Primary Care Behavioral Health Provider Training: Systematic Development and Implementation in a Large Medical System

The expansion of integrated, collaborative, behavioral health services in primary care requires a trained behavioral health workforce with specific competencies to deliver effective, evidence-informed, team-based care. Most behavioral health providers do not have training or experience working as primary care behavioral health consultants (BHCs), and require structured training to function effectively in this role. This article discusses one such training program developed to meet the needs of a large healthcare system initiating widespread implementation of the primary care behavioral health model of service delivery. It details the Department of Defense’s experience in developing its extensive BHC training program, including challenges of addressing personnel selection and hiring issues, selecting a model for training, developing and implementing a phased training curriculum, and improving the training over time to address identified gaps. Future directions for training improvements and lessons learned in a large healthcare system are discussed.     

Addressing the Mental Health Needs of the Rural Underserved: Findings from a Multiple Case Study of a Behavioral Telehealth Project

Behavioral telehealth is a reasonable solution to the accessibility to mental health care problem that exists in many rural communities. This paper reports the results of a multiple case study of a behavioral telehealth program administered through a marriage and family therapy training program. The results suggest that mental health services can be effectively delivered using existing distance education technology to underserved rural populations. Rural communities have unique barriers to accessing mental health care, some of which can be overcome through the distance delivery of services and some of which cannot. In order to effectively deliver treatment, accommodations to the technology must be made by both therapist and client.     

The Starting Early Starting Smart Integrated Services Model: Improving Access to Behavioral Health Services in the Pediatric Health Care Setting for At-Risk Families with Young Children

We evaluated the Starting Early Starting Smart (SESS) national initiative to integrate behavioral health services (parenting, mental health, and drug treatment) into the pediatric health care setting for families with young children. Data are presented from five pediatric care (PC) sites, drawing from families at risk due to demographic and behavioral health factors, with infants less than 12 months of age (n = 612). Families were randomly assigned to either the SESS program or a standard care Comparison group. We utilized longitudinal analyses to estimate differences in utilization rates for parenting, mental health, and drug treatment over 6 follow-up time points (3, 6, 9, 12, 15 and 18 months). Our findings indicate that SESS caregiver participants were 4.6 times (p < 0.001; CI = 3.33–6.26) more likely to receive parenting services, 2.1 times (p < 0.001; CI = 1.48–2.86) more likely to receive outpatient mental health treatment, and 1.8 times (p = 0.025; CI = 1.08–3.14) more likely to receive drug treatment than Comparison group participants. Our results demonstrate the success of the SESS program in coordinating and improving access to behavioral health services for high-risk caregivers within the pediatric health care setting and highlight the importance of continuing to focus public health policy on the behavioral health care needs of families with young children.     

Genetic Counseling in a Busy Pediatric Metabolic Practice

Patients with inborn errors of metabolism and their families require unique clinical care including management of acute illnesses, screening for long term complications, discussion of the etiology of the condition, connections to social supports, and clarification of the recurrence risks and prenatal testing and treatment options. Our multidisciplinary pediatric metabolic clinic combines the skills of metabolic geneticists, pediatric dieticians, social workers, clinical pharmacists, nurses and genetic counselors to provide optimal and well-rounded care for our patients and their families. Given the inherited nature of most inborn errors of metabolism and the necessary long-term management for these disorders, the genetic counselor’s role in this clinic setting is integral in providing ongoing support and education for patients and their families. This includes coping with the disease burden, helping patients and families adapt to a condition in the family and ensuring adequate understanding of the genetic risks and the available prenatal diagnostic and reproductive choices. Our clinic provides services to a large geographic area with many isolated populations where unique metabolic diseases are highly prevalent secondary to a founder effect. In this paper, we share our experience in providing longitudinal care to children with complex medical needs due to metabolic disorders and highlight the role of the genetic counselor in this clinic setting.     

Behavioral Health Integration in Health Care Settings: Lessons Learned from a Pediatric Hospital Primary Care System

Behavioral health integration within primary care has been evolving, but literature traditionally focuses on smaller scale efforts. We detail how behavioral health has been integrated across a large, urban pediatric hospital system’s six primary care clinics (serving over 35,000 children annually and insured predominately through Medicaid) and discuss strategies for success in sustaining and expanding efforts to achieve effective integration of behavioral health into primary care. In a time span of 3 years, the clinics have implemented routine, universal behavioral health screening at well child visits, participated in a 15-month behavioral health screening quality improvement learning collaborative, and integrated the work of psychologists and psychiatrists. Additional work remains to be done in improving family engagement, further expanding services, and ensuring sustainability.     

Pediatric Psychology: Child Psychological Health in the Next Century

The future of pediatric psychology is reviewed and placed in brief historical context in relation to children's psychological health care. Contemporary trends affecting the delivery of psychological services, research, and clinical training are highlighted, with suggestions for future development. Pediatric psychology is a child-based, developmentally-focused multidisciplinary practice directed toward psychosocial and neuropsychological issues of health and illness in children and youth. Pediatric psychologists need to develop strong professional identities as health care psychologists combined with a collegial and collaborative arrangement with physicians to ensure the future growth and development of pediatric psychology in the next century as a major vehicle to promote children's health care.     

The Effect of Racial and Ethnic Diversity on the Delivery of Mental Health Services in Pediatric Primary Care

The effects of racial and ethnic diversity on the detection and management of behavioral and emotional problems in pediatric primary care are addressed. Service access and utilization as a function of race and culture are initially examined. Important barriers within pediatric training including minimal emphases on behavioral training and the limited supply of minority physicians are underscored. The impact of ethnicity on the development and maintenance of the clinical relationship that is critical to accurately and sensitively identifying and managing behavioral and developmental problems is briefly addressed. Recommendations for further integration of racial/ethnic issues into mental health service provision within the pediatric primary care arena are presented.     

Triple P-Positive Parenting Program: Towards an Empirically Validated Multilevel Parenting and Family Support Strategy for the Prevention of Behavior and Emotional Problems in Children

This paper outlines the theoretical and empirical foundations of a unique multilevel parenting and family support strategy designed to reduce the prevalence of behavioral and emotional problems in preadolescent children. The program known as Triple P-Positive Parenting Program is a multilevel system of family intervention, which provides five levels of intervention of increasing strength. These interventions include a universal population-level media information campaign targeting all parents, two levels of brief primary care consultations targeting mild behavior problems, and two more intensive parent training and family intervention programs for children at risk for more severe behavioral problems. The program aims to determine the minimally sufficient intervention a parent requires in order to deflect a child away from a trajectory towards more serious problems. The self-regulation of parental skill is a central construct in the program. The program uses flexible delivery modalities (including individual face-to-face, group, telephone assisted, and self-directed programs) to tailor the strength of the intervention to the requirements of individual families. Its multidisciplinary, preventive and community-wide focus gives the program wide reach, permitting the targeting of destigmatized access points through primary care services for families who are reluctant to participate in parenting skills programs. The available empirical evidence supporting the efficacy of the program is discussed and its implications for research on dissemination are discussed.     

Impact of Location and Availability of Behavioral Health Services for Children

Literature suggests advantages for co-locating behavioral health care in primary care. We compared the impact of location of services on attendance at behavioral health appointments when access to care was assured for externalizing behavior problems with referral as usual. Two primary care pediatric practices had an evidence-based parenting program co-located in the practice for parents of children aged 2?C12 years and two practices had the program available using an enhanced-referral procedure for locations external to the practices. The program was available at the regional children??s hospital (referral as usual). During an 8-month period, the rate of attendance at first appointments was significantly higher in the co-located than the enhanced referral condition (.38 and .12 % of patient visits, respectively; ??² = 13.32; p < .0003; OR = 3.10; 95 % CI: 1.63, 5.89). These outcomes, while low, were better than the near 0 rate of attendance to referral as usual. Availability of behavioral health services in both conditions increased rates of attended appointments. However, the low rates of attendance indicate increasing availability of services, alone, is not sufficient to decrease the unmet need of children with behavioral problems. Factors other than availability must be addressed in order to improve outcomes for children.     

Delivering Parent Management Training in an Integrated Primary Care Setting: Description and Preliminary Outcome Data

This paper describes how behavioral health consultants (BHCs) in an integrated primary care setting use evidence-based principles that underlie parent management training (PMT) to assist caregivers of youth with externalizing behavior problems. Illustrated is the decision-making process that BHCs utilize from the moment they receive a patient referral from a primary care provider to how interventions are selected and delivered. When delivering PMT in integrated care, operant-based learning principles underlying PMT are often selected based on a combination of factors, including match with presenting problem, caregiver efficacy, caregiver beliefs about the causes and maintaining factors, and feasibility of implementation. We further present preliminary outcome data on the effectiveness of BHCs’ efforts to use PMT principles in a primary care setting. Participants were 21 caregivers and their children (M_age = 7.76 years, 38.1% female; 66.7% Hispanic) seen for an average of 2.38 visits. Pre-post data provided by caregivers (for youth 11 years or younger) and adolescents (self-report of patients 12–17 years of age) taken at the time of first and last sessions revealed significant reductions in global distress scores and high levels of satisfaction with services received. Findings support the viability of providing brief, focused PMT interventions for pediatric populations seen in primary care.     

Telephone Assessment,Support, and Counseling for Depression in Primary Care Medical Clinics

The Telephonic Assessment, Support, and Counseling Program (TASC) was developed to improve access to behavioral health assessment, counseling, and evidence-based psychotherapy in a public health system with an underserved, diverse population. The program is described in detail with examples of materials that can be replicated in other sites. TASC was designed to augment the management of depression provided through primary care clinics, which is where most people in the United States receive treatment for depression. The program used behavioral activation treatment for depression (BA), a well-researched evidence-based form of cognitive behavioral therapy that can be delivered by telephone in a relatively brief time period. TASC also incorporated motivational interviewing (MI) strategies into medication adherence and depression counseling. The intervention was conducted with primary care patients diagnosed with depression by their PCPs through five telephone calls targeting education about depression, medication adherence, and strategies to teach patients to monitor their mood and daily activities and to increase the number of specific activities in which they engage. Prior to beginning BA treatment, the Patient Health Questionnaire-9 and the Mini-International Neuropsychiatric Inventory were conducted to effectively identify alternative diagnoses or serious comorbidities. Primary care clinics providing medical care to low-income, diverse populations have many patients who could benefit from contact with a mental health provider, and telephonic delivery of these services in a program such as the TASC model may be a viable and cost-effective option that can increase access.     

Service Delivery Issues and Program Evaluation in Pediatric Psychology

Presents a framework for categorizing pediatric psychology research into practice and service system outcomes and functioning. The questions of importance are (a) who is being served, (b) what services are provided, (c) how treatments are implemented, (d) how services are organized and staffed, (e) what are the outcomes of the services, (f) how do various consumers perceive services, (g) how services are reimbursed, and (h) what are alternatives and innovations? The framework of program evaluation is detailed for domains most germane to service delivery in pediatric/child health psychology. Such domains include diagnostic information on patients, types of intervention, behavioral/psychological outcome variables, costs of treatments, service system functioning, and perceptions of satisfaction from multiple sources. This framework may be useful in directing future research on the delivery of services in pediatric psychology settings, thereby adding to the value of the field.     

Providers' voices on telebehavioral health: Survey of an outpatient counseling agency in Alaska

Hope Counseling Center sought to expand behavioral health services to underserved populations in Alaska by offering telebehavioral health services. Providers completed a questionnaire addressing their experiences, opinions, and training needs as they relate to telebehavioral health. Open conversations about the training needs, limitations, and benefits of telebehavioral health supported program development and led to training on new equipment, rapport building, and telebehavioral health outcome studies. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Biopsychosocial Factors Associated with Parenting Stress in Pediatric Sickle Cell Disease

Caregivers of children with sickle cell disease (SCD) experience significant physical and emotional hardship with their child’s disease management. Little is known about the potential contributors to parenting stress in pediatric SCD. The present study aimed to identify child and caregiver biopsychosocial factors associated with disease-related parenting stress in pediatric SCD. Participants included 74 caregiver-youth dyads. Parenting stress was associated with increased child pain frequency, more missed school days, and increased healthcare utilization, and inversely correlated with caregiver mental health and social-emotional functioning. Parenting stress also partially explained the relationship between child pain frequency and healthcare utilization after controlling for parent depression and anxiety. Parenting stress may play a unique and critical role in pediatric SCD and underscore the impact parenting stress may have on youth in medical and academic settings. Further research is warranted to determine risk factors and appropriate interventions for parenting stress to improve comprehensive patient care.

     

Interpersonal Skills Training to Reduce Aggressive and Delinquent Behavior: Limited Evidence and the Need for an Evidence-Based System of Care

The prevention of aggressive and delinquent behavior during childhood and adolescence is one of the highest priorities for public health and crime prevention. The most common approach to preventing or treating these conduct problems has been to provide interpersonal skills training to the affected youth. This paper reviews all randomized controlled trials evaluating interpersonal skills training programs as an intervention to reduce conduct problems. Research shows that such programs have weak empirical support as isolated interventions. An alternative evidence-based system of care is described. Such a system would include behavioral parent training and behavioral classroom-based interventions for young children at risk of developing problems, as well as multisystemic family therapy or multidimensional treatment foster care for chronic delinquents. Within such a network of services, interpersonal skills training could play an important supportive role. Such a system holds the greatest promise for reducing the prevalence of aggressive and delinquent behavior in communities.     

Integrating mind and body: Graduate psychology education in primary behavioral health care

Extensive research supports the biopsychosocial model, but the current health care system generally operates according to a model of mind-body dualism. Integrated primary behavioral health care offers an alternative to this dualism. This paper describes the University of Louisville Graduate Psychology Education (GPE) program, a pre-doctoral integrated primary behavioral health care training program. This program emphasizes four shared psychosocial determinants that have been associated with physical health status: Victimization and potentially traumatic stress exposure, emotional functioning, social relationship functioning, and illness representations. It does so within the broader context of providing care for individuals who are underserved and economically disadvantaged. The initial phase of the program is evaluated and implications for graduate psychology education and patient care are discussed.     

Examining Parents’ Preferences for Group Parent Training for ADHD When Individual Parent Training is Unavailable

Parent training programs are considered well-established interventions for attention deficit hyperactivity disorder in children as they reduce behavioral impairment, but limited parent engagement decreases service effectiveness. We used a discrete choice experiment to examine how parent preferences for group vs. individual format might influence their participation in Parent training. Parents (N?=?260) seeking mental health services for children with elevated symptoms of attention deficit hyperactivity disorder in Ontario, Canada were participants. They preferred Individual parent training in another study and completed a discrete choice experiment composed of 30 choice tasks measuring Parent training format preference. In this paper, parents’ preferences for alternatives to Individual Parent training, specifically Group Parent training and Minimal Information options, were estimated. Specifically, this study asked “if first choice is unavailable, what is the second choice?” This question is important as many clinics may not be able to offer both group and individual therapy given state funding cuts for youth mental health services. Simulations predicted that 85.8?% of parents who initially preferred Individual Parent training would switch to Group Parent training that included step-by-step solutions to children’s emotional and behavior problems, and the possibility of feeling informed and confident. The remaining 14.2?% of parents preferred Minimal Information; these parents preferred internet services offered conveniently and timely. Findings highlight consideration of less appealing factors that families might trade for more desirable service elements in a cost-restrictive environment.     

Federal Funds to Train Clinical Psychologists for Work with Underserved Populations: The Bureau of Health Professions Graduate Psychology Education Grants Program

This paper describes the Bureau of Health Professions (BHPr) Graduate Psychology Education program (GPE), which supports projects that train health service psychologists for work with underserved populations. BHPr history and funding criteria are discussed, as are those of BHPr's parent organization, the Health Resources Service Administration. BHPr objectives and methods for support of clinical psychology training parallel those that BHPr has used to support training in other heath professions. The paper also describes three psychology internship training programs in academic medical settings that competed successfully for BHPr GPE funding in 2002. The three training projects differ significantly in training rotation sites, target populations with which trainees work, and the other health care professions that partner with psychology in interdisciplinary training—but they are similar in that each project provides an example of a program that effectively satisfied BHPr criteria for expanding psychology's scope of practice with underserved populations.     

The Welch Emotional Connection Screen: Adapting observational methods to pediatric primary care via resident training

The Welch Emotional Connection Screen (WECS) is a novel instrument that is a brief, practicable, evidenced-based observational screening tool for assessing relationship health between parent and child. The WECS requires observing 2−3 min of face-to-face interactions between parent and child, without toys, prompts, paradigms or technology. Here, we describe a translational project from the coding lab to the primary care provider via a residency training program conducted with 50 residents during a 30-day developmental and behavioral pediatrics medical resident education rotation. The aims of this study were to evaluate the efficacy of WECS pediatric resident training: 1) to improve residents' accuracy in recognizing the dyadic behaviors of emotional connection (EC) via WECS training; and 2) to improve residents' attitudes, self-efficacy, and perceived professional norms (ASPPN) pertaining to Early Relational Health in Pediatrics. Results indicate that using a rapid prototyping approach to training, residents improved in their identification of dyads showing low to midrange levels of emotional connection. As well, resident attitudes about the importance of relationship health in pediatrics and their self-efficacy in identifying emotional connection improved significantly after this brief resident training.