduates
chose to enter a subspecialty and only 10% are
going into primary care (American Academy of
Family Physicians, 2006; American Medical
Association Health Care Trends, 2006). This
has resulted in an extremely out-of-balance
workforce that not only has difficulties meeting
the current demands, but will become even
more under resourced and over burdened if ac-
cess to care is improved for some portion of the
currently 47 million uninsured Americans.
Sadly, in a large study of 6,600 primary care
physicians, two thirds reported not being able to
access outpatient behavioral health for their pa-
tients (Cunningham, 2009). Shortages of mental
health care providers, health plan barriers (i.e.,
in and out of network providers), and lack of
coverage or inadequate coverage were all cited
by primary care providers as barriers to mental
health care access (Cunningham, 2009). With
ample evidence to suggest the potential quality
and cost savings to be realized by increasing the
primary care workforce, the fiscal necessity of
integrating behavioral health is unequivocal.

Epidemiology of Mental Illness and
Behavioral Health

Two seminal articles have demonstrated re-
markably consistent findings related to the un-

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derlying behavioral and lifestyle factors that
contribute to the actual causes of mortality in
the United States. Most recently, using 2002
mortality data from the Centers for Disease
Control and Prevention, Mokdad, Marks,
Stroup, and Gerberding (2004) used estimates
of relative risks and prevalence reported in pub-
lished reputable studies and estimated the cause
of death by multiplying estimates of the cause-
attributable fraction of preventable deaths with
the mortality data to reveal the external, modi-
fiable risk factors underlying mortality. In this
study, tobacco use was the leading cause of
death, accounting for 18.1% of all premature
deaths in the United States, followed by poor
diet and inactivity, which accounted for 16.6%
of total deaths and represented an increase
by nearly 3% from the prior, similar study
(McGinnis & Foege, 1993). Alcohol consump-
tion also accounted for another 3.5% of deaths.
Collectively, nearly half (48.2%) of all prema-
ture deaths were accounted for by a fairly lim-
ited number of largely preventable and modifi-
able risk factors and exposures (Mokdad et al.,
2004). Whereas genetics, access to health care,
the environment, and other nonmutable factors
undoubtedly play a role in morbidity and mor-
tality, ample evidence suggests that health be-
haviors commonly lead to the occurrence of one
or more chronic medical conditions before they
cause death.

The number of Americans diagnosed with a
chronic medical condition is steadily increasing,
and health care expenses for chronic medical
conditions account for 78% of all health care
spending based on the Medical Expenditure
Panel Survey data (Stanton & Rutherford,
2005). Expenditures rise proportionately when
comorbid chronic conditions exist, which are
more often the norm rather than the exception.
Moreover, the costs associated with managing a
chronic medical condition, such as diabetes or
hypertension, are also significantly higher when
there is a comorbid mental illness (Petterson et
al., 2008), and there is a higher than random
co-occurrence of depression with 11 chronic
medical conditions (Welch, Czerwinski, Ghi-
mire, & Bertsimas, 2009). For example, 20 –
30% of patients with diabetes experience de-
pression (Anderson, Freeland, Clouse, &
Lustman, 2001). A large study on depressed
patients in primary care suggested that 75%
presented to primary care with physical com-

plaints and stated that the physical ailments
were the reason they sought health care, not
their mood (Unützer et al., 2003). Obesity exists
in 30% of the population and nearly 60% of
Americans live a sedentary lifestyle (Ogden,
Carroll, McDowell, & Flegal, 2007). Racial and
ethnic minorities are even less inclined than
Whites to seek treatment from mental health
specialists (U.S. Department of Health and Hu-
man Services, 1999). Instead, primary care be-
comes the point of entry for many minorities.
Collectively, these data underscore a central
role for nonphysician providers to address
health behaviors, help manage chronic illnesses,
and address traditional mental health needs. As
experts in human behavior, psychologists are a
natural fit to fill this role.

In addition to health behaviors, the most
common epidemiological reason cited for inte-
grating behavioral health into primary care is
the high prevalence of mental illness that exists
in the United States. The National Comorbidity
Survey is conducted among U.S. households
every 10 years (it excludes institutionalized and
homeless populations) and is a reliable source
for epidemiological data for mental illness. In
the last survey, 26% of respondents reported
symptoms sufficient to warrant a mental health
diagnosis in the past 12 months, and a lifetime
prevalence estimate for any mental health dis-
order was 46.4% (Kessler, Berflund et al.,
2005). Of these, anxiety disorders were most
prevalent, followed by mood disorders. Despite
the scope of and severity of conditions, 59% of
respondents with a mental health condition re-
ported receiving no treatment for their mental
illness; of the 41% who did receive treatment,
only 44% received any mental health care. All
others received care in the primary care clinic
by primary care providers. Another more recent
study conducted on the scope and nature of
anxiety disorders in a primary care clinic found
similar results in that 19.5% of the sample had
one or more anxiety disorders but 41% were not
receiving any treatment (Kroenke, Spitzer, Wil-
liams, Monahan, & Lowe, 2007). Of those who
were treated, 42% were treated with medication
only (Kroenke et al., 2007). The reasons for the
lack of treatment in general and lack of mental
health treatment in particular are many, includ-
ing access to care. However, stigma remains
another common and substantial barrier to seek-
ing mental health care. Based on a survey

59PSYCHOLOGY IN PRIMARY CARE PCMHS

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of 3,239 adults conducted in 2000, 42% of
people with a mental health condition reported
that they were embarrassed or ashamed of their
symptoms (National Mental Health Associa-
tion, 2000). Thirty-two percent of adults with-
out a mental health condition stated they would
likely turn to their primary care provider to help
with mental health issues if the need arose; only
4% stated they would specifically seek mental
health care (National Mental Health Associa-
tion, 2000). Other data confirm this reality—
approximately 50% of all behavioral health dis-
orders are treated in primary care and 48% of
psychotropic agents are prescribed by nonpsy-
chiatric primary care providers (Kessler, Dem-
ler et al., 2005; Pincus et al., 1998). Mental
health care is and will continue to be delivered
in primary care clinics. Psychology can opt to
integrate into primary care where the patients
are, or remain in a specialty care model of
practice and risk being marginalized from over-
all health care, thereby making little dent in the
health and well-being of the population. The
choice seems clear, but will it work?

Evidence Supporting Integrated Care

Integration takes many forms and there is no
one best model of integrated care. However,
most models of integration are predicated on the
notion of stepped care and work well only in the
context of a larger behavioral health delivery
system that includes specialty mental health,
substance abuse services, and behavioral ser-
vices for common chronic and acute conditions.
Just as primary medical care relies on the avail-
ability of specialists for consultation and man-
agement of complex patients, integrated pri-
mary behavioral health care relies on these other
types of services and providers. Various models
of integrated care have been described and, in
practice, the implementation of integrated care
tends to take on unique characteristics and per-
mutations depending on the specific setting.
Thus, rather than define a specific model of
integrated care, the framework below (Kirk
Strosahl, cited in Robinson & Reiter, 2007)
identifies key components of integration as well
as an illustration of how a fully integrated care
model might function:

• Mission integration: the extent to which
the behavioral and general medical service sys-
tems are pointing toward the same health objec-
tives, goals, and strategies. In well-integrated
systems, the overarching and shared constancy
of purpose is to improve the health of the entire
population, not just to treat the sick.

• Clinical service integration: the degree to
which general medical and behavioral providers
seamlessly engage in coordinated assessment,
intervention, and follow-up activities with well-
integrated systems using a lot of comanagement
processes, protocols, and assessment tools.

• Physical integration: the degree to which
the general medical and behavioral health pro-
viders work in the same space, allowing for
instantaneous access to care, with well-
integrated systems being colocated at a mini-
mum.

• Operations integration: the degree to which
the general medical and behavioral health pro-
viders work off the same clinic “platform,” with
well-integrated systems sharing as many oper-
ational processes as realistic given that there are
some nuisances to mental health care in any
setting.

• Information integration: the degree to
which the general medical and behavioral
health provider can access real-time client care
information, with well-integrated systems hav-
ing shared and open access to documentation.

• Financial integration: the degree to which
general medical and behavioral health services
are funded as a “basic” form of health care, with
well-integrated systems including some aspects
of integrative behavioral care as a core primary
care service and not exclusively dependent on
fee for service/productivity to support the pro-
viders.

Evidence for integrated care has been accu-
mulated on a variety of clinical outcomes,
including symptoms as well as disease manage-
ment indicators, process outcomes (e.g., no-
show rates and recognition rates), economic
outcomes (cost-effectiveness and cost-offset),
as well as patient and provider satisfaction. A
thorough review of all of the evidence is beyond
the scope of this article, but interested readers
are referred to several comprehensive reports
summarizing this evidence, including the World
Health Organization and World Organization of
Family Doctors’ (2008) report Integrating Men-
tal Health Into Primary Care: A Global Per-

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spective; the Agency for Health Care Research
and Quality’s report Integration of Mental
Health and Substance Abuse in Primary Care
(Butler et al., 2008); the Hogg Foundation for
Mental Health’s (2008) report Connecting Body
and Mind: A Resource Guide to Integrated
Health Care in Texas and the United States; and
the Milbank Memorial Fund report Evolving
Models of Behavioral Health Integration in Pri-
mary Care (Collins, Hewson, Munger, & Wade,
2010). The National Council for Community
Behavioral Health Care’s website is also an
extraordinary one-stop online shopping re-
source for a variety of articles, reports, mea-
sures, research, and other information about in-
tegrated care (http://www.thenationalcouncil
.org/cs/new_at_the_resource_center). In sum,
these reports describe numerous successful pro-
grams employing various models of integrated
care.

Several recent meta-analyses have not only
further documented the effectiveness of inte-
grating care but have tried to isolate the most
critical elements of effective integration mod-
els. Gilbody, Bower, and Fletcher (2006)
published a meta-analysis of 37 randomized
studies, which included 12,355 patients with
depression in primary care. Results suggested
that integrated care improves depression out-
comes at 6 months (standardized mean differ-
ence [SMD] � 0.25, 95% CI [0.18, 0.32]). Fur-
thermore, a sustained benefit was found with
clinical improvements after 12 months
(SMD � 0.31), 18 months (SMD � 0.25), 24
months (SMD � 0.15), and even up to 5 years
(SMD � 0.15, 95% CI [0.001, 0.31]). Effective-
ness, as measured by the magnitude of the effect
size, was directly linked to medication compli-
ance (slope coefficient � 0.19; 95% credible
interval [0.08, 0.30]); using care managers with
mental health backgrounds (SMD � 0.34) com-
pared with nonmental health backgrounds
(SMD � 0.164); and regular, planned supervision
of the care managers (SMD � 0.29) compared
with unplanned supervision (SMD � 0.14; Gil-
body et al., 2006). Bower, Gilbody, Richards,
Fletcher, and Sutton (2006) completed a
metaregression of 28 studies of collaborative
care reporting outcome data on antidepressant
use and 34 studies with data on clinical out-
comes. Collaborative care had a positive and
significant impact on antidepressant use
(OR � 1.92, 95% CI [1.54, 2.39]) and reduction

in depressive symptoms (SMD �
0.24, 95% CI [0.17, 0.32]). In further analyses,
three unique components of collaborative care
predicted improved depression outcomes. Spe-
cifically, systematic identification of depressed
patients in primary care ( p � .061), using case
managers with a mental health background
( p � .004), and regular supervision of case
managers ( p � .033) were the strongest predic-
tors of effectiveness (Bower et al., 2006).

Although both meta-analyses found compli-
ance with antidepressant medication to be a
strong predictor of improvement on depression
outcomes, there was no attempt to compare or
include studies that used integrated care models
with a nonmedication treatment condition. This
is relevant because three large and methodolog-
ically sound studies document little evidence of
the specific pharmacological effect of antide-
pressant medications, relative to pill placebo,
for patients with mild to moderate depression
(Fournier et al., 2010; Khan, Leventhal, Khan,
& Brown, 2002; Kirsch et al., 2008). Results
from the most recent patient-level meta-analysis
(718 patients) indicate that the magnitude of the
benefit from medication, compared with pla-
cebo, increases with the severity of the depres-
sion symptoms. For patients in the mild to mod-
erate range of depression, the Cohen d effect
size was 0.11 (95% CI [�0.18, 0.41]), and for
patients in the severe range, d � 0.17 (95% CI
[�0.08, 0.43]), both of which fall below the
conventional threshold for a small effect size
(d � 0.20). In contrast, for patients in the very
severe range of depression, d � 0.47 (95% CI
[0.22, 0.71]), suggesting a medium effect size.
These data imply that psychologists might be
enormously useful in helping primary care phy-
sicians identify depression symptoms early to
prevent disease progression, assist with diag-
nostic clarification and severity classifications,
and support primary care treatment for mild to
moderate depression to help prevent excessive
prescribing of potentially iatrogenic medica-
tions.

Studies on the effect of short-term behavioral
interventions, and behavioral activation in par-
ticular, have demonstrated statistically and clin-
ically meaningful effects on reducing depres-
sion at a level comparable to antidepressant
medication, with few if any risks (Dimidjian et
al., 2006). Moreover, a well-done study on the
recognition and treatment of anxiety in primary

61PSYCHOLOGY IN PRIMARY CARE PCMHS

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care using cognitive– behavioral therapy (CBT)
and medications also demonstrated that both
types of treatment had a significant and sus-
tained (12 months) improvement over treatment
as usual (Roy-Byrne, 2005). In addition, pa-
tients receiving both medication and CBT were
less symptomatic at 3 and 12 months as mea-
sured by the Anxiety Sensitivity Index (Reiss et
al., 1986), the World Health Organization’s
Disability Assessment Schedule II (Epping-
Jordan and Üstün, 2000), and the Social Avoid-
ance subscale of the Fear Questionnaire (Marks
& Mathews, 1979), compared with those re-
ceiving medication alone. There is also a sizable
and growing body of literature demonstrating
the clinical and economic benefits of treating
mental health conditions associated with
chronic medical conditions with a variety of
pharmacological and nonpharmacological inter-
ventions. These studies consistently demon-
strated positive effects on clinical outcomes,
cost reduction, and decreased fragmentation of
care, which often reduces redundancy in ser-
vices that drive up health care costs (see Ouw-
ens, Wollersheim, Hermens, Hulscher, & Grol,
2005, for a review of systematic reviews on this
topic).

Research on the central organizational and
process parameters associated with effective in-
tegration models suggests that integrating the
principles of population health and chronic care
management in the primary care setting helps
achieve the goals of clinical quality, efficiency,
and maximal return on investment. These prin-
ciples include, but are not necessarily limited to,
the following:

• Proactive identification of conditions of in-
terest (screening);

• Timely access to services;
• Locus of service delivery within primary

care
• Full involvement of a treatment team, in-

cluding primary care practitioners, care coordi-
nators, and behavioral health specialists;

• Inclusion of pertinent behavioral health in-
terventions in a unified treatment plan;

• Careful and systematic monitoring of pa-
tients (registry) and treatment response;

• Patient engagement, reengagement, and
active collaboration; and

• Reliance on evidence-based behavioral
health practices and defined clinical/administra-
tive workflows.

Although it remains unclear how to effec-
tively finance models of integrated care, it is
obvious that exclusively fee-for-service models
are woefully insufficient and not commensurate
with the guiding principles of the PCMH. Op-
tions such as bundled payments and payments
based on processes and outcomes are being
evaluated to include mechanisms for financing
behavioral health providers and services within
the PCMH. To the extent that these efforts are
successful, psychologists who are trained, pre-
pared, and willing to practice in such settings
will undoubtedly be in high demand. As such,
the requisite knowledge and competencies for
psychologists to work effectively in the primary
care setting, how to obtain this training, and the
types of positions that will be available consti-
tute the remaining topics of this article.

Training Psychologists as Health Care
Professionals

It should be noted that the concept and prac-
tice of integrating behavioral health into medi-
cine is not new. For many years, psychologists
and social workers have been embedded in both
primary care and tertiary care medical settings
such as organ transplant units, oncology, reha-
bilitation units, and other hospital-based spe-
cialties. Thus, it is not surprising that many
behavioral health providers migrating into pri-
mary care settings come from a few limited
training models and traditions, namely behav-
ioral medicine (clinic health psychology), med-
ical social work, and family therapy. The two
parallel disciplines that have contributed most
to the understanding of behavioral health in
primary care are clinical health psychology and
family therapy— both with rich but varying ed-
ucation and training traditions. Family therapy
is steeped in history, theory, and clinical prac-
tice, whereas behavioral medicine evolved as a
more scientific discipline based in developing
and conducting empirical studies on assessment
and treatment approaches. Nonetheless, the two
models can and do blend well in primary care
practice. The requisite knowledge and skills for
primary care practice incorporate and expand on
both of these fields. Added concepts include
population health, epidemiology, proactive
screening, medical terminology, culture unique
to primary care, privacy in medical settings,
chronic disease management, pharmacology

62 RUNYAN

T
hi
s
do
cu
m
en
t i
s
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

(not only psychopharmacology), care across the
life span, a team of providers and medical staff,
and continuous quality improvement. Table 2
provides an overview of the core knowledge
base that would be ideal for practitioners enter-
ing primary care settings and how this differs
from traditional curricula. Table 3 further delin-
eates core competencies as well as some orga-
nizational knowledge and skills that tend to be
helpful not only to become an effective practi-
tioner in primary care but an effective and in-
fluential change agent as well.

The breadth and depth of knowledge and
skills necessary for primary care cannot be con-
tained within any single discipline as currently
defined; the need for most practitioners to ob-
tain additional training is clear. Currently, there
are few opportunities for formal education and
training. A few psychology graduate schools
offer specialties in integrated care, including
Forest Institute of Professional Psychology in
Springfield, Missouri; the University of Nevada
at Reno; and a newly developed program lead-
ing to a nonclinical doctorate in behavioral
health has been established at Arizona State

University. Fortunately, graduate programs are
increasingly developing partnerships with med-
ical agencies and offering practicum experi-
ences of varying duration, intensity, and set-
tings to students. Moreover, many predoctoral
internships also offer integrated care minor
or major rotations and primary care is now
a searchable field in the Association of Psy-
chology Postdoctoral and Internship Centers
(APPIC) database (http://www.appic.org/
directory/4_1_directory_online.asp). A recent
search of this database identified 92 American
Psychological Association-accredited predoc-
toral internship programs reportedly offering a
major rotation in primary care. Finally, a limited
number of primary care postdoctoral fellow-
ships have been developed throughout the coun-
try; these can also be queried using the APPIC
database— 43 postdoctoral programs currently
list a primary care experience, many of which
are exclusively dedicated to offering a primary
care training experience. This summer, the
Health Resources and Services Administra-
tion’s Graduate Professional Education division
funded several training grants to American Psy-

Table 2
Comparison of Curriculum Components for Clinical Health Psychology, Medical Family Therapy, and
Primary Care Psychology

Basic health psychology Basic (medical) family therapy Proposed primary care psychology

Biopsychosocial (spiritual) Biopsychosocial (spiritual) Biopsychosocial (spiritual)
1:1 patient care, groups Family therapy 1:1, families, teams, health care

systems, population based
Specialist model Specialist model Generalist model in content
Typically specialize in either

adults or children
Families, couples Generalist model in population

served
Medical literacy and language Medical literacy and language Medical literacy and language
Pharmacology knowledge Limited pharmacology

knowledge
Pharmacology knowledge and

application
Mostly targeted assessments; some

more lengthy and
comprehensive assessments

Little reliance on formal and
objective assessments

Brief symptom-based
questionnaires and screeners

Primary provider for behavioral
health needs

Primary provider to patients
and families for behavioral
health needs

Collaborator, no case load

Chronic and acute illness Chronic illness Chronic and acute illness
Cultural competence Cultural competence Cultural competence
Adherence—Barriers to and

interventions for evidence-based
medicine (motivational
interviewing, health behavior
change, etc.)

Adherence —Barriers to and
interventions for family/
contextual interventions
more likely

Theory-driven interventions;
evidence based as available

Adherence—Barriers to and
interventions for evidence-based
medicine (motivational
interviewing, health behavior
change, etc.) but adopted for
primary care and short-term
treatment

63PSYCHOLOGY IN PRIMARY CARE PCMHS

T
hi
s
do
cu
m
en
t i
s
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

T
ab

le
3

S
p
ec

ifi
c

S
ki

ll
s

fo
r

P
ri

m
a
ry

C
a
re

P
sy

ch
o
lo

g
y

C
li

ni
ca

l
pr

ac
ti

ce
sk

il
ls

D
oc

u

m
en

ta
ti

o

n
sk

il
ls

C
on

su
lt

at
io

n
sk
il
ls

O
rg

an
iz

at
io

na
l

an
d

im
pl

em
en

ta
ti

on
sk

il
ls

A
pp

ro
pr

i

a
te

ly
de

fi
ne

be
ha

vi
or

a

l
he

al
th

ca
re

ro
le

an
d

sc
op

e
of

se
rv

ic
e

to
pa

ti
en

t

s
an

d
pr

ov
id

er
s

W
ri

t

e
cl

ea
r,

co
nc

is
e

ch
ar

t
no

te
s

F
oc

us
on

an
d

an
sw

er
re

fe
rr

al
qu

es
ti

on
S

cr
ee

ni
ng

(a
du

lt
s,

pe
di

at
ri

cs
,

ge
ri

at
ri

cs
�d

em
en

ti
a�

,
su

bs
ta

nc
es

,
w

om
en

’s
he

al
th
)

A
bl

e
to

ra
pi

dl
y

id
en

ti
fy

an
d

as
se

ss
pr

ob
le

m
s

w
hi

le
li

m
it

in
g

sc
op
e
of
as
se

ss
m

en
t

G
et

no
te

s/
fe

ed
ba

ck
to

pr
im

ar
y

ca
re

ph
ys

ic
ia

n,
id

ea
ll

y
on

th
e

s

a
m

e
da

y
pa

ti
en

t
is

se
en

O
ff

er
re

co
m

m
en

da
ti

on
s

ta
il

or
ed

to
pr

im
ar

y
ca

re
w

or
k

pa
ce

T
ea

m
-b

as
ed

ca
re

so
m

et
im

es
as

a
m

em
be

r;
at

ti
m

es
,

le
ad

in
g
a
te

am

K
no

w
le

dg
e

of
be

st
pr

ac
ti

ce
s

an
d
pr
im
ar
y
ca
re

cl
in

ic
al

pr
ac

ti
ce

gu
id

el
in

es
W

ri
te

ch
ar
t
no
te
s

th
at

ar
e

fr
ee

of
m

en
ta

l
he
al
th

ja
rg

on
an

d
co

ns
is

te
nt

w
it

h
ve

rb
al

fe
ed

ba
ck

C
on

du
ct

ef
fe

ct
iv

e
cu

rb
si

d

e
co

ns
ul

ta
ti

on
K

no
w

le
dg

e
ab

ou
t

th
e

cu
lt

ur
e

of
pr

im
ar
y
ca

re
,

cu
lt
ur
e
of
m

ed
ic

in
e,

an
d

m
ed

ic
al

ed
uc

at
io

n
U

se
ap

pr
op

ri
at

e
cl

in
ic

al
as

se
ss

m
en

ts
A

ss
er

ti
ve

ly
fo

ll
ow

up
w

it
h

pr
im
ar
y
ca
re
ph
ys
ic
ia

n
w

he
n

in
di

ca
te

d
K

no
w
le
dg
e
ab
ou
t

he
al

th
ca

r

e
in

ge
ne

ra
l

an
d
he
al
th
ca

re
ec

on
om

ic
s

F
oc

us
es

on
fu

nc
ti

on
al

m
ea

su
re

s
an

d
ou

tc
om

e

s
D

ev
el

op
an

d
su

gg
es

t
re

co
m
m
en
da
ti
on
s

to
re

du
ce

pr
im
ar
y
ca
re
ph
ys
ic
ia
n
w
or
k

lo
ad

Q
ua

li
ty

im
pr

ov
em

en
t

sk
il

ls
;

kn
ow

le
dg

e
an

d
ab

il
it

y
to

ap
pl

y
P

la
n,

D
o,

S
tu

dy
,

A
ct

(P
D

S
A

)
cy

cl
es

U
se

se
lf

-m
an

ag
em

en
t/

ho
m

e-
ba

se
d

pr
ac
ti
ce
fo
r
in
te

rv
en

ti
on

s
D

is
pl

ay
w

il
li

ng
ne

ss
to

be
in

te
rr

up
te

d
an

d
be

av
ai

la
bl

e
to
pr
im
ar
y
ca
re
ph
ys
ic
ia
ns
K
no
w
le
dg
e
an
d

us
e

of
te

ch
no

lo
gy

re
so

ur
ce

s
fo

r
pr

im
ar
y
ca
re
,

su
ch

as
U

pT
oD

at
e

an
d

E
po

cr
at

es
so

ft
w

ar
e

D
es

ig
n

an
d

de
li

ve
r

in
te
rv
en
ti
on

s
th

at
ar

e
co

nc
re

te
an

d
su

pp
or

ta
bl

e
by

pr
im
ar
y
ca
re
ph
ys
ic
ia
n

A
bi

li
ty

to
te

ac
h

pr
im
ar
y
ca
re
ph
ys
ic
ia

ns
fo

rm
al

ly
an

d
in

fo
rm

al
ly

A
pp

ly
un

de
rs

ta
nd

in
g

of
th

e
bi

op
sy

ch
os

oc
ia

l
m

od
el

B
us

in
es

s
ac

um
en

(b
il

li
ng

,
le

ve
ra

gi
ng

vi
si

ts
,

an
d

pa
yi

ng
fo

r
be

ha
vi

or
al

he
al

th
)

B
as

ic
kn

ow
le

dg
e
of
m
ed
ic
in
es
an
d

ab
il

it
y

to
ap

pl
y

th
is

kn
ow
le
dg
e
in
pr
ac
ti
ce
K
no
w
le
dg
e

of
ro

ut
in

e
pr

ev
en

ti
ve
ca
re
pr
im
ar
y
ca
re
ph
ys
ic
ia

ns
de

li
ve

r

64 RUNYAN

T
hi
s
do
cu
m
en
t i
s
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

chological Association-accredited programs
offering multidisciplinary training to psycholo-
gists, many of which are in primary care set-
tings. Informally, conference presentations as
well as webinars have become a common mo-
dality for disseminating knowledge and sharing
experiences in integrated care. Various agencies
have produced integrated care trainings videos,
including the National Council for Community
Behavioral Health Care, which recently com-
pleted a series of three webinars designed to
educate providers and administrators about in-
tegrated care. Toolkits and manuals are also
becoming a more common mechanism to dis-
tribute content knowledge and tools for inte-
grated care practice (e.g., see Integrated Behav-
ioral Health Project at http://www.ibhp.org/).
Perhaps the flagship training opportunity in in-
tegrated care is at the University of Massachu-
setts Medical School under the direction of
Alexander Blount (http://www.umassmed.edu/
FMCH/PCBH/Welcome.aspx?linkidentifier�
id&itemid�76312). This program is exclu-
sively distance learning and comprises a
6-month curriculum delivered one Friday a
month for 6 hours. The content of the program
includes the following core topics: primary care
culture and needs, evidence-based therapies and
substance abuse, behavioral health care for
chronic illness, the toolbox and overview of
psychopharmacology, behavioral medicine
techniques, caring for the seriously and persis-
tently mentally ill in primary care, and families
and culture in primary care. Continuing educa-
tion credits are available for this program,
which costs $1,600 per participant, per site.

Implications for Training

Despite all of the opportunities noted above,
the skills necessary to work in an integrated
clinic cannot be learned from didactic education
and technology-enhanced distance learning
alone. We need to develop a pipeline of trained
clinicians who can then serve as clinical educa-
tors and supervisors for new learners and train
those who demonstrate a proclivity toward pri-
mary care how to supervise and train others.
The same model of clinical training that has
been used for many years in clinical psychol-
ogy, family therapy, and medical education
(i.e., a combination of didactic education and
experiential training) must be created for the

practice of primary care. To accomplish this, a
critical mass of well-trained and dispersed
group of practitioners in various health care
settings must be available to offer clinical train-
ing opportunities to students. As discussed in an
article by Blount and Miller (2009), unless we
can radically increase the workforce available to
work in primary care, we run the risk of being
marginalized as part of routine health care as it
becomes redefined through health care reform
legislation and clinical practice.

The mechanisms for achieving this goal are
neither entirely clear nor easy. American Psy-
chological Association-accredited graduate
schools are, at least partially, in service to a
somewhat prescribed and standardized curricu-
lum that leaves little room for ingenuity and
modification without extending the program.
Adding material is not feasible in most pro-
grams that are already bursting at the seams
with requisite coursework and requirements. In
addition, curriculum change, even adding a new
course, might require years and considerable
committee involvement and approvals. Inde-
pendent graduate schools of psychology might
have a slightly advantageous position in this
regard; however, regardless of setting, adding
new curricula can be a long and laborious pro-
cess. Thus, considerable reengineering of grad-
uate psychology curricula is required to produce
health care practitioners that can serve in pri-
mary care clinics. The educational requirements
(guidelines and principles) set forth by the
American Psychological Association Commit-
tee on Accreditation should embrace a curricu-
lum that prepares all psychologists to practice
within the full scope of psychology as a health
profession. Material that holds historical inter-
est but little applicability for clinical practice
might be eliminated or required at the under-
graduate level prior to admission to graduate
school. This would allow time and room in the
curriculum to add content that is more relevant
to today’s health care delivery system and de-
rived from the latest scientific evidence. Fortu-
nately, much of the material and competencies
that are relevant to primary care provide robust
scaffolding for generalist psychology training.
For example, primary care psychologists should
be well versed in the theory and applications of
cognitive– behavioral techniques, dialectical be-
havior techniques, mindfulness techniques, mo-
tivational interviewing techniques, and psycho-

65PSYCHOLOGY IN PRIMARY CARE PCMHS

T
hi
s
do
cu
m
en
t i
s
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

pharmacology. Moreover, primary care practice
requires a comfort with implementing tech-
niques as opposed to full versions of manual-
ized CBT protocols, which are not feasible in
this setting. Patients in primary care are often
less sick than those entering the mental health
system and may not be willing or ready to
accept a mental health diagnosis to explain their
symptoms. Although the recommended knowl-
edge and skills are clearly not unique to primary
care, training these techniques exclusively in
traditional mental health settings falls short
given the population.

In primary care, patients may have a broad
array of needs given their medical conditions,
and behavioral health clinicians will need to be
both aware of and relatively comfortable dis-
cussing these as a member of their health care
team. Other critical shifts include assuming the
role of an ancillary provider, rather than being
exclusively in charge of a patient’s treatment
plan, adapting to a different workflow and
pace as well as different confidentiality stan-
dards, and learning about the roles of nurses,
medical assistants, and a variety of other work-
ers who are less commonly encountered in tra-
ditional mental health settings. Didactic educa-
tion is necessary, but experiential training will
also be required to prepare behavioral health
clinicians for the above realities to effectively
practice in the PCMH.

A multitude of professional opportunities ex-
ist for psychologists who obtain the breadth and
depth of expertise needed to work in a primary
care setting given that it is an avenue to expand,
not narrow, occupational growth. Well-trained
primary care practitioners can expect to serve in
clinical positions within community health cen-
ters, federally qualified health centers, and other
types of primary care settings. In addition, the
need for practice-based research in this field is
enormous, and psychologists who have an in-
terest in combining research and clinical prac-
tice will be in high demand and will undoubt-
edly offer meaningful contributions to a field
hungry for more evidence. Another possible
professional role includes becoming a behav-
ioral science faculty member within family
practice residency programs. Psychologists with
the knowledge and skills to work in primary
care will be able to teach future family practi-
tioners about assessing and treating behavioral
health conditions and how to work as a collab-

orative team member during their 3-year resi-
dency program, which always includes a behav-
ioral science element per their education and
training requirements. By its very nature, be-
coming a primary care behavioral health clini-
cian requires one to specialize in a discipline
that, similar to family medicine, is actually a
generalist model in which one must be prepared
to address patients across the life span and
across all aspects of health, wellness, sickness,
and death. In a rapidly changing environment,
psychologists have and should seize the oppor-
tunity to position themselves at forefront by not
only responding to but helping to define the
future of high-quality, cost-effective health care
in the United States.

References

American College of Physicians. (2006). The im-
pending collapse of primary care medicine and its
implications for the state of the nation’s health
care: Report from the American College of Physi-
cians. Philadelphia, PA: Author.

American Medical Association. (2006). Health care
trends, an environmental analysis report. Re-
trieved from http://www.ama-assn.org/ama1/pub/
upload/mm/409/2006trends

Anderson, R. J., Freeland, K. E., Clouse, R. E., &
Lustman, P. J. (2001). The prevalence of comorbid
depression in adults with diabetes. Diabetes
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Received June 2, 2010
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Accepted February 1, 2011 �

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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 across

the 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).

The Institute 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. KELLY 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.
HELEN L. COONS 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.
MIGUEL GALLARDO served as the action editor for this article.
CORRESPONDENCE 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: jfkphd@aol.com

Professional Psychology: Research and Practice © 2012 American Psychological Association
2012, Vol. 43, No. 6, 586 –595 0735-7028/12/$12.00 DOI: 10.1037/a0030090

586

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the process of the health care delivery becoming more 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). The Patient 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; see www
.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,
see Interprofessional Education Collaborative Expert Panel (2011)
and Team-Based Competencies Conference Proceedings (2011),
as well as the books listed in Table 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.

587INTEGRATED HEALH CARE AND PROFESSIONAL PSYCHOLOGY

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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 by Liss 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 the Centers 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 Medicare

and 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 to Doherty, 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 2 summarizes the common roles and respon-

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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 patients

who 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

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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

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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) and Bray 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 have

established 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

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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 be

resistant 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

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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.

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Received December 30, 2011
Revision received June 30, 2012

Accepted July 12, 2012 �

New Editors Appointed, 2014 –2019

The Publications and Communications Board of the American Psychological Association an-
nounces the appointment of 4 new editors for 6-year terms beginning in 2014. As of January 1,
2013, manuscripts should be directed as follows:

● Journal of Experimental Psychology: Animal Behavior Processes (http://www.apa.org/pubs/
journals/xan/), Ralph R. 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
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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.

595INTEGRATED HEALH CARE AND PROFESSIONAL PSYCHOLOGY

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Integrating Behavioral Health Services Into a University
Health Center: Patient and

Provider Satisfaction

Jennifer S. Funderburk, PhD
VA Center for Integrated Healthcare, Syracuse,

New York, Syracuse University, and University of
Rochester

Robyn L. Fielder, MS
Syracuse University

Kelly S. DeMartini, PhD
Syracuse University and Yale University School of

Medicine

Cheryl A. Flynn, MD
University of Vermont

The goals of this study were to (a) describe an Integrated Behavioral Health Care
(IBHC) program within a university health center and (b) assess provider and patient
acceptability and satisfaction with the IBHC program, including behavioral health
screening and clinical services of integrated behavioral health providers (BHPs).
Fifteen providers (nine primary care providers and six nurses) and 79 patients (75%
female, 65% Caucasian) completed program ratings in 2010. Providers completed an
anonymous web-based questionnaire that assessed satisfaction with and acceptability of
behavioral health screening and the IBHC program featuring integrated BHPs. Patients
completed an anonymous web-based questionnaire that assessed program satisfaction
and comfort with BHPs. Providers reported that behavioral health screening stimulated
new conversations about behavioral health concerns, the BHPs provided clinically
useful services, and patients benefited from the IBHC program. Patients reported
satisfaction with behavioral health services and reported a willingness to meet again
with BHPs. Providers and patients found the IBHC program beneficial to clinical care.
Use of integrated BHPs can help university health centers support regular screening for
mental and behavioral health issues. Care integration increases access to needed mental
health treatment.

Keywords: integrated behavioral health care, integrated primary care, mental health care

Integrated behavioral health care (IBHC), in
which primary care providers (PCPs) and be-
havioral health providers (BHPs) collaborate to
provide coordinated care, is an emerging model
of patient care. Over the past decade, research
has identified IBHC as a clinically effective and
cost-effective method for improving clinical

outcomes within primary care settings (Blount
et al., 2007; Bryan, Morrow, & Appolonio,
2009; Cigrang, Dobmeyer, Becknell, Roa-
Navarrete, & Yerian, 2006; Goodie, Isler, Hun-
ger, & Peterson, 2009). Typically, this research
has focused on integrating mental and behav-
ioral health care within adult primary care set-

This article was published Online First May 21, 2012.
Jennifer S. Funderburk, PhD, VA Center for Integrated

Healthcare, Syracuse, New York, Department of Psychol-
ogy, Syracuse University, and Department of Psychiatry,
University of Rochester; Robyn L. Fielder, MS, Depart-
ment of Psychology, Syracuse University; Kelly S. DeMar-
tini, PhD, Department of Psychology, Syracuse University
and Department of Psychiatry, Yale University School of
Medicine; Cheryl A. Flynn, MD, Center for Health and
Wellbeing, University of Vermont.

The views expressed in this article are those of the authors and
do not reflect the official policy of the Veterans’ Affairs’ depart-
ment or other departments of the U.S. government. This material
is based upon work supported by the American College Health
Association United Healthcare Student Recourse Initiatives in
College Mental and Behavioral Health grant.

Correspondence concerning this article should be ad-
dressed to Jennifer S. Funderburk, Center for Integrated
Healthcare, 800 Irving Avenue, Room 116C, Syracuse,
NY 13210. E-mail: jennifer.Funderburk@va.gov

Families, Systems, & Health © 2012 American Psychological Association
2012, Vol. 30, No. 2, 130 –140 1091-7527/12/$12.00 DOI: 10.1037/a0028378

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tings, such as private family medicine practices,
academic medical center primary care clinics,
and primary care services offered within the
Veterans Health Administration or Federal
Qualified Centers. However, there is little re-
search examining IBHC in university health
clinics.

University health centers share many features
with standard primary care settings. For exam-
ple, university health centers tend to offer am-
bulatory care and other basic medical services
to a wide range of patients (Christmas, 1995).
These clinics tend to be students’ first option
when seeking medical care in nonemergency
situations. University health centers may coor-
dinate referrals to off-campus specialists as nec-
essary. Thus, in terms of services offered and
general approach to care, university health cen-
ters and primary care clinics are quite similar.
Nevertheless, compared with typical primary
care practices, university health clinics are
somewhat unique in that they generally serve a
restricted age range (i.e., 18 –24 years of age)
for a limited period of time (i.e., academic se-
mesters) that has predictable elevations in
stress/illness as a result of the increased work-
load that occurs toward the end of the semester.
In addition, a majority of students are develop-
mentally just beginning to take care of them-
selves while continuing to maintain significant
ties to their parents, sometimes limiting their
financial resources and ability to travel off cam-
pus for additional specialty services. Another
caveat is that most university health clinics pro-
vide services to students using a general health
fee that is wrapped into their tuition, eliminating
difficulties with insurance claims (Mills, Gold,
& Curran, 1996).

The lack of research examining the integra-
tion of mental health services into university
health clinics is surprising because of the alarm-
ing rates of mental health issues on college
campuses (American College Health Associa-
tion [ACHA], 2010a; Mowbray et al., 2006) and
the fact that most college students with clini-
cally significant psychological distress do not
receive mental health treatment (Rosenthal &
Wilson, 2008). For instance, only 15% of stu-
dents with moderately severe to severe depres-
sion or past-month suicidal ideation received
any mental health care (Garlow et al., 2008). A
recent ACHA white paper (2010b) argued for
the integration of campus medical and counsel-

ing clinics, given the great potential for inte-
grated care to increase treatment access, en-
hance clinical outcomes, and improve patient
satisfaction.

Similar to other primary care settings, IBHC
in university health centers can provide an av-
enue to address many of the obstacles to treat-
ment access for college students. For instance, a
higher proportion of students use campus health
clinics than campus mental health clinics (79%
vs. 10% in one recent study; Eisenberg, Golber-
stein & Gollust, 2007), and many students feel
more comfortable seeing PCPs than therapists
(ACHA, 2010b). Moreover, because many
mental health issues cause physical symptoms,
many students seek evaluation at health clinics
first (ACHA, 2010b). The few studies examin-
ing IBHC within university health settings have
reported numerous benefits, including increased
accessibility of mental/behavioral health care,
increased referral follow-through, and higher
quality patient care (Masters, Stillman, Brown-
ing & Davis, 2005; Tucker, Sloan, Vance, &
Brownson, 2008; Westheimer & Steinley-
Bumgarner, 2008).

Besides clinical outcomes, another vital com-
ponent in the process of evaluating a new
program of service, and whether others should
consider implementing such a program within
college health, is obtaining feedback from the
“consumers” involved in the program (Gallo et
al., 2004; Reiss-Brennan, Briot, Daumit, &
Ford, 2006; Runyan, Fonseca, & Hunter, 2003).
For IBHC, primary consumers include PCPs
and patients. A lack of acceptability and/or sat-
isfaction among the PCPs with the various com-
ponents of the IBHC program would ultimately
sabotage the program because of (a) the pivotal
role PCPs have within IBHC (i.e., referring
patients to BHPs) and (b) the focus all IBHC
programs have on increasing collaboration be-
tween PCPs and BHPs. Similarly, it is ex-
tremely important that the patients are satisfied
with clinical services provided by a new
program, otherwise patients may not remain
engaged or comply with treatment recommen-
dations, which could compromise treatment
success. Patient satisfaction is an important out-
come measure that identifies problems with
health care (Sitzia & Wood, 1997) and is asso-
ciated with treatment adherence and provider/
program selection (Fitzpatrick, 1991).

131INTEGRATING BEHAVIORAL HEALTH SERVICES

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A
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or
o
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o
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p
ub
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T
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s
ar
tic
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is
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te
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s
ol
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y
fo
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so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

Preliminary studies have begun to examine
patient and provider opinions about IBHC
within the college health setting. Tucker et al.
(2008) examined an international student’s ex-
perience of the Integrated Health Program at the
University of Texas at Austin using a case study
design and found his overall experience to be
positive. Westheimer and Steinley-Bumgarner
(2008) examined provider behaviors, opinions,
and experiences during the integration process
of IBHC within the same university and found
PCPs ascribed a high level of value to the col-
laborative effort integrated BHPs could provide
in helping with a diverse number of conditions.
However, neither of these studies provided a
sound understanding of patient or provider sat-
isfaction with the IBHC program and its various
components.

Two studies have examined the use of screen-
ing questionnaires designed to increase discus-
sion of mental and behavioral health issues dur-
ing university health center visits. In a pilot
study, Cowan and Morewitz (1995) found that
use of a screening questionnaire prompted dis-
cussion of psychosocial concerns that may not
have otherwise come up. However, this study
did not use a validated screening measure or
examine provider or patient satisfaction with
use of the screening measure. Alschuler,
Hoodin, and Byrd (2008) examined provider
and patient satisfaction with the integration of a
screening questionnaire for behavioral health
issues in a college health center. They found
that patients who were randomly assigned to fill
out the screening questionnaire reported it
helped them discuss concerns with their provid-
ers and they would like its use to continue in the
future. The providers reported that they also
found the screening questionnaire helpful and
would be happy to collaborate with integrated
BHPs on-site. Although this study provided pre-
liminary evidence toward patient and provider
satisfaction with IBHC, it focused on integrat-
ing the screening measure and it did not involve
the actual integration of BHPs, which is a fun-
damental component of IBHC programs.

In sum, IBHC is an emerging approach to
health care that can increase access to mental
and behavioral health care while reducing the
burden on PCPs and specialty mental health
centers. University health centers are an oppor-
tune setting in which to implement the IBHC
model. However, despite the importance of en-

suring provider and patient acceptability and
satisfaction when implementing new clinical
programs, little research has examined these
factors with respect to IBHC in university
health centers. Therefore, the purpose of this
study was to collect feedback from PCPs and
patients to assess the acceptability and satisfac-
tion with all aspects of integrating an IBHC
program at Syracuse University, which included
the implementation of a behavioral health
screening questionnaire as well as the integra-
tion of several BHPs. It was expected that PCPs
and patients would indicate a high level of sat-
isfaction and acceptability with all aspects of
the program.

Method

Our Integrated Behavioral Health Primary
Care Program

We developed our IBHC program by adapt-
ing a common model of integrated health care
called the Primary Mental Health Care model
described by Strosahl (1998). Syracuse Univer-
sity Health Services (SUHS), which serves ap-
proximately 9,038 patients per year, collabo-
rated with the Syracuse University doctoral
program in clinical psychology to integrate
three to five advanced doctoral students as
BHPs per academic year (for additional infor-
mation regarding this type of collaborative ef-
fort, see Masters et al., 2005). The BHPs pro-
vided clinical services 20 –35 hours per week as
part of an Advanced Practicum course. Working
under the supervision of a licensed psychologist
and an onsite medical provider, the BHPs saw
approximately 152 students per semester for
various presenting problems (e.g., insomnia, de-
pressive symptoms). BHPs acted as consultants
to the PCPs, seeing patients for brief sessions
(i.e., one to three sessions lasting approximately
15–30 minutes each; Strosahl, 1998). The aver-
age number of sessions per patient was 1.43
(SD � 0.83, range 1–5) for the Spring, 2010
semester and 1.61 (SD � 0.97, range 1– 6) for
the Fall, 2010 semester.

In this IBHC model, the PCP ultimately
maintains responsibility for patient manage-
ment throughout the course of treatment. None-
theless, the PCPs can utilize the BHPs in several
ways: (a) to conduct further assessment of be-
havioral health issues; (b) to provide brief in-

132 FUNDERBURK, FIELDER, DEMARTINI, AND FLYNN

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og
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A
ss
oc
ia
tio
n
or
o
ne
o
f i
ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

terventions for patients reporting mild-moderate
mental health symptomatology, behavioral
health issues (e.g., sleep problems), or symp-
toms associated with chronic disease; (c) to
triage patients reporting more severe mental
health symptoms to more specialized services;
and (d) to provide crisis assessment. BHPs
maintain an open access schedule, keeping at
least 15 minutes free between half-hour ap-
pointments to allow PCPs to walk patients
down for same-day visits. Assessments and pa-
tient progress notes are shared among the team
via verbal and/or written communications
within the electronic medical record. Therefore,
this IBHC model is strikingly different from the
colocation of specialty mental health services
within a university health clinic, which often
continues to maintain separate medical records,
provide more intensive treatment (i.e., a higher
number of sessions, longer sessions), see pa-
tients for more severe symptomatology, and is
often unable to accommodate same-day noncri-
sis appointments.

To help facilitate referrals and to follow na-
tional recommendations regarding screening for
depression and at-risk alcohol use among young
adults (American Academy of Pediatrics, 2001;
Nimalasuriya, Compton, Guillory & Prevention
Practice Committee of the American College of
Preventive Medicine, 2009; U.S. Preventive
Services Task Force, 2009), we implemented a
screening tool as part of our IBHC program.
Specifically, all students seen by PCPs for any
reason were screened for the following symp-
toms: (a) depression and suicidal ideation with
the Patient Health Questionnaire-9 (PHQ-9;
Spitzer, Kroenke & Williams, 1999); (b) at-risk
alcohol use with the Alcohol Use Disorders
Identification Test-Consumption (AUDIT-C;
Saunders, Aasland, Babor, de la Fuente &
Grant, 1993); (c) sleep problems with two items
from the Insomnia Severity Index (ISI; Bastien,
Valliéres & Morin, 2002); and (d) tobacco use
with three items to assess smoking habits. Stu-
dents were given the screening tool by nurses
as they waited for the medical providers follow-
ing the nurse obtaining vital signs. The screen-
ing tool clearly describes the purpose of the
questionnaire, the confidentiality of the infor-
mation, and that the items ask about symptoms
unrelated to any current acute illness (e.g., cold,
flu).

Procedure

This study was approved by the Syracuse
University Institutional Review Board. To ob-
tain the provider satisfaction data, we sent three
recruitment emails, one week apart, to all PCPs
and nurses working at the university health
clinic over a 4-week period during the Spring
semester of 2010. The email provided a brief
description of the study and linked the provider
to an anonymous web-based questionnaire. Af-
ter providing informed consent, participants
provided information on whether they were a
PCP (MD, NP) or nurse and filled out a provider
satisfaction survey. Providers were not given
any compensation for participation.

To obtain the patient satisfaction data, we
obtained a list of all students who had at least
one session with an integrated BHP during the
Spring (i.e., January 15 to May 15, 2010) or Fall
semester in 2010 (i.e., August 15 to Decem-
ber 15, 2010) by pulling a list of all patients
who were included in the electronic medical
record as having the specific encounter code
used only by the BHPs to identify behavioral
health visits. Then, email addresses were lo-
cated using the publicly available student email
address directory. In addition, basic demo-
graphics of all IBHC patients were obtained
from a tracking database maintained by the
BHPs. We sent three recruitment emails, ap-
proximately 3– 4 weeks apart, to each identified
patient at the end of each semester to their
university-provided email address to ask them
to participate in an anonymous web-based pa-
tient satisfaction survey. After completing in-
formed consent, participants completed the
questionnaire. As an incentive, participants
were offered a chance to win one of 12 $25 gift
cards to an online retailer.

Participants

All PCPs (n � 9, two physician and seven
nurse practitioners) and nurses (n � 10) work-
ing in the university health clinic were eligible
to complete the provider satisfaction question-
naire. Fifteen participants (nine PCPs and six
nurses) did so, yielding a 79% (100% for PCPs
and 60% for nurses) response rate. Because of
the small number of providers at the clinic and
the need to maintain their anonymity to encour-
age higher response rates and candid respond-

133INTEGRATING BEHAVIORAL HEALTH SERVICES

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A
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oc
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tio
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or
o
ne
o
f i
ts
a
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ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

ing, we did not collect demographics from the
participants.

A total of 303 (175 Spring semester, 128 Fall
semester) unique IBHC patients were identified
using the electronic medical record. A total
of 27 (23 from Spring semester and four from
Fall semester) had recruitment emails returned
because of a nonexistent address error likely
resulting from the fact that the student left the
university for some reason (e.g., graduation). Of
the remaining participants who were eligible
(n � 276), 79 participants (32 Spring semes-
ter, 47 Fall semester) completed the patient sat-
isfaction survey, resulting in an overall 29%
response rate (n � 152, 21% for Spring semes-
ter and n � 124, 38% for Fall semester). The
majority of the participants were female
(n � 59, 75%), white (n � 51, 65%), and not
Hispanic or Latino (n � 72, 91%). To under-
stand the representativeness of our sample, Table
1 presents the demographics for those who partic-
ipated in the study and for the total sample of
patients (n � 303) who saw a BHP during the
Spring and Fall semesters of 2010. Because the
patient satisfaction survey was anonymous, we
were unable to test for demographic differences
between responders and nonresponders.

Measures

Provider satisfaction questionnaire. Par-
ticipants rated their level of agreement with 18
statements about the acceptability and useful-

ness of each component of the IBHC program
on a Likert scale that ranged from strongly
disagree (1) to neutral (3) to strongly agree (5).
The 18 items (see Table 2) were generated by
the first and fourth author and focused on each
element of the IBHC program implemented. For
several items, the participant could choose “not
applicable” because of the lack of relevance of
the statement to nurses versus PCPs and vice
versa. Cronbach’s alpha for the scale was .80.

Patient satisfaction questionnaire. Par-
ticipants answered five demographic questions
(i.e., age, sex, race, ethnicity, and class in
school), and three yes/no questions (i.e.,
whether they remembered filling out the screen-
ing measure, whether their PCP discussed one
of the topics on the screening measure with
them, and whether they met with an integrated
BHP). Those who remembered filling out the
screening measure and meeting with the inte-
grated BHP completed an additional six state-
ments (see Table 3) which asked participants to
rate their level of satisfaction, comfort, or will-
ingness on a Likert scale that ranged from (1)
extremely unsatisfied/uncomfortable/unwilling
to (3) neutral to (5) extremely satisfied/
comfortable/willing on a variety of elements
associated with the IBHC program. These items
were generated by the first and fourth author.
For those participants who completed the Likert
portion of the questionnaire, Cronbach’s alpha
for those six items was .75.

Table 1
Demographics of Survey Participants and All IBHC Patients

Participant Demographics All IBHC Patients

M SD n % M SD n %

Age 30.0 3.8 79 21.7 4.1 303
Males 20 25.3 121 40.0
Hispanic or Latino 7 8.9 22 7.3
Racea

White 51 64.6 201 66.3
Black 7 8.9 34 11.2
Asian 10 12.7 24 7.9
Other 10 12.7 44 14.5

Classb

Freshman 4 5.1 55 18.2
Sophomore 22 27.8 55 18.2
Junior 17 21.5 47 15.5
Senior 9 11.4 67 22.1
Graduate Student 27 34.2 75 24.8

a One participant left race unknown. b Four patients’ class was unknown.

134 FUNDERBURK, FIELDER, DEMARTINI, AND FLYNN

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A
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o
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a
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p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el
y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.

Data Analytic Plan

Because of the descriptive nature of the ob-
jectives of this study, our data analytic plan
focused primarily on examining distributions
and calculating the frequencies, modes, means,
and standard deviations of individual survey
items.

Results

Provider Satisfaction

As shown in Table 2, both PCPs and nurses
reported a high level of support for regular
implementation of the screening measure across
all four screening domains and reported that

patients were comfortable answering the ques-
tions on the screening measure. Providers
strongly agreed that the screening measure
helped stimulate discussion on topics that
would not have come up during the visit other-
wise. There was a greater level of variability
yielding average (i.e., means ranging from 2.5–
3.0) and modal responses within the neutral
range for the two items assessing whether the
screening measure took too much time away
from other clinical duties and was difficult to
score and interpret.

PCPs and nurses considered the integrated
BHPs a part of the primary care team and felt
the IBHC program helped patients receive treat-
ment more quickly. PCPs perceived that pa-

Table 2
Provider Ratings of IBHC Acceptability and Satisfaction

Item

PCPs Nurses

n M (SD) Range n M (SD) Range

Rate your level of agreement with the
implementation of regular screening at
SUHS for

a) Depression 9 4.7 (0.5) 4–5 6 4.7 (0.5) 4–5
b) Sleep problems 9 4.3 (1.0) 2–5 6 4.7 (0.5) 4–5
c) Tobacco use 9 4.2 (0.7) 3–5 6 4.6 (0.5) 4–5
d) Alcohol misuse 9 4.7 (0.5) 4–5 6 4.7 (0.5) 4–5

The items that assessed the problem below
were useful in my clinical practice

a) Depressed mood 9 4.4 (0.5) 4–5 2 4.0 (1.4) 3–5
b) Sleep problems 9 3.9 (0.9) 2–5 1 5.0 (0.0) 5
c) Tobacco use 9 3.4 (0.7) 3–5 1 5.0 (0.0) 5
d) Alcohol consumption 9 3.8 (1.0) 2–5 2 4.5 (0.7) 4–5

The screening measure
Took too much time away from clinical

duties 9 2.9 (0.8) 2–4 6 2.5 (0.8) 1–3
Was difficult to score and interpret 9 2.6 (1.2) 1–4 5 3.0 (0.7) 2–4
Helped stimulate discussion of topics that

would not have come up during patient
visits 9 4.3 (0.7) 3–5 1 5.0 (0.0) 5

A majority of my patients felt comfortable
answering the questions on the
screening measure 9 4.3 (1.0) 2–5 6 3.8 (0.8) 3–5

The BHPs
Were useful within my clinical practice 9 4.7 (0.5) 4–5 3 4.7 (0.6) 4–5
Became part of our primary care team 9 4.1 (0.6) 3–5 6 3.8 (1.0) 3–5
Benefited my patients 9 4.8 (0.4) 4–5 2 5.0 (0.0) 5
Helped my patients receive treatment

more quickly 9 4.8 (0.4) 4–5 6 5.0 (0.0) 5
I would recommend this service to other

colleagues 9 4.4 (0.7) 3–5 6 4.1 (1.0) 3–5
I would like the integrated behavioral health

service to continue 9 4.7 (0.5) 4–5 6 4.7 (0.5) 4–5

Note. The ns vary because some providers chose “Not Applicable” for a response.

135INTEGRATING BEHAVIORAL HEALTH SERVICES

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or
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o
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p
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T
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s
ar
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s
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so
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in
di
vi
du
al
u
se
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to
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em
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at
ed
b
ro
ad
ly
.

tients benefited from seeing the BHPs. Both
PCPs and nurses would recommend this service
to other colleagues within college health and
would like IBHC to continue in the future.

Patient Satisfaction

Results of the satisfaction assessment indi-
cate that a majority of the sample of patients
were satisfied with their overall care at SUHS
(see Table 3). A number of students did not
remember filling out the screening question-
naire (n � 13, 17%) or meeting with a BHP
(n � 26, 33%), so they did not rate their satis-
faction or report on those elements of the IBHC
program in Table 3. Of those who remembered
completing the questionnaire, the majority re-
ported that they talked to the medical provider
about a topic on the screening measure (n � 57,
86%). Of those who remembered meeting with
a BHP, the majority reported that they felt that
the BHP helped them with the topic that they
discussed (n � 38, 73%).

As shown in Table 3, overall participants
reported a general level of comfort filling out
the screening measure, were satisfied with the
service provided by the integrated BHP, and
would be willing to seek help from the BHP
again if necessary. Although the average re-
sponse was within a level of agreement

(M � 3.6), there was a greater level of variabil-
ity when it came to having the service within the
university health setting as compared with a
specialty mental health clinic on campus, with a
mode of 3.0 indicating a neutral response.

Discussion

As expected, this study found that PCPs,
nurses, and patients reported positive experi-
ences with the two major components of the
IBHC program: the implementation of a behav-
ioral health screening assessment and the inte-
gration of BHPs into the university health cen-
ter. The results provide further evidence that
this model of care can be used on college cam-
puses with success in terms of provider and
patient satisfaction.

Similar to past research (Alschuler et al.,
2008; Cowan & Morewitz, 1995), this study
found that providers indicated that having brief
screening items to assess sleep problems, de-
pression, alcohol use, and tobacco use was help-
ful to their clinical practice. In addition, the
assessment items reportedly helped stimulate
discussions with patients about topics that
would not have otherwise been discussed.
Alschuler and colleagues (2008) found a similar
result such that those providers whose patients

Table 3
Patient Ratings of IBHC Satisfaction and Acceptability

Item n Mode M SD Range

Rate your overall level of satisfaction with
the visit(s) you had at University Health
Service 79 4.0 3.4 1.1 1–5

Rate your level of comfort filling out the
screening questionnaire during your visit 66 4.0 3.5 1.1 1–5

Rate your level of satisfaction with the
service you were provided during the visits
with the integrated behavioral health
provider 52 4.0 3.4 1.2 1–5

Rate your level of willingness meet with one
of those providers again if something else
or that issue continued 52 4.0 3.4 1.4 1–5

Rate your level of comfort meeting with them
at University Health Service rather than
some other location on campus (e.g., SU
Counseling Center) 52 3.0 3.6 1.0 2–5

Rate your level of comfort with the length of
the meetings (i.e., typically less than 40
minutes) with the integrated behavioral
health provider 52 4.0 3.7 0.9 2–5

136 FUNDERBURK, FIELDER, DEMARTINI, AND FLYNN

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A
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A
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oc
ia
tio
n
or
o
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o
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ts
a
lli
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p
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lis
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rs
.
T
hi
s
ar
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le
is
in
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nd
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s
ol
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y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
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.

were randomly assigned to fill out a mental
health questionnaire discussed those issues with
their patients more than those providers whose
patients were not assigned to fill out the ques-
tionnaire. Not only did providers perceive the
screening questionnaire as having a high level
of utility within their clinical practice, but the
patients also reportedly were comfortable with
filling out the questionnaire during their ap-
pointments.

Our findings highlight the importance of se-
lecting an appropriate screening questionnaire
that can be completed and scored quickly. A
common concern among providers when dis-
cussing the implementation of regular screening
for mental health issues is the time involved in
integrating the screen within the clinical ap-
pointment (Thomas, Waxmonsky, McGinnis, &
Barry, 2006). Within this study, a majority of
the providers and nurses reported responses
within the neutral range when asked about
whether the screening measure took time away
from other clinical duties. This is not surprising
as the questionnaire obviously does add time to
the patient visit, as noted in prior research
(Alschuler et al., 2008). The typical patient ap-
pointment at this clinic is only 15 minutes, so
allocating 1–2 minutes to review the screen with
the patient would reduce the time left to focus
on the patient’s presenting complaint. The fact
that providers endorsed a modal response
within the neutral range suggests that the
screening can be incorporated without a signif-
icant negative impact. One study on behavioral
health screening found that using a measure that
includes areas specific to college students (e.g.,
academic stress, risky sexual behavior) im-
proved detection of students struggling with
adjustment issues compared to a more general
screening measure (Alschuler, Hoodin, & Byrd,
2009). However, the benefit of added sensitivity
from a college-specific screening measure may
not offset the cost of greater administration and
scoring time. As completion time increases, the
rate of compliance with screening may de-
crease.

Another element that was identified within
this study was the importance of not only de-
signing the screening questionnaire to be easily
comprehended by patients but to make sure it is
easily scored and interpreted by providers. Most
providers did not indicate difficulty scoring or
interpreting the screen. However, anecdotally

there were some problems with patients incor-
rectly self-scoring the PHQ-9; this may have led
to some confusion or the need for providers to
double-check or recalculate scores. The screen-
ing tool was later modified to discourage pa-
tients from totaling their own scores. To maxi-
mize screening coverage and efficiency, it is
important to select brief, user-friendly, vali-
dated measures that are easy to score and inter-
pret (Kirkcaldy & Tynes, 2006).

As university health centers work toward im-
proving the identification and treatment of men-
tal health issues as well as implementing rec-
ommended screening guidelines for depression,
suicidal ideation, tobacco use, and alcohol mis-
use, this study suggests that an IBHC program
may be one way to effectively accomplish this
while maintaining provider and patient satisfac-
tion. A previous study of behavioral health
screening in university health centers found that
screening increased discussion of behavioral
health issues among patients and PCPs
(Alschuler et al., 2008). However, PCPs re-
ported that they did not have the time or the
expertise to adequately address behavioral
health issues with patients, but they were open
to collaborating with BHPs. Likewise, our re-
sults suggest high willingness to refer patients
to BHPs to improve attention to behavioral
health issues. Thus, the IBHC program can help
PCPs deal with positive screens by providing
the integrated BHPs, who are trained to assess
mental health issues and provide brief treatment
on-site or facilitate a referral to a specialty men-
tal health clinic.

Regarding the integrated BHPs component of
the IBHC program, PCPs also strongly indi-
cated that their patients benefited from the ser-
vices provided by the BHPs. The providers felt
that having the integrated BHPs helped patients
receive treatment faster (compared to referring
them to specialty mental health) and that the
BHPs functioned as part of the overall care
team. All of the providers reported that they
would strongly recommend the IBHC to other
colleagues working in college health. Taken
together, these results indicate satisfaction
among the medical providers, which is essential
for the success of IBHC. Strong buy-in on the
part of PCPs is needed to sustain the implemen-
tation of a new clinical program like IBHC,
which requires procedural changes and addi-
tional effort (i.e., reviewing screens, referring

137INTEGRATING BEHAVIORAL HEALTH SERVICES

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p
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fo
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b
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.

patients to BHPs). Acceptability among the
nurses is also important, as they were the ones
responsible for offering patients the behavioral
health screens in our IBHC program.

Similarly, satisfaction and acceptability were
high among patients. Patients who were seen by
BHPs reported feeling comfortable with the ser-
vices received and were willing to be seen again
should the service be needed in the future.
These results corroborate Westheimer and
Steinley-Bumgarner’s (2008) finding that pa-
tients were accepting of referrals to BHPs. Pa-
tients may like the convenience of being seen
quickly by BHPs in health centers. In the case
of BHPs having open access schedules, patients
can be seen immediately after their PCP visit,
which eliminates the need for scheduling an-
other appointment or returning to the health
center; in contrast, specialty mental health cen-
ters may have long (e.g., up to 2–3 weeks) wait
times (Mowbray et al., 2006). Also, health cen-
ters carry less stigma compared with specialty
mental health settings. On average, the patients
were comfortable seeking services at the uni-
versity health center, but there was a greater
level of variability suggesting some individual
differences as to the comfort of seeking those
services at a specialty mental health clinic.

Limitations

Interpretation of the findings should take into
account the limitations of the study. First, al-
though slightly higher than that found in other
research using similar methodology (Shih &
Fan, 2009), our response rate for the patient
satisfaction survey was 29%. The response rate
may be improved by contacting patients soon
after their final IBHC visit instead of at the end
of each semester, which is generally a busy time
for students. Second, a significant proportion of
the patients did not remember completing the
screening questionnaire or meeting with a BHP.
Patients may not have remembered completing
the screening questionnaire because it was a
brief (i.e., 2–3 minutes) activity and/or because
their health center visit was up to four months
before completing the satisfaction survey. It is
possible that the students who did not remember
meeting with a BHP had a more neutral expe-
rience than the students who remembered the
program. Thus, the satisfaction ratings could be
artificially elevated because of this lack of data.

It is also possible, however, that these students
did not remember the meeting with the BHP
because they simply considered the components
of the IBHC part of standard medical care.
Authors have noted that primary care has be-
come the “de facto mental health care system”
(Kessler & Stafford, 2008, p. 9), so these stu-
dents may have expected to discuss behavioral
health problems during their visit and may not
have perceived the BHP as different from a
regular medical provider.

Third, patient data were obtained via anony-
mous self-report. Though this method of data
collection was necessary because of the scope
of this study, it prohibited collection of identi-
fying information, including diagnostic infor-
mation. The ability to compare satisfaction
across diagnostic categories would have pro-
vided beneficial information, including whether
patients with more severe diagnoses (e.g., major
depressive disorder vs. adjustment disorder with
depressed mood) had equally positive experi-
ences with the program. In addition, the satis-
faction ratings are limited to only those patients
who were seen by an integrated BHP. Future
research should compare satisfaction between
patients seen within IBHC and patients seen
within standard care (i.e., the PCP provides any
treatment for behavioral health concerns or
makes a referral to specialty mental health).
Fourth, the provider and patient satisfaction
measures were created specifically for this
study. The limited range of response options
(1–5) may contribute to restricted range/
variability and ceiling effects. These limitations
should not be ignored when considering the
generalizability of the study.

Finally, the scope of this study did not allow
us to obtain information on the clinical out-
comes associated with the IBHC program. Al-
though providers reported that patients benefit-
ted from meeting with BHPs, their perceptions
were based solely on behavioral observations of
and/or self-report from patients, not on clinical
outcome data. Future research should evaluate
the clinical effectiveness of interventions deliv-
ered by integrated BHPs. From an IBHC per-
spective, other markers of success that are wor-
thy of future study include increased access to
mental/behavioral health services, improved
identification of mental/behavioral health issues
through screening, increased referral uptake
(i.e., BHPs referral attendance compared to spe-

138 FUNDERBURK, FIELDER, DEMARTINI, AND FLYNN

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e
A
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or
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a
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p
ub
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rs
.
T
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s
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is
in
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s
ol
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fo
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p
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so
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f t
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in
di
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to
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di
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in
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ed
b
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ly
.

cialty mental health referral attendance) attrib-
utable to colocation and “warm hand-offs,” im-
proved provider communication (e.g., between
BHPs and PCPs), reduced burden on specialty
mental health centers from patients with sub-
threshold or mild symptoms, and reduced bur-
den on PCPs from repeat visits because of psy-
chosocial issues.

Conclusions

In summary, providers and patients indicated
a high level of satisfaction with this IBHC pro-
gram. Accordingly, providers are likely to refer
patients to BHPs, and patients are likely to
engage in brief treatment within the IBHC pro-
gram. Given the increasing demand on univer-
sity primary care clinics to address the mental
health needs of students, IBHC offers a prom-
ising method whereby to address this need. Par-
ticularly in light of data that indicate that most
college students do not seek needed mental
health treatment (Rosenthal & Wilson, 2008),
the finding that IBHC patients would feel com-
fortable seeing a BHP again in the future is a
positive step toward making mental health care
more accessible to patients who need treatment.

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Received September 6, 2011
Revision received January 5, 2012

Accepted March 26, 2012 �

140 FUNDERBURK, FIELDER, DEMARTINI, AND FLYNN

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p
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T
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s
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le
is
in
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s
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y
fo
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p
er
so
na
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se
o
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he
in
di
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al
u
se
r a
nd
is
n
ot
to
b
e
di
ss
em
in
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b
ro
ad
ly
.

Establishing an Integrated Care Practice in a Community Health Center

Andrea Auxier and Tillman Farley
Salud Family Health Centers, Fort Lupton, Colorado and

University of Colorado, Denver

Katrin Seifert
Salud Family Health Centers, Fort Lupton, Colorado

In a progressively complex and fragmented health care system and in response to the need to provide
whole-person, quality care to greater numbers of patients than ever before, primary care practices
throughout the United States have turned their attention and efforts to integrating behavioral health
into their standard service-delivery models. With few resources and little guidance, systems struggle
to gather the support required to establish effective integrated programs. Based on first-hand
experience, we describe a working integrated primary care model, currently utilized in a large
community health center system in Colorado, that encompasses universal screening, consultation,
psychotherapy, and psychological testing. With appreciation for the way an organization’s unique
circumstances inform the best approach for that particular organization, we highlight the clinical-
level and system-level variables that we consider necessary for successful practice development and
address how our behavioral health program operates despite funding limitations. We conclude that
organizations that aim for integrated primary care must mobilize leadership to implement systemic
changes while making difficult decisions about program development, financing, staffing, and
interagency relationships.

Keywords: integrated care, primary care, integrative medicine, health psychology, collaborative care

The health care system in the United States is facing a paradox
of declining outcomes and rapidly increasing costs (Rabin et al.,
2009). In 2008, mental health conditions accounted for $72 billion
in expenditures, making them the third most costly group of
conditions (along with cancer), exceeded only by heart conditions
and trauma-related disorders or conditions (Agency for Healthcare
Research & Quality, 2008). In an effort to improve the provision
of health care, many experts and key organizations are lending
support to the movement for integration of behavioral health into

primary care settings (Blount, 2003; Institute of Medicine, 2001,
2006; Pincus, 2003; U.S. Department of Health and Human Ser-
vices, 2006; World Health Organization & World Organization of
Family Doctors, 2008). Numerous studies have demonstrated that
integrated services can improve access to mental health care,
enhance quality of care, decrease health care costs, improve over-
all health, decrease the burden on primary care providers (PCPs),
and improve PCPs’ ability to address patients’ mental health needs
(Butler et al., 2008; Chiles, Lambert, & Hatch, 1999; O’Donohue,
Cummings, & Ferguson, 2003; World Health Organization &
World Organization of Family Doctors, 2008).

The decision to organize integration efforts at our community
health center was, in part, based on well-known data regarding
primary care patients. For example, psychiatric conditions are
common in patients who are seen in primary care practices
(Cwikel, Zilber, Feinson, & Lerner, 2008) and many patients who
have mental health needs seek treatment for these concerns
through their PCP (Goldman, Rye, & Sirovatka, 2000; Petterson et
al., 2008; Wang et al., 2006). Additionally, the majority of medical
problems seen in primary care practices are undeniably linked with
behaviors, and it has been estimated that 40% of premature deaths
in the United States are attributable to health behavior factors
(McGinnis & Foege, 1993; Mokdad, Marks, Stoup, & Gerberding,
2004). Behavioral health integration is an integral part of a solution
to the complex health care needs of these patients.

Although the terms mental health and behavioral health are
sometimes used interchangeably, we conceptualize them as differ-
ent constructs. The term behavioral health applies to patients
whose primary diagnosis is somatic and whose psychological
symptoms, if present, are subclinical and related to the primary
diagnosis. The term mental health applies when the focus of
treatment is psychiatric; there may or may not be an accompanying

This article was published Online First August 29, 2011.
ANDREA AUXIER received her PhD in clinical psychology from the Uni-
versity of Massachusetts, Boston. She is Director of Integrated Services
and Clinical Training at Salud Family Health Centers and a senior clinical
instructor at the University of Colorado, Denver, Department of Family
Medicine. Her areas of professional interest include integrated primary care
research and practice, especially as they apply to immigrant populations
with trauma histories.
TILLMAN FARLEY received his MD from the University of Colorado, School
of Medicine, and completed his residency at the University of Rochester.
He is board certified in Family Medicine. He is the Medical Services
Director at Salud Family Health Centers and an associate professor at the
University of Colorado, Denver, Department of Family Medicine. His
areas of professional interest include integrated primary care and health
disparities, particularly as they apply to immigrant populations.
KATRIN SEIFERT received her PsyD in clinical psychology from the Uni-
versity of Denver. She is the Associate Psychology Training Director at
Salud Family Health Centers. Her areas of professional interest include
practice and clinical training in integrated primary care as well as complex
trauma.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Katrin
Seifert, Salud Family Health Centers, P.O. Box 189, Frederick, CO 80530.
E-mail: kseifert@saludclinic.org

Professional Psychology: Research and Practice © 2011 American Psychological Association
2011, Vol. 42, No. 5, 391–397 0735-7028/11/$12.00 DOI: 10.1037/a0024982

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medical condition. In this article, however, the term behavioral
health will subsume both categories.

Integrated Primary Care at Salud Family
Health Centers

Founded in 1970, Salud Family Health Centers (Salud) is a
federally qualified community health center consisting of nine
health care clinics covering eight counties in North Central Colo-
rado. Salud is an important part of the health care safety net,
providing population-based, fully integrated medical, dental, and
behavioral health services regardless of finances, insurance cov-
erage, or ability to pay–Salud focuses on the needs of the medi-
cally indigent, uninsured, and underinsured populations. The na-
tional distribution of payer sources for federally qualified health
centers is 35% Medicaid and 25% Medicare or private insurance,
with 40% of patients falling into the uninsured category (Adashi,
Geiger, & Fine, 2010). By comparison, 30% of Salud’s patients
have Medicaid, 14% have Medicare or private insurance, and 56%
are uninsured, leaving Salud to support the health care of a greater
proportion of patients with no funding source.

Salud employs 540 individuals, including 60 medical providers,
14 dentists, 9 dental hygienists, and 15 behavioral health providers
(BHPs). In 2010, Salud served more than 80,000 patients with
approximately 300,000 visits, making it the second largest health
care provider in a six-state region. The most common visit types
include well-child checks, prenatal visits, diabetes, and hyperten-
sion. About 3,000 of Salud’s patients are migrant and seasonal
farmworkers, and 65% of patients are Latino, many of whom
speak Spanish as their primary or only language.

In response to the extraordinary number of patients with behav-
ioral health needs, immigration-related stressors, and limited fi-
nancial means, Salud’s move toward integration began in 1997
under the leadership of its medical director, who had received
training in an integrated model. The need for integration was
apparent, but it soon became clear that incorporating a team of
behavioral health providers into an established medical setting was
a more complex proposition than it initially seemed. The program
started with one BHP in one clinic. PCPs who found value in the
service vocalized their desire for an expanded behavioral health
presence. As Salud hired more BHPs, it became necessary to build
an infrastructure designed to support integration at an organiza-
tional level. We set out to create a service-delivery model and
develop job descriptions, billing and coding practices, policies,
protocols, standard operating procedures, and data tracking mech-
anisms. In order to accomplish these tasks, the focus shifted
toward securing administrative support from key members of the
organization. Over time, with the collective mission to provide
quality health care—and with the implicit acceptance that behav-
ioral health needs must be addressed as part of its delivery—
efforts materialized into an integrated care program. In an effort to
measure the effectiveness of our program, we recently have begun
to work toward an information-technology-driven, outcome-based
approach, whereby we collaborate with university partners to
measure and benchmark our data through regional and national
comparative effectiveness research networks.

In 2010, we developed a mission statement that reads: “To
deliver stratified, integrated, patient-centered, population-based
services utilizing a diversified team of behavioral health profes-

sionals who function as PCPs, not ancillary staff, and who work
shoulder-to-shoulder with the rest of the medical team in the same
place, at the same time, with the same patients.” The implications
of this mission include that BHPs have the ability to see a patient
at any time, for any reason, without requiring a consult request
from a PCP. This approach requires a paradigm shift from a
superior/subordinate mentality to one of implicit understanding of
the unique skills that all persons involved in the patient’s care
contribute to the patient’s overall well-being. It gives BHPs the
latitude to determine which patients they need to assess on a given
day, and providers see each patient as “our patient” not “my
patient.”

Components of Integrated Care

Over time, we have become familiar with many factors that
influence the development, success, and sustainability of an inte-
grated primary care practice. Below is a summary of what we have
found to be essential components of integration, broken down into
those variables related to clinical decisions and interventions and
those related to system-level considerations.

Clinical Variables

One prospect of integration is the provision of real time inter-
ventions. As soon as a need is identified, a BHP is present to
provide services. PCPs who might otherwise shy away from un-
covering mental health issues are less likely to do so if they know
they can call upon a BHP to address identified concerns. Just as
some primary care visits are considered urgent, so are some
behavioral health visits. Having a BHP available when these
situations arise can mean that a patient actually receives care as
opposed to falling through the cracks in a health care system in
which timely access is often a problem (Pincus, 2003; Strosahl,
1998).

In any large primary care system, behavioral health services
must be population-based and not disease specific. A population-
based approach focuses on the needs of a defined community with
an emphasis on evidence-based practice and effective outcomes as
well as primary prevention (Ibrahim, Savitz, Carey, & Wagner,
2001). In order to meet the needs of an entire community, BHPs
must be capable of assessing and addressing multiple presenting
concerns of varying levels of severity. BHPs in primary care
cannot be limited to utilizing interventions that target only a
specific disease category, primarily because comorbidity is the rule
rather than the exception (Klinkman, 2009). In response to this
reality, treatment approaches must be geared toward the whole
person, not the illness.

BHPs who work in a primary care setting need to have strong
generalist training, with sufficient understanding of normal and
abnormal developmental processes across the life span, and to be
flexible. The nature of the setting requires BHPs to make instant
connections with patients, to formulate quick assessments, and to
communicate the relevant findings to the PCP immediately. From
a logistical standpoint, BHPs must be willing to swap the comfort
and controllability of a therapy room for the unpredictable and
unsettling reality of seeing patients in the medical rooms, often
with interruptions.

392 AUXIER, FARLEY, AND SEIFERT

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System Variables

Colocation is crucial for successful integrated primary care
(Blount, 2003). For integration to be truly seamless, the BHP must
be in the flow of the action occurring in the clinic and must be
visible to patients and PCPs alike. Although 80% of patients with
unexplained symptoms and psychosocial distress accept manage-
ment by PCPs, only 10% will attend a psychosocial referral (Smith
et al., 2003). Not having to travel to another facility or even a
different area of the clinic to access behavioral health may help
reduce the stigma associated with mental illness and thus increase
the number of patients receiving services (Pincus, 2003; Strosahl,
1998).

Although the concept of a multidisciplinary team is not a new
one, redefining the team approach to include PCPs and BHPs
requires a willingness to accept a paradigm shift of shared respon-
sibility for a patient. A reevaluation of the systems that maintain
power differentials among providers at the expense of quality,
comprehensive care is necessary, along with efforts to dismantle
and rebuild those systems.

Using a shared medical record, in which PCPs and BHPs have
access to each other’s notes, can help support the paradigm shift.
The Health Insurance Portability and Accountability Act (HIPAA)
regulations clearly delineate the differences between psychother-
apy notes and progress notes (Gillman, 2004) and it is the latter
kind of note that we suggest BHPs use in integrated settings.
Psychotherapy notes are granted special protection under HIPAA
due to the likelihood that they contain particularly sensitive infor-
mation, are considered the personal notes of the treating therapist,
and must be kept separate from the medical record. Progress notes
are limited to medication information, modality and frequency of
treatment, and a summary of diagnosis, functional status, symp-
toms, prognosis, and progress to date. Unlike psychotherapy notes,
these notes are part of the medical record.

An ideal integrated care system does not operate within a
vacuum, but rather allows for coordination of care within and
across health care settings. In order to achieve this goal, a service-
delivery model must be defined. What patients will be referred out,
to whom, and for what reasons? Similarly, what kinds of patients
will be accepted from other agencies and for what reasons? In
theory, patients with higher mental health needs are better-suited to
receive treatment in specialized agencies such as community men-
tal health centers (CMHCs). In practice, however, there are sig-
nificant barriers to implementing this transition. These obstacles
include patients’ reluctance to go to a CMHC because of the
stigma associated with mental illness, a previous negative experi-
ence, long waiting lists, limited transportation options, or failure to
meet diagnostic or funding requirements. Moreover, some patients
prefer having all health care needs met in one place even when the
aforementioned barriers do not apply. Therefore, we argue that an
integrated practice that emphasizes primary-care-level behavioral
interventions must remain flexible enough to accommodate all
patients, regardless of problem severity.

Putting It All Together: Salud’s Integrated
Care Model

There is tremendous variability in the kinds of behavioral health
issues seen in our setting, and symptom severity in each patient is

fluid rather than static. We argue that behavioral health is not a
bimodal phenomenon determined by the presence or absence of
health; rather, it exists along a continuum. We conceptualize this
continuum as having four levels of severity; at any given time
fewer patients fall into the more severe levels and more patients
fall into the less severe levels. Conceptualizing our population in
this fashion allows us to better allocate resources based on the
distribution of patients.

Patients presenting at Level 1 are in a state of acute need,
requiring immediate referral to emergency departments and/or
inpatient care. Examples include imminent suicidal depression,
acute psychosis, and manic crisis. Because of the seriousness and
visible nature of their symptoms, these patients are more likely to
present to an emergency room or to be detained by police than they
are to present to PCP offices. Level 2 consists of patients who have
severe and persistent mental illness. Although these patients can
benefit from psychiatric follow-up in a specialized mental health
setting, the need is not immediate. Many can be monitored in
primary care settings when stable, especially when psychiatry
consultation is available. Patients at Level 3 present with problems
that are chronic and of lower severity. They are common in
primary care practice and include somatization disorders, nonpsy-
chotic depression, acute stress disorder, and anxiety disorders
where functional impairment is present but the symptoms are not
completely debilitating. Level 3 patients frequently seek care in
primary care settings, but PCPs are not always equipped with the
expertise and knowledge to address their needs (Goldman et al.,
2000). Level 4 includes patients with temporary mental health and
psychosocial problems, including concerns such as marital diffi-
culties, parenting problems, bereavement, employment problems,
financial stress, and so forth. Left untreated, Level 4 problems can
progress, potentially leading to risky behaviors, unhealthy life
choices, and worsening of chronic diseases. Last, at any given
time, there are patients who do not qualify for assignment to a
particular level but who nevertheless might benefit from educa-
tional and preventive interventions.

In an attempt to provide adequate services to the 80,000 patients
in the Salud system in alignment with our mission, we grappled
with how BHPs were going to spend their time. We wanted to
maximize their ability to see a high number of patients while still
maintaining a high standard of care. Based on the four-level model
of severity just described, BHPs spend 30% of their time providing
more traditional therapy services to Levels 1 and 2, the highest-
needs patients, who make up a significant portion, though not the
majority of our population. BHPs spend 70% of their time provid-
ing various integrated services to Levels 3 and 4 and the unas-
signed, whose symptoms are less severe or temporarily nonexistent
but who make up a much larger portion of our patient population.

After careful consideration, we decided that the best service-
delivery model for patients in our geographical area is a stepped-
care approach. The initial point of contact with a BHP typically
occurs during a medical visit. Of patients requiring follow-up care,
some are referred out but many continue with onsite therapy
services. Therapy appointments are scheduled separately from
medical appointments and consist of a limited number of visits,
which can be extended if necessary by department approval. His-
torically, referrals to CMHCs more commonly were driven by
payer source (i.e., Medicaid) than by patient need, creating a dual
standard of care whereby some but not all patients received inte-

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grated care. Recently, we have determined that this standard is
unacceptable and have made modifications to our care model to
allow primarily clinical determinants to inform referral decisions.
These clinical determinants include when a patient a) needs ser-
vices for a longer period than we can provide; b) requires specialty
services such as vocational rehabilitation, day treatment, wrap-
around services, and so forth; and c) qualifies as severely and
persistently mentally ill or severely emotionally disturbed.

Services Offered

BHPs at Salud offer a variety of evidence-based services, in-
cluding screenings, consultations, psychotherapy, and psycholog-
ical assessment. A report by the Institute of Medicine (2001)
defined evidence-based practice in psychology as the “integration
of the best available research with clinical expertise in the context
of patient characteristics, culture, and preferences” (p. 147). Re-
search suggests that sensitivity and flexibility in administering
therapeutic interventions produces better outcomes than rigid ap-
plication of manuals or principles (Castonguay, Boswell, Constan-
tino, Goldfried, & Hill, 2010; Henry, Schacht, Strupp, Butler, &
Binder, 1993; Huppert et al., 2001). Because clinicians with sound
clinical judgment will be more effective when operating from
treatment perspectives that are most consistent with their views
(Benish, Imel, & Wampold, 2008; Luborsky et al., 1999;
Wampold, Minami, Baskin, & Tierney, 2002), we encourage
BHPs to utilize all of their clinical knowledge from an evidenced-
based perspective, rather than limiting themselves to a narrow
range of interventions.

As opposed to evidence-based practice, empirically validated
treatments (EVTs) are specific treatments for defined groups of
individuals who have particular disorders. We argue that, although
there is certainly a place for EVTs in any setting, applying such
interventions in a primary care setting is particularly challenging
for several reasons. First, much of the work being done in primary
care is brief, which can limit the ability of the BHP to provide the
intervention in full-form. Second, the population in primary care is
extremely heterogeneous. Primary care patients cover the entire
life span, present with multiple comorbidities, and do not usually
request treatment for a well-defined condition, thus making it
extremely difficult to choose the appropriate EVT. Supporting
evidence-based practice over EVT makes sense in an integrated
primary care setting because it is research-based without being
prescriptive. BHPs therefore have latitude to make difficult treat-
ment decisions and to derive interventions from the research even
when the available research does not fully address the population’s
clinical needs (American Psychological Association, 2005). The
following section describes Salud’s service-delivery model in
greater detail.

Screening. The purpose of screening is to identify patients
who may be at risk for behavioral health difficulties by detecting
previously unrecognized symptoms. Establishing a smooth screen-
ing process that does not interrupt the workflow can be challeng-
ing. We found that there needs to be clear communication to all
employees, including PCPs and support staff, of the expectation
that the practice is integrated. Additionally, BHPs and PCPs must
have open dialogues about workflow. Last, priority groups need to
be established so that BHPs can decide which patients to screen
first when it is not possible to screen every patient.

Screenings are intended to be structured and brief (5–10 min-
utes) and targeted at specific priority groups—for Salud, this
includes pregnant patients, postpartum patients, new patients, and
children. We designed our screenings to encompass conditions
specified by the United States Preventive Task Force as well as
those concerns commonly seen in our setting. For patients older
than 16, we developed an eight-item prescreen the Screen for Life
Stressors, containing Yes/No responses about symptoms of de-
pression; anxiety; posttraumatic stress disorder (PTSD); tobacco,
alcohol, and substance use; and safety in the current living envi-
ronment. The questionnaire is a combination of items from the
Primary Care Evaluation of Mental Disorders (PRIME-MD), a
questionnaire designed to assist general practitioners in the diag-
nosis of minor psychiatric disorders (Spitzer et al., 1994); the
Primary Care PTSD Screen, a 4-question screen for symptoms of
PTSD (Prins et al., 2003); questions based on Screening Brief
Intervention Referral to Treatment guidelines for substance use
and abuse (Colorado Clinical Guidelines Collaborative, 2008); and
questions we developed specifically for this purpose.

We typically administer the prescreen face-to-face to help es-
tablish a relationship with the patient and to provide the opportu-
nity for immediate brief interventions. Positive prescreens trigger
a more intensive screening with standardized instruments assess-
ing depression, anxiety, alcohol abuse, substance abuse, and
PTSD. Depending on the patient’s literacy level, these question-
naires can be filled out by the patient or administered interview-
style by the BHP. We currently use the following instruments:
Patient Health Questionnaire – 9 from the PRIME-MD or Edin-
burgh Postnatal Depression Scale (Cox, Holden, & Sagovsky,
1987); Generalized Anxiety Disorder (7-item) Scale from the
PRIME-MD; PTSD Checklist (Blanchard, Jones-Alexander,
Buckley, & Forneris, 1996); Drug Abuse Screening Test (Skinner,
1982); and Alcohol Use Disorders Identification Test (Saunders,
Aasland, Babor, de la Fuente, & Grant, 1993). Children are
screened using the Parents’ Evaluation of Developmental Status
(for ages 0 – 8; Glascoe, 2010) and the Pediatric Symptom Check-
list (for ages 9 –16; Jellinek, Murphy, & Burns, 1986).

Because false positives are inherent in any screening procedure,
formal diagnoses are not based solely on the results of a screening.
Screenings that turn into diagnostic assessments are documented
separately. When patients screen positive, the BHP or PCP offers
follow-up services, either onsite, if possible, or through an outside
agency (Pignone et al., 2002).

Consultation. Although BHPs can see any patient at any time
for any reason, PCPs will often ask a BHP to evaluate and/or treat
a patient during a medical visit. Reasons for requesting consulta-
tion include but are not limited to psychoeducation or therapeutic
interventions for a specific behavioral health concern, health be-
havior change interventions, and assessment for diagnostic impres-
sions, suicide risk, and capacity to make health care decisions.
PCPs also frequently request crisis management services and/or
referral for onsite or offsite services.

Psychotherapy. Full time BHPs have the ability to schedule
up to three patients per day for individual psychotherapy appoint-
ments. Patients seen in this capacity complete disclosure and
informed-consent forms and work with their BHP to develop a
treatment plan. The typical session length is 50 minutes, although
some clinicians prefer shorter intervals. Scheduling is done either
by the BHP directly or through a centralized call center. Given the

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nature of a primary care setting, termination for no-shows/
cancellations is determined on a case-by-case basis. BHPs need to
be flexible when scheduling patients as many will not fall into the
traditional once per week model.

Psychological testing. Psychological testing for adults is
provided through Salud’s psychology training program, which
includes six postdoctoral fellows and several graduate-level practi-
cum trainees. A licensed psychologist on staff provides supervi-
sion to any trainee completing testing. Reasons for testing include
diagnostic clarification to inform medication management and
psychotherapy, to rule out a learning disorder, to evaluate memory
(e.g., normal aging vs. abnormal memory functioning; specify type
of memory impairment), to determine need for intensive neuro-
psychological testing, and to assess intellectual functioning.

Patient Contacts

Using the reporting functions from our electronic health record
and billing system, we were able to capture the number of patients
seen in 2010. Table 1 shows the results of the prescreenings
described above. Table 2 reflects the other behavioral health ser-
vices rendered in 2010. The behavioral health team provided
approximately 3000 screenings, 5500 consults, and 1800 individ-
ual therapy visits in 2010.

Financing

In a health care system characterized by barriers to integrated
practice, especially financial ones, it is surprising that so many
practices are making the move toward integration. We think inte-
gration is essential for comprehensive patient care consistent with
a patient-centered philosophy, but cost-effectiveness is hard to
measure. Higher levels of integration are more costly due to the
staffing and administrative demands associated with more com-
plex service delivery. Integration reduces costs for the entire health
care system to a point (Chiles et al., 1999; Katon et al., 2006;
Mumford, Schlesinger, Glass, Patrick, & Cuerdon, 1984), but
primary care practices may not share directly in the cost savings
from effectiveness. From a strict revenue-producing standpoint,
Salud’s integrated care team does not generate enough revenue to
support its staffing. Nevertheless, the cost of funding integration
must be compared to the cost of not funding integration.

As a federally qualified health center, Salud receives 20% of its
$50 million/year operating budget from the federal government,
20% from state grants, and 60% from direct patient fees. Enhanced
Medicaid reimbursements for medical visits help offset the costs of
providing services to such a large percentage of uninsured indi-

viduals. Federally qualified health centers cannot receive any
additional reimbursement from Medicaid for behavioral health
services during medical visits because the Medicaid rate is a flat
per-patient rate regardless of the number or type of services
rendered during a particular visit. It is possible to bill Medicaid for
services outside a regular medical visit by contracting with the
behavioral health organizations that administer Medicaid. How-
ever, for the time being, we have chosen not to pursue this funding
stream because the current regulations are not favorable to inte-
grated systems. Salud generates a small amount of revenue through
direct patient fees for therapy and assessment services rendered to
non-Medicaid patients. Third-party payers are not billed because
of paneling and credentialing requirements for providers, same-
day billing restrictions, administrative burden, and internal costs
associated with electronic claims. We thus decided to pursue other
funding for our integrated program.

The behavioral health program remains viable through two
ongoing Health Resources Services Administration (HRSA)
grants, included in Salud’s annual HRSA funding for operating as
a federally qualified health center. The psychology training pro-
gram is sustained through a combination of grants, including a
large one dedicated specifically to postdoctoral training. Finally,
many of our BHPs are employed through collaborative arrange-
ments with our CMHC partners or similar agencies. In these cases,
Salud does not pay the BHP’s salary; the outside agencies benefit
by increasing their Medicaid penetration rate and/or by demon-
strating that they are reaching more patients.

Conclusion

Primary care patients who have behavioral health problems are
very expensive to the system (Petterson et al., 2008), and behav-
ioral health affects overall health whether we address it or not. This

Table 1
Prescreening Results 2010

Dimension Positive screen Negative screen Total % Positive

Depression 1066 1924 2990 35.7
Anxiety 979 1865 2844 34.4
Trauma 338 2549 2887 11.7
Alcohol 302 2689 2991 10.1
Tobacco Use 879 1551 2430 36.2
Other Substance Abuse 105 2319 2424 4.3
Unsafe Living Environment 59 2845 2904 2

Table 2
Other Behavioral Health Contacts, 2010

Service Number of contacts

Consultation 5507
Diagnostic Evaluations 310
Individual therapy 1844
Family therapy 82
Group therapy 37
Smoking cessation 237
Alcohol/Substance Treatment 73
Child Screen 299

395ESTABLISHING AN INTEGRATED CARE PRACTICE

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article has been an attempt to describe how these basic consider-
ations have driven the evolution of an integrated care practice in a
large community health center system that serves vulnerable pop-
ulations across North Central Colorado. With the caveat that there
is no one correct way to achieve integrated care, we have presented
the various considerations and decisions made along the way in
hopes that others who are considering or are in the process of
establishing an integrated care practice might learn from our
experiences. We have detailed our thoughts about the necessary
and sufficient components of successful integration, with special
attention to the role of evidence-based practice. We have also
argued that paradigm shifts from a medically focused mentality
to a patient-centered mentality must be made at the organizational
level.

For practices considering integrating behavioral health into pri-
mary care, is value measured by dollars brought into the organi-
zation, provider satisfaction, patient satisfaction, decreased utili-
zation, fewer emergency room visits, or improvement in physical
markers? If the only way to generate revenue through behavioral
health services is by moving from an integrated to a colocated
model, is this approach consistent with the organizational mission?
Do the administrative burdens and costs of billing fee-for-service
outweigh the benefits? Do they impact the organization’s ability to
offer high-volume quality services? These are merely a few of the
questions that will arise when setting up an integrated care prac-
tice.

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Received March 21, 2011
Revision received June 9, 2011

Accepted June 15, 2011 �

397ESTABLISHING AN INTEGRATED CARE PRACTICE

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