MODULE 3

PRIMARY CARE PATIENTS

WHO ARE THEY AND HOW
CAN PSYCHOLOGISTS
BE HELPFUL?
MODULE 3

PRIMARY CARE PATIENTS:

WHO ARE THEY AND HOW CAN
PSYCHOLOGISTS BE HELPFUL?
Curriculum developed by the Integrated Primary Care Curriculum Committee of
the Society for Health Psychology:
Barbara Ward-Zimmerman, PhD, William B. Gunn, Jr., PhD, and Nancy Ruddy, PhD, Co-Chairs

Mark E. Vogel, PhD, ABPP, Barbara A. Cubic, PhD, Lisa K. Kearney, PhD, ABPP, Christopher Neumann, PhD, Mark A.
Stillman, PhD, and Shanda Wells, PsyD

GUEST CONTRIBUTOR:
Christine Runyan, PhD

The Society for Health Psychology and the APA Education Directorate
are gratefully acknowledged for their financial support.

© 2017 by the
LEARNING OBJECTIVES

Following this presentation, participants will be able to:

describe common patient behavioral health concerns

in primary care;

identify the skills for practice management, clinical assessment,

and screening in primary care;

consider nuances of integrated primary care psychology related to

patient cultural backgrounds and ethical issues.
 Common Patient Behavioral
Health Concerns in Integrated
Primary Care
TEAM HUDDLE
WHEN A PRIMARY CARE PROVIDER MAY AUTOMATICALLY
INCLUDE A PSYCHOLOGIST IN PATIENT CARE:

CHILD WITH PATIENT WITH

BEHAVIORAL OR DEPRESSION, ANXIETY,
EMOTIONAL PROBLEMS SUBSTANCE MISUSE

SUICIDAL PATIENT ADULT CHILDREN

CONCERNED ABOUT
AN ELDERLY PARENT’S
MEMORY
WHEN A PRIMARY CARE PROVIDER MAY AUTOMATICALLY
INCLUDE A PSYCHOLOGIST IN PATIENT CARE

PARENTING ISSUES BEREAVEMENT

PREGNANCY CONCERNS CANCER DIAGNOSIS

AGING-RELATED COMPLICATIONS MARITAL AND FAMILY STRESS

SOCIAL SERVICE NEEDS PANIC ATTACKS

ALCOHOL MISUSE DOMESTIC VIOLENCE

SEXUALLY TRANSMITTED DISEASES CHRONIC PAIN

STRESSFUL LIFE TRANSITIONS SCHOOL REFUSAL

 WHEN NEED FOR A PSYCHOLOGIST IS LESS OBVIOUS
TO THE PRIMARY CARE PROVIDER

RATIONALE FOR
PSYCHOLOGY INTERVENTION
Sleep concerns,
headaches, gastro- PATIENT MAY BE REPORTING STRESS-
PATIENT PRESENTATION

intestinal distress (IBS) RELATED SOMATIC CONCERNS

Heart disease, diabetes, PATIENT MAY NOT BE MANAGING

hypertension, asthma MEDICAL CONDITIONS IN HEALTHY WAYS

CHALLENGING PROVIDER–PATIENT
Patient’s manner of
INTERACTIONS COULD COMPROMISE
presentation is
CARE IF NOT ADDRESSED
challenging for provider
WARM HANDOFF
Practice 1
Management :
SETTING PRIORITIES, BEING FLEXIBLE,
AND MAKING YOURSELF USEFUL
PRACTICE MANAGEMENT: ESSENTIAL COMPONENTS
FOR PRIMARY CARE PSYCHOLOGISTS1

Meets needs with the resources available within the time constraints of the settings
(RESOURCE MANAGEMENT)

Applies principles of population-based care along a care continuum (e.g., prevention

and wellness to treatment of subclinical issues and acute/chronic needs)
(POPULATION-BASED CARE)

Operates at a variety of paces, consistent with the PC setting

(PROPER PACING)

Co-interviews, co-assesses, and co-intervenes with other PC providers

(SHARED INTERVENTION)

Understands how payment for services may influence the type of services and treatment
provided (PAYMENT SERVICES)

Communicates information that addresses a patient’s needs, improves PC practice, and

allows for approved research without revealing unnecessary confidential information
(CLEAR COMMUNICATION)

Uses most up-to-date technology and methods to guide clinical service delivery
(TECHNOLOGY UTILIZATION)
WHERE TO BEGIN:
COMPLETING A NEEDS ASSESSMENT

Integrated primary care (IPC) psychologists must begin their work in

primary care (PC) by identifying the needs of the population they are
serving, including:
1) patients, 2) patients’ families, and 3) the PC team.

A formal needs assessment can assist in identifying the services

desired by each of these customers.

After collating the data from all customers, the IPC psychologist
can provide summaries of the top needs identified and target
these areas to begin building services.

Needs assessments combined with future program evaluations

should be completed periodically to assess for emerging needs in
line with program outcomes.
POPULATION-BASED CARE:
SCREENING vs. FUNCTIONAL ASSESSMENT1

SCREENING:1
• Universal: structured brief tools used uniformly across
an ENTIRE POPULATION to detect common, but
under diagnosed conditions

• Selective: structured brief tools used to identify

conditions of concern within particular high-risk groups

FUNCTIONAL ASSESSMENT:
• Evaluation completed after a target concern is
identified by reviewing the impact of the concern on
overall functioning
POPULATION-BASED CARE: UNDER WHAT CONDITIONS
DOES UNIVERSAL SCREENING MAKE SENSE?1

CONDITION HAS CONSIDERABLE KNOWN HEALTH RISKS (e.g., smoking,

depression)

RELIABLE AND VALID MEASURES EXIST

TIMING OF SCREENING CAN BE IDENTIFIED

EVIDENCE-BASED INTERVENTIONS EXIST FOR POSITIVE “HITS”

BENEFITS OF SCREENING OUTWEIGH HARM

POPULATION-BASED CARE:
WHAT SHOULD WE SCREEN FOR?
YES,
WITH SYSTEMS
FOR ADDRESSING IT
(GRADE B) YES,
WITH SYSTEMS
FOR ADDRESSING IT
(GRADE B)

MAYBE,
INSUFFICIENT
ALCOHOL EVIDENCE
DEPRESSION:
MISUSE
ADULTS, INCLUDING SMOKING
OLDER ADULTS, PREGNANT CESSATION
AND POSTPARTUM WOMEN;
ADOLESCENTS OBESITY DEMENTIA
INTIMATE PARTNER
ANXIETY
VIOLENCE

U.S. PREVENTIVE SERVICES TASK FORCE SCREENING GUIDELINES1,2

SCREENING
A SHARED INTERVENTION EXAMPLE:
RESPONSE TO A POSITIVE SCREEN

FURTHER ASSESSMENT BY PRIMARY CARE

PROVIDER, FOLLOWED BY INVOLVEMENT
OF PSYCHOLOGIST
• Warm Handoff to psychologist
• Scheduled follow-up assessment by psychologist

COLLABORATIVE TREATMENT APPROACH

• Team decision to engage in Watchful Waiting
• Intervention Plan developed by the team to be
reinforced by the entire team
POPULATION-BASED CARE: ASSESSING FUNCTIONAL
IMPAIRMENT AND HABITS1
ASK:
Typical Weekday, Weekend?
What Would Change if Problem
Improved/Disappeared?

FUNCTIONAL
IMPAIRMENT HABITS

School/Work Exercise

Sleep/Energy/Concentration/
Relationships Appetite Changes

Social & Recreational Substance Use (caffeine/

Activities alcohol/tobacco/over-the-
counter medication)
 SYMPTOM SEVERITY? PATIENT PREFERENCE?

READINESS TO CHANGE? CULTURAL BELIEFS?

PSYCHOSOCIAL STRESSORS? RESOURCES?

COMORBID CONDITIONS? HEALTH BELIEFS?

TREAT BY PSYCHOLOGIST IN
PRIMARY CARE OR REFER TO
SPECIALTY MENTAL HEALTH?
PROPER PACING: WORKING WITHIN A
30-MINUTE TIME FRAME

Overview of psychologist’s goals in first encounter:

Describe role on the health care team

Specify how communication with team is completed (e.g., documentation)

Clarify and define the patient’s (&/or provider’s) current concerns
Conduct brief, focused biopsychosocial assessment

Collaboratively develop a plan to target the problem with the patient

Implement an evidence-based, focused intervention, including connecting the
patient to resources (e.g., handouts, apps, and Internet sites) when applicable
Respect patient preferences and cultural background

Be flexible and creative with follow-up planning

PROPER PACING: MANAGING AN INITIAL CONSULT1

2 Min

INTRODUCTION: PSYCHOLOGIST’S
ROLE, JOINT UNDERSTANDING
OF REASONS FOR CONSULT
10–15 Min

ASSESSMENT: PROBLEM DEFINITION,

FOCUSING ON PRESENT SYMPTOMS
AND FUNCTIONING

INTERVENTION: SHARED DECISION MAKING,

TREATMENT PLAN DEVELOPMENT

WRAP-UP: SUMMARY AND

FOLLOW-UP PLAN 5–10 Min

POSTCONSULT: FEEDBACK AND

ADMINISTRATIVE TASKS

2–5 Min

5 Min
GENERAL CLINICAL ASSESSMENT STRATEGIES

Recognize “red flags” signifying common medical conditions,

more severe mental health disorders, and medication side effects

Selectively use open-ended questions and reflection

Pursue only questions that impact intervention

Focus on the present – gather only relevant family history

RESOURCE MANAGEMENT: USING RESOURCES
BEYOND THE PRACTICE

COMMUNITY EDUCATIONAL INTERNET

RESOURCES SERVICES RESOURCES

APPS SUPPORT
SERVICES
YOUR TOOL BOX

PATIENT HANDOUTS DESCRIPTION

FOR COMMON OF PHONE APPS
CONDITIONS

COPIES OF YOUR
SCREENING BUSINESS
MEASURES CARD

INFORMATION
ABOUT COMMUNITY
RESOURCES
YOUR TOOL BOX

PATIENT HANDOUTS
FOR COMMON
CONDITIONS
EXAMPLES
Coping with Depression

Relaxation Scripts

AA Meeting Directories

Pointers for Parents of Children with ADHD

Sleep Hygiene

Managing Caregiver Stress

YOUR TOOL BOX

DESCRIPTION
EXAMPLES OF PHONE APPS

ACT COACH
CBT-i COACH
CONCUSSION COACH
CPT COACH
MINDFULNESS COACH
MOVE! COACH APP
MOVING FORWARD
PARENTING2GO
PE COACH
PFA MOBILE
PTSD COACH
STAY QUIT COACH
Putting Screening and Clinical
Assessment into Context:
CULTURAL, FAMILY, AND ETHICAL AWARENESS IN
INTEGRATED PRIMARY CARE SETTINGS
CULTURAL AWARENESS AND COMPETENCY
IN PRIMARY CARE1

CULTURE IMPACTS:

SYMPTOM PRESENTATION

INTERACTION WITH THE HEALTH CARE SYSTEM

COMMUNICATION (VERBAL/NONVERBAL)

INTERPRETATION OF SCREENING TESTS

RECEPTIVITY TO SEEING A PSYCHOLOGIST

CULTURAL AWARENESS AND COMPETENCY
IN PRIMARY CARE1

UNDERSTAND MEANING OF
HEALTH AND ILLNESS FROM
THE PATIENT AND FAMILY’S
PERSPECTIVE
 Patient
Personal
Gender Health
Beliefs

Practice Provider
Approach of Personal
Provider and Health
Health Facility Beliefs
CULTURAL
CONSIDERATIONS
IN INTEGRATED Patient
Socioeconomic PRIMARY CARE Perceptions of
Status Health Care

Provider Patient
Cultural Cultural
Background Background
ONE CULTURAL CONSIDERATION:
LACK OF ENGLISH FLUENCY IS AN INDEPENDENT
PREDICTOR OF…1,2,3

POOR CONTROL OF CHRONIC DISEASE

REDUCED HEALTH CARE USE

ABSENCE OF A REGULAR SOURCE OF CARE

LACK OF CONTINUITY OF CARE

LACK OF PATIENT SATISFACTION

POOR QUALITY PATIENT EDUCATION AND UNDERSTANDING OF DISORDER

CULTURALLY AND LIGUISTICALLY APPROPRIATE
SERVICES ARE…1

RESPECTFUL OF AND RESPONSIVE TO:

INDIVIDUAL CULTURAL HEALTH BELIEFS AND PRACTICES

CONSIDERED
BY THE
PREFERRED LANGUAGES ENTIRE TEAM
AT EVERY
POINT OF
HEALTH LITERACY LEVELS
CONTACT

COMMUNICATION NEEDS
 INTEGRATING THE
FAMILY PERSPECTIVE
INTEGRATING THE FAMILY PERSPECTIVE: EXAMPLES

UNDERSTANDING IMPACT OF
UNDERSTANDING IMPACT OF
THE FAMILY ON HEALTH
HEALTH ISSUES ON THE FAMILY
Factoring in the role of cultural issues
Appreciating effect on family
resources, including: time; financial Conceptualizing how family health
stability; emotional support beliefs impact the patient
Recognizing effect on family life, including: Recognizing family life cycles
routines; meal planning; availability and
Identifying relational patterns
use of leisure time

ENGAGING THE FAMILY IN CARE

 ETHICAL CONSIDERATIONS
IN INTEGRATED PRIMARY CARE
ETHICAL GUIDANCE... (OR CONFUSION)?1,2,3,4

CONFIDENTIALITY
HIPAA
INFORMED
CONSENT IMPAIRED
CLINICIAN

BOUNDARY PATIENT
CONFLICTS CAPACITY
ADDITIONAL ISSUES CONCERNING THE ETHICS
CODE AND PRIMARY CARE PSYCHOLOGY

CONSULTATIONS (4.06)
Too narrow for common situations in primary care

PROVIDING THERAPY TO THOSE SERVED BY

OTHERS (10.04)

TERMINATING THERAPY (10.10)

 GOAL:
STRIKE A BALANCE AND REMEMBER THE SPIRIT OF THE CODE1,2

• Assure electronic health information is protected

• Allow flow of health information needed to provide and promote high-quality
health care
• Protect the public’s health and well-being
• Be clear on intention, seek consultation, consider models and resources
• Protect confidentiality in substance abuse treatment (42 CFR Part 2 is under revision)
SUMMARY POINTS

Primary care psychologists address a broad range of behavioral

health concerns as well as medical conditions responsive to
behavioral health interventions.

Essential for success as a primary care psychologist: adaptability,

a broad knowledge base, and a fast work pace.

Universal screening identifies concerns not readily observable

and results in earlier intervention.

Awareness of unique cultural and ethical considerations in

primary care is essential.

© 2017 by the