APA's Education Council Issues Report on Need for Integrated Care Training

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Back to table of contents Previous article Next article Education and TrainingFull AccessAPA's Education Council Issues Report on Need for Integrated Care TrainingMark MoranMark MoranSearch for more papers by this authorPublished Online:3 Mar 2015https://doi.org/10.1176/appi.pn.2015.3a29AbstractEducational programs in psychiatry need to further develop their ability to train students, residents, and psychiatrists to practice in integrated care models.Integrated, or collaborative, care is the future of health care delivery, and physicians and physicians-to-be at all levels of training and professional life need to be trained in emerging models of collaboration with primary care and other specialties. Richard Summers, M.D., says the report of APA’s Council on Education and Lifelong Learning is designed to help drive interest and innovation in education around integrated care.Richard Summers, M.D.That’s the conclusion of a comprehensive report by APA’s Council on Medical Education and Lifelong Learning that was published online in Academic Psychiatry this month, with specific recommendations for undergraduate, graduate, and continuing medical education (see box). The report, “Training Psychiatrists for Integrated Behavioral Healthcare,” also offers perspectives on future directions for interprofessional and interspecialty training. The report, which was presented at the December 2014 meeting of the APA Board of Trustees, had its genesis two years ago in discussions among council members when Richard Summers, M.D., became chair of the council. “We identified the emerging integrated care models as really important in terms of overall system change and therefore important to the world of education, because practitioners were going to need to develop a new set of skills, new ways of collaborating, new knowledge, and new cultural values to be able to practice in these new models,” Summers told Psychiatric News. Council Offers Recommendations for Teaching IntegrationIn a report presented to APA’s Board of Trustees last December, the Council on Medical Education and Lifelong Learning outlined specific recommendations for undergraduate, graduate, and continuing medical education on integrated care. Highlights appear below; the entire list appears in the council’s report.Undergraduate Medical EducationPromote a view of medical care, including integrated behavioral health care, as a collaborative, interspecialty, and interdisciplinary enterprise through the creation of didactic content and early preclinical exposure to role models and care systems.Engage medical students in a range of activities designed to improve interprofessional and interdisciplinary communication, beginning in the preclinical years, to promote the development of interpersonal and teamwork skills. This should include didactics that emphasize cross-system understanding of pathology, interdisciplinary collaboration, and collaborative service delivery.Develop integrated care clinical experiences as part of the psychiatry clerkship, when possible, utilizing effective teaching sites where residents, fellows, and attending psychiatrists experienced in integrated care are working. Support innovation in rotation design, especially in settings offering integrated behavioral health, and study the educational outcomes of these experiences. Programs should consider the potential for longitudinal educational experiences, which by their nature involve interdisciplinary and interspecialty collaborative experiences.Include the psychiatrist’s role in integrated behavioral health care in discussions about physician career choice in recruitment activities.Graduate Medical EducationDevelop a comprehensive, four-year, developmental sequence of educational experiences to prepare residents to provide psychiatric care in integrated settings.Create a didactic experience in integrated care, probably in PGY-3 or PGY-4. A minimal educational experience for a residency would probably be a didactic experience in the later years of the residency. Engage residents in a range of activities designed to improve interprofessional and interdisciplinary communication, including didactics that emphasize cross-system understanding of pathology, shared clinical case conferences and grand rounds, and collaborative service delivery.Provide clinical experience in recognition and management of common medical conditions, metabolic side effects of psychopharmacologic treatments, causes of early mortality in patients with psychiatric illness, motivational interviewing, lifestyle interventions such as smoking cessation, and techniques for psychiatrists to ensure adequate primary medical care for their patients.Plan clinical experiences for residents and fellows that arise organically out of existing integrated care settings, rather than attempting to graft rotations for trainees onto clinical services that are functioning without behavioral health input. Co-location, improved primary care, and telemedicine settings may be more available in some institutions currently, while collaborative practice models are less prevalent but expanding. Continuing Medical EducationDevelop tools that help practitioners assess whether they have the knowledge to be successful in the new health care environment. Focus on the components of integrated care that are knowledge- and skills-based, such as supporting evidence base, screening tools, and registry technology. Develop materials across the range of integrated behavioral health care including providing consultation in the primary care setting and addressing the health status of the seriously mentally ill population.The report emphasizes that the nature of integrated care models is evolving and that integrated care will likely take different forms in different parts of the country and different systems of care and practice settings—public, private, small-group, and large organized systems of care. The report also stresses that models for reimbursement of collaborative care—which will be especially fateful for the success or failure of integrated care and for psychiatric participation—have not been realized on a systemwide scale.“We anticipate building excitement and enthusiasm around these new models and developing psychiatrists who are both competent and confident in the provision of these new models of care,” the council report states. “We recognize that our conclusions and specific recommendations reflect the view from 2014 and know that we will learn much from greater experience with integrated care models and educating students and practitioners for these roles. These recommendations will surely need to be updated with that additional experience.”Summers told Psychiatric News that the evolving and still-to-be-determined nature of collaborative care presents what he called a “chicken and egg” problem for educators. “The reimbursement reform that will support these models hasn’t happened yet nationally, though everyone expects it to happen,” he said. “So should we train people for working in a model that isn’t quite reimbursable yet” or wait for the models to evolve more fully?“We decided our goal should be to drive interest and innovation in education around integrated care,” Summers said. “We want to get people excited and provide some specific recommendations and examples of best practices for educators so they can begin to implement some models for integrated care training in their own settings.”The 36-page report addresses undergraduate, graduate, and continuing medical education as well as training for interprofessional and interspecialty collaboration; for each category, the council provides data on the extent of current training and examples of best practices. “Interspecialty and interprofessional collaboration will need to be a priority across the continuum of medical education,” the report states. “The integrated care model rests on collaboration among health care professionals, cross-fertilization of medical knowledge across specialties, shared technology platforms, and new approaches to collecting empirical data. Education about collaboration and collaboration in education will surely improve these essential components of care.”Within undergraduate medical education, a survey of members of the Association of Directors of Medical Student Education in Psychiatry showed that clinical rotations that give medical students exposure to integrated care are relatively rare; where they do exist, the rotations tend to be in Veterans Administration (VA) settings, federally qualified health centers, and other primary care clinics and to involve traditional psychiatric consultation with primary care providers. “Exposure to integrated care for medical students is just the beginning,” the report concludes. “There are many exciting opportunities for modeling interspecialty collaboration, developing team participation skills, and incorporating a population-based framework for understanding illness and care. As the health care system changes to reflect these new values, and clinical services are increasingly organized along these lines, the clinical educational opportunities for medical students will surely improve.”In May and June 2014, the American Association of Directors of Psychiatric Residency Training (AADPRT) Integrated Care Task Force conducted a survey on integrated care education. Learn More About Practicing in Integrated CareAPA offers the following courses to help psychiatrists learn more about integrated care and common conditions that psychiatrists may encounter in integrated care settings. The courses can be accessed in the course catalog at APA’s education portal, http://www.apaeducation.org. Both courses are free to APA members.The Integration of Primary Care and Behavioral HealthThis course focuses on the models of care, the evidence for these models, and funding issues around the integration of primary and behavioral health. It also discusses the value that is added to a health care system when psychiatric and behavioral health resources are included. As the health care system evolves, there will be greater accountability for outcomes, cost containment, and patient satisfaction (the “triple aim” of integrated care). Health care systems will seek psychiatric expertise to design systems of care to meet these goals. Psychiatrists need to be prepared for these changes to assist in well-informed and meaningful ways. Participants can earn up to 1.50 AMA PRA Category 1 credits. Primary Care Updates for Psychiatrists This course presents updates on the current treatments for health conditions commonly found in in populations with serious mental illness in public mental health settings. Case examples and an overview of preventive measures to reduce the risk of cardiovascular disease are presented. Hypertension, diabetes, obesity, smoking cessation, and dyslipidemia are reviewed along with the latest treatment recommendations and treatment algorithms. Cases are presented to demonstrate treatment options. The course is led by Lori Raney, M.D., chair of APA’s Council for Healthcare Systems and Financing Workgroup on Integrated Care, with presentations by dual-boarded med-psych physicians in the field. Handouts providing a case for discussion are available for download. Participants can earn up to 4 AMA PRA Category 1 credits.There were 88 respondents: 52 general psychiatry program directors and 36 child and adolescent program directors. Seventy-eight percent of general psychiatry program directors and 72 percent of child and adolescent psychiatry (CAP) program directors stated that they offered one or more integrated care rotations. Of these, 65 percent of general psychiatry rotations and 40 percent of CAP rotations were elective.The most common type of integrated care rotation was psychiatric consultation within a primary care clinic, while the least common was provision of both primary care and psychiatric care by psychiatry residents. In general psychiatry residency programs, rotations were most commonly offered in VA settings, followed by other primary care clinics, while the most common sites for CAP rotations were federally qualified health centers. Forty-three percent of programs also offered didactics about integrated care. Claudia Reardon, M.D., notes that some ACGME milestones call for trainees to demonstrate ability to collaborate with other specialties in integrated care.Claudia Reardon, M.D, who co-wrote the section on residency education, emphasized in an interview with Psychiatric News that the new Accreditation Council for Graduate Medical Education “milestones” for psychiatry, which went into effect last July, provide benchmarks that residents are expected to meet by the time they graduate and include those that are uniquely suited for accomplishment in integrated care settings. For example, under the domain of “systems-based practice,” the milestones state that “residents should be able to provide integrated care for psychiatric patients through collaboration with other physicians.” (For more comprehensive coverage of the Milestone Project, see Psychiatric News, August 28, 2013.)“Integrated care is coming close to being a requirement” for residency programs, Reardon said, noting that resident performance against the milestones will be critical in the evaluation and reaccreditation of programs: “Programs are seeing the imperative to offer these kinds of experiences. Many of these rotations at this point are elective and are offered to senior residents who have honed the skills required to practice in integrated care.”Reardon is associate residency training director in general psychiatry at the University of Wisconsin and chair of the AADPRT Integrated Care Task Force.“Beyond that, it is becoming increasingly clear that the typical model of psychiatric care—an individual psychiatrist providing frequent, lengthy, one-on-one sessions—will certainly continue to be an important part of the package of psychiatric care but isn’t going to be the whole story,” she said. “Integrated care is a highly efficient way we can work with primary care colleagues to manage populations of patients.” ■The full text of the council’s report, including recommendations for undergraduate, graduate, and continuing medical education, can be accessed here. An audio interview with Richard Summers, M.D., about the report is available here. ISSUES NewArchived