Psychology essential to achieving goals of patient-centered medical homes

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WASHINGTON – Psychologists can offer critical experience and expertise in strengthening the increasingly common model of coordinated health care, the patient-centered medical home, helping to achieve the "triple aim" of improved outcomes, decreased cost and enhanced patient experience, according to articles published by the American Psychological Association.

"Primary and specialty health care in America for youth, adults and their families are undergoing substantial redesign through the implementation of the patient-centered medical home, in which teams of medical and behavioral health care providers work collaboratively, often in the same practice, to achieve the triple aim," said Anne E. Kazak, PhD, editor of American Psychologist, APA's flagship journal. "Psychology must embrace its rightful place as a health profession in the PCMH model, which prioritizes the integration of behavioral and physical health care."

The January issue of American Psychologist is composed of five articles that highlight the valuable role of psychologists in PCMHs and the evidence that their inclusion results in improved health outcomes. The articles also emphasize opportunities for more effective coordination and address the challenges inherent in making fundamental changes to how health care is delivered, including payment models that pose barriers to coordinated care.

"A prime reason for integrating behavioral health into patient-centered medical homes is that behavioral health problems are very common in medical patients and frequently complicate care delivery and effectiveness," said Nadine J. Kaslow, PhD, of Emory University, who was one of the issue's scholarly leads, along with Kazak and Kimberly Hiroto, PhD, of Puget Sound VA Health Care System. "Up to 30 percent of primary care patients meet diagnostic criteria for behavioral health problems, including anxiety, mood and substance use disorders. The costs of managing chronic disease increase markedly when co-occurring behavioral health conditions exist. Largely preventable and modifiable health behaviors, such as poor diet, lack of exercise, and tobacco and other substance use, contribute to nearly half of all premature deaths."

Among the proven benefits of the PCMH, which is a "one-stop-shop" that reduces the need for patients to go elsewhere for behavioral health care, are improved attendance at appointments, better adherence by patients to care recommendations, increased engagement in health promotion activities, and more effective communication and care planning among health care team members and patients and their loved ones.

However, one of the chief impediments to more widespread implementation of the PCMH model is the fragmented payment system that has evolved in American health care, according to one of the articles in the special section. Historically, medical and behavioral health services have been paid through two distinct channels in which providers are reimbursed for specific services during separate visits. Some state policies even limit billing for medical and behavioral health services on the same day. "To fully transform the U.S. health care system, payment structures will need to change to focus on patient outcomes, rather than fee for service," Kazak said.

The medical home concept came originally from pediatrics in 1967 when it was put forward in the Standards of Child Health Care, published by the American Academy of Pediatrics Council on Pediatric Practice.

"In 2006, the concept was tested in 36 family practices in the United States and by 2008, it had been endorsed by the major primary care professional organizations and an increasing number of specialty care organizations," Kaslow noted. "Because of its demonstrated effectiveness, the PCMH model should be the universal standard of care."

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Following is a summary of articles in the special section:

"Psychologists in Patient-Centered Medical Homes (PCMHs): Roles, Evidence, Opportunities, and Challenges," Anne E. Kazak, PhD, Sidney Kimmel Medical School of Thomas Jefferson University; Justin M. Nash, PhD, Warren Alpert Medical School of Brown University and Memorial Hospital of Rhode Island; Kimberly Hiroto, PhD, Puget Sound VA Health Care System American Lake Division; and Nadine J. Kaslow, PhD, Emory University.

This is an overview of the special section, laying out the evidence and roles for psychologists across a range of pediatric, adult and geriatric health care populations and settings.

Contact: Anne E. Kazak, PhD at [email protected]

"Payment Reform in the Patient-Centered Medical Home: Enabling and Sustaining Integrated Behavioral Care," by Benjamin F. Miller, PhD, and Kaile M. Ross, MA, University of Colorado School of Medicine; Melinda M. Davis, PhD, Oregon Health and Sciences University; Stephen P. Melek, BA, Milliman, Wakefield, Massachusetts; Roger Kathol, MD, University of Minnesota; and Patrick Gordon, MPA, Rocky Mountain Health Plans, Grand Junction, Colorado.

Health care payment and financing, like clinical delivery, is fragmented. Medical and behavioral health services have traditionally been paid through two separate channels with separate billing codes, reimbursement pathways and reporting requirements. These mechanisms make it difficult to integrate psychologists and other behavioral health clinicians in the patient-centered medical home. This article describes alternatives to the traditional fee-for-service payment model, including bundled payments and pay for performance.

Contact: Benjamin F. Miller, PsyD, at [email protected]

"The Pediatric Patient-Centered Medical Home: Innovative Models for Improving Behavioral Health," by Joan Rosenbaum Asarnow, PhD, and Jeanne Miranda, PhD, University of California, Los Angeles; David J. Kolko, PhD, University of Pittsburgh School of Medicine; Anne. E. Kazak, PhD, Nemours Children's Health System, Wilmington, Delaware, and Sidney Kimmel Medical School of Thomas Jefferson University.

The PCMH model offers unique opportunities for enhancing the health and behavioral health of youth – particularly the economically disadvantaged, minority and uninsured — with effects that potentially last into adulthood. Continuity of care within a pediatric PCMH and access to a range of professionals provide opportunities to address developmental sensitivities at the most effective time points, according to this article.

Contact: Joan Rosenbaum Asarnow, PhD, at [email protected]

"Psychology in Patient-Centered Medical Homes: Reducing Health Disparities and Promoting Health Equity," Eugene W. Farber, PhD, Emory University; Mana K. Ali, PhD, Johns Hopkins University; Kristi S. Van Sickle, PsyD, Florida Institute of Technology; and Nadine J. Kaslow, PhD, Emory University.

The PCMH model offers solutions to the vexing problem of delivering physical and mental health care to medically underserved communities, according to this article. Psychologists can make tangible contributions as health care team members focus upon reducing health disparities, it says. Psychologists have evidence-based clinical expertise that helps ensure that all parties engage in patient- and family-centered care.

Contact: Eugene W. Farber, PhD, at [email protected]

"Meeting Evolving Workforce Needs: Preparing Psychologists for Leadership in the Patient-Centered Medical Home," Abbie O. Beacham, PhD, University of Colorado; Kristi S. Van Sickle, PsyD, Florida Institute of Technology; Parinda Khatri, PhD, Cherokee Health Systems; Mana Ali, PhD, Johns Hopkins University; Daniel Reimer, PhD, University of Nevada, Reno; Eugene W. Farber, PhD, and Nadine J. Kaslow, PhD, Emory University.

The evolution toward the PCMH model of care will require approximately 90 percent of the 93,000 health service psychologists trained in the United States, according to conservative estimates. This article calls for a competency-based training framework to meet this need.

Contact: Kristi S. Van Sickle, PhD, at [email protected]

The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States. APA's membership includes more than 117,500 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance the creation, communication and application of psychological knowledge to benefit society and improve people's lives.

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