Roles of Perceived Provider Cultural Sensitivity and Health Care Justice in African American/Black Patients’ Satisfaction with Provider

The present study tests a refined first component of the Patient-Centered Culturally Sensitive Health Care (PC-CSHC) Model—the evidence supported component that links perceived provider cultural sensitivity to patient satisfaction with provider care and identifies trust of provider as the mediator of this linkage. The refined first component of the PC-CSHC Model tested in the present study is novel in that it includes the three dimensions of provider cultural sensitivity and includes perceived provider impartiality (fairness), a core aspect of perceived health care justice, as a mediator in addition to trust of provider (the other core aspect of perceived health care justice). Study participants were 298 African American/Black primary care clinic patients with low household incomes. Mediation analyses revealed that the three dimensions of patients’ perceived provider cultural sensitivity were significant predictors of the participating patients’ reported satisfaction with their provider, and that some of these predictive relationships were partially mediated by (1) patients’ perceived provider impartiality (fairness), and (2) patients’ trust of their provider. Implications of these findings for providers’ interactions with patients, development of the PC-CSHC Model, and the roles of psychologists in facilitating patient-provider interactions are discussed.     

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.     

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.     

Recent trends in cultural theories

Multiculturalism is probably the most important and most misunderstood psychological construct of this decade. This article identifies specific and uniquely valuable contributions of a multicultural perspective and demonstrates the importance of multicultural awareness training as a primary prevention strategy, directed toward preventing multicultural misunderstandings before they happen by training mental health providers to become more aware of their culturally learned assumptions and the contrasting cultural contexts of their clients. The development of recent multicultural theories will be reviewed to demonstrate how the definition of cultural theories have changed over time toward a broader and more complicated perspective. Finally practical applications of culture-centered theories will be reviewed through the presentation of a Cultural Grid for separating behaviors from expectations in each cultural context.     

Interprofessional Education: Preparing Psychologists for Success in Integrated Primary Care

Rapidly occurring changes in the healthcare arena mean time is of the essence for psychology to formalize a strategic plan for training in primary care settings. The current article articulates factors affecting models of integrated care in Academic Health Centers (AHCs) and describes ways to identify and utilize resources at AHCs to develop interprofessional educational and clinical integrated care opportunities. The paper asserts that interprofessional educational experiences between psychology and other healthcare providers are vital to insure professionals value one another’s disciplines in health care reform endeavors, most notably the patient-centered initiatives. The paper highlights ways to create shared values and common goals between primary care providers and psychologists, which are needed for trainee internalization of integrated care precepts. A developmental perspective to training from pre-doctoral, internship and postdoctoral levels for psychologists in integrated care is described. Lastly, a call to action is given for the field to develop more opportunities for psychology trainees to receive education and training within practica, internships and postdoctoral fellowships in primary care settings to address the reality that most patients seek their mental health treatment in primary care settings.     

Ethical Care for Vulnerable Populations Receiving Psychotropic Treatment

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primary care providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations (e.g., older adults, people currently low in social status, immigrants, and racial/ethnic minorities) face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacological care and are differentially vulnerable to deleterious outcomes associated with misdiagnosis and overmedication. Taken together, these factors fuel inequities in the access, quality, and utilization of mental health care. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitable care across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy.     

Patient and health care provider views of depressive symptoms and diabetes in American Samoa

High Type 2 diabetes prevalence, associated with recent cultural changes in diet and physical activity, characterizes the U.S. territory of American Samoa. Comorbid diabetes and depression rates are high worldwide and contribute to negative diabetes outcomes; these rates have not been assessed in American Samoa. In this study, 6 focus groups were conducted with 39 American Samoan adults with diabetes; questions on perceptions of diabetes and depressive symptoms were included. Thirteen health care staff interviews were conducted to gain insight into diabetes care in American Samoa. Focus groups and health care staff interviews were translated, transcribed, and entered into NVivo 8 to facilitate analysis. Thematic analysis showed that diabetes patients saw depressive symptoms as directly contributing to high blood sugar. However, these symptoms were rarely mentioned spontaneously, and providers reported they seldom assess them in patients. Many patients and health care staff believed the best ways to respond to feelings of depression involved relaxing, leaving difficult situations, or eating. Staff also discussed cultural stigma associated with depression and the importance of establishing rapport before discussing it. Health care providers in American Samoa need training to increase their awareness of depressive symptoms' negative impact on diabetes management in patients who screen positive for depression. All providers must approach the subject in a supportive context after establishing rapport. This information will be used for cultural translation of a community health worker and primary care-coordinated intervention for adults with diabetes in American Samoa, with the goal of creating an effective and sustainable intervention.     

Collaborative Communication Between Psychologists and Primary Care Providers

Psychologists frequently collaborate in the care of patients managed in primary care. Communication with a patient’s primary care team is important to ensure coordination and continuity of care. The communication is far from seamless. Although The Health Information Privacy and Portability Act (HIPPA) is designed to promote sharing of clinical information while protecting patient confidentiality, unique problems arise when mental health records are included. Mental health records are subject to different regulations to protect the patient’s confidentiality. Thus, what is communicated and how it will be accomplished are challenges. Further, psychologists and primary care providers often view documentation differently, resulting in different styles of documenting that may also impede coordinated care. Increasingly, health care systems are moving toward electronic medical records, creating greater opportunities for an integrated record. Improved communication through the record can keep other providers abreast of the mental health care being provided as well as suggestions they can use to reinforce the mental health care treatment plan.     

Primary Care Prescribing Psychologists in the Indian Health Service

Some of the largest health care disparities are those related to services for American Indians and Alaska Natives (AI/ANs), who show significantly greater prevalence for diabetes, coronary heart disease, smoking, obesity, heavy alcohol use, depression, and PTSD than the general population. Given the recognition of the behavioral components of all of these conditions, the Indian Health Service, the federal agency responsible for providing comprehensive health care services to AI/ANs, has been focusing on increasing the integration of behavior health and primary care. One innovation has been to hire prescribing psychologists on primary care teams. This paper describes the role of a prescribing psychologist on three treatment teams at an IHS facility in Montana. Prescribing psychologists in the Indian Health Service can serve as valuable members of comprehensive care teams, providing exceptional wrap-around care for some of our most vulnerable and underserved citizens. This model could be an example of how a prescribing psychologist could contribute to primary care clinics in a variety of other settings.     

Prescribing Psychologists in Integrated Primary Care: Introduction to the Special Section

The authority to prescribe could differentiate psychologists from other non-physicians in primary care, achieving a significant step for the growth of our profession. Psychologists are currently prescribing in primary care settings in a number of public service venues, as well as medical school training facilities. In this Special Section of the Journal of Clinical Psychology in Medical Settings, results of a survey of physicians working with a prescribing psychologist indicate that the psychologist is highly valued and seen as a competent prescriber. A series of papers providing case examples demonstrate how psychologists are evolving in these new clinical roles, as well as participating in behavioral and psychopharmacology training of primary care physicians.     

Leadership Perspectives on Integrating Psychologists into Specialty Care Clinics: An Evolving Paradigm

Integration of health psychologists into specialty care is a shift in the tertiary care construct that addresses all aspects of a patient’s presentation, including psychiatric/social history, psychological well-being, and behavioral contributions to the disease process, assuring both optimal health outcomes and cost-effectiveness in a financially challenging healthcare environment. In this paper, we discuss leadership perspectives (physician and psychologists) on the factors involved in integrating a health psychologist into a busy tertiary care environment. Ultimately, we hope that this information provides a primer on how to frame a proposal for an integrated health psychologist emphasizing the elements important to senior medical leadership and administration. First, we briefly discuss the current payer framework, providing support for integration emphasizing costs and other metrics. Second, we introduce organizational structure models and strategies for integration. Lastly, we will discuss the unique skillset psychologists possess, and additional skills necessary, to be effective in the changing landscape of healthcare. We think this information is important both for leaders attempting to integrate a health psychologist into specialty care and for the early career health psychologist embarking on his/her first senior staff position.     

Training Pediatric Psychologists for Perinatal Behavioral Health Services in a Pediatric Hospital

Although pediatric hospitals specialize in providing care to children and adolescents, at The Children’s Hospital of Philadelphia (CHOP), our team has been providing behavioral health services for two unique parent populations—parents with a child in the Newborn Infant Intensive Care Unit and pregnant women carrying fetuses with specific birth defects and receiving prenatal care in the Center for Fetal Diagnosis and Treatment. A new training program was developed to expand the scope of pediatric psychologists’ practice to include perinatal behavioral health services, specifically for these two unique parent populations served at CHOP. The program includes direct service provision for adult mental health concerns, as well as education and support to help families cope with the existing medical conditions. This article describes the training program and its implementation as a model of training for other pediatric hospitals. The roles of psychologists embedded in these units and hospital privileges are discussed.     

Trauma-Informed Medical Care: Patient Response to a Primary Care Provider Communication Training

Trauma exposure predicts mental disorders and health outcomes; yet there is little training of primary care providers about trauma’s effects, and how to better interact with trauma survivors. This study adapted a theory-based approach to working with trauma survivors, Risking Connection, into a 6-hour CME course, Trauma-Informed Medical Care (TI-Med), to evaluate its feasibility and preliminary efficacy. We randomized four primary care sites to training or wait-list conditions; PCPs at wait-list sites were trained after reassessment. Primary care providers (PCPs) were Family Medicine residents (n = 17; 2 sites) or community physicians (n = 13; 2 sites). Outcomes reported here comprised a survey of 400 actual patients seen by the PCPs in the study. Patients, mostly minority, completed surveys before or after their provider received training. Patients rated PCPs significantly higher after training on a scale encompassing partnership issues. Breakdowns showed lower partnership scores for those with trauma or posttraumatic stress symptoms. Future studies will need to include more specific trauma-related outcomes. Nevertheless, this training is a promising initial approach to teaching trauma-informed communication skills to PCPs.     

Factors affecting behavioral health provider turnover in US Air Force primary care behavioral health services

Turnover and retention of integrated behavioral health practitioners in primary care is a significant challenge with limited empirical evidence to inform risk factors. This study used retrospective archival data from the Air Force Medical Service’s Behavioral Health Optimization Program on all civilian contractors hired from September 2012 to November 2014 to examine the potential influence of training background (e.g., social work v. psychology), size of healthcare facility, or the presence of on-site mentors. Turnover was evaluated across a large managed healthcare organization of 121 civilian contractors (psychologists and social workers) in 72 specific clinic settings. These sites varied considerably in regards to geographic location, population diversity, size of patient empanelment, rural, suburban, and urban settings and all provided care to active duty military, their civilian dependents and civilian retirees. Results found that 54% of all psychologists and social workers hired for these positions quit or were fired within 8 months of employment. Smaller medical facilities were found to have a more significant attrition rate compared to medium- and large-sized facilities; no other differences were noted. Findings provide initial insight into a potential critical period in the first year of a behavioral health consultants on-boarding, as well as unique considerations for consultants placed in smaller facilities who may be at elevated risk for attrition. These preliminary findings suggest targeted interventions for new integrated care programs as well as important avenues for future research.     

Interkulturelle Trainings für die psychosoziale Versorgung

The psychosocial care of patients with a migration background is often related to higher access barriers. Also for professionals in mental health care service the treatment of patients with a migration background often represents a challenge. One way to overcome such barriers is to train care givers in order to enhance cross-cultural competence. In addition to knowledge transfer such training focuses on the process of self-reflection and examination of ones own, as well as the unknown cultural orientation system. Sufficient effectiveness of cross-cultural training has been proven on an international level. However, evaluation studies are lacking in the German speaking region. Additionally, guidelines or quality criteria for providers of training for psychosocial care professionals are lacking. Validated psychometric instruments which assess cross-cultural competence in individuals hardly exist. The present article gives an overview of concepts of cross-cultural competence and the effectiveness of such training. Also an outlook is given on the future prospects of development in the field.     

General practitioners' perceptions of psychologists: A response to the Medicare changes in Australia

General practitioners (GPs) have historically been at the centre of primary health‐care delivery in Australia, including delivery of mental health‐care services. Recent changes, however, by the Australian Federal government have led to the creation of a number of mental health‐care items provided by psychologists that are now available on the Medicare Benefits Schedule. The aim of the present study was to examine GPs' perceptions of psychologists and the ways in which GPs have responded to these policy changes in making referrals for mental health patients. Nine GPs were interviewed regarding the provision of mental health‐care services. Analysis of the interviews indicated a number of themes including the benefits of the new Medicare policy in increasing accessibility of psychologists, GPs' frustrations with the bureaucracy surrounding the use of this policy, GPs' knowledge about the specific skills and training of psychologists, and the importance of GPs' matching patients and clinicians. Recommendations are made to facilitate the professional and clinical relationship between GPs and psychologists.     

Integration: Opportunities and Challenges for Family Therapists in Primary Care

Integration of behavioral and physical health is becoming critical for the overburdened primary care system. Policy changes are needed to accommodate integration nationally. Locally, medical and behavioral health providers are working together to create models that better fit their patients?? comprehensive needs while respecting the clinical, operational, and financial constraints of the current system. Family therapists trained to work in medical settings have an opportunity to emerge as clinical, research, and administrative leaders in this context. However, a paradigm shift is crucial to adapting their systemic orientation to interactions between individual patients, providers, staff, and healthcare and support systems. This article provides family therapists with: (1) an overview of the basic structure and barriers of integration, (2) suggestions on how to deliver quality care despite barriers at the local level, and (3) examples of key advocacy efforts representing possible entryways on a larger scale.