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Integrated Care in Rural Communities: A Psychologist’s Perspective

Posted By James L. Werth, Thursday, January 24, 2013
Rural blog series logo
James's blog is the
fourth post in a
month-long series
on integrated
care in rural settings.


Read the entire
series here.

As the Director of a doctoral program in Counseling Psychology since 2007, I have attempted to keep up with the literature, anecdotal reports, and personal opinions regarding the future of psychology as a profession so that I could help our students be ready when they graduate. I started hearing about "integrated care” almost immediately upon assuming my position but it was not until I served on the American Psychological Association's Committee on Rural Health that I fully appreciated the importance of integrated care for the field, especially for practitioners who would be working in rural areas. My colleagues helped me understand the value of integrated care for the patient, family, medical providers, and psychologists and other behavioral health professionals. As a result, I became convinced that we had to try to provide training opportunities in integrated care settings for our students.

   Fortunately, such an opportunity arose when the Executive Director of two of the local free medical clinics contacted me and asked if we had any students who would want to work alongside their providers who struggled with some of the psychological issues presented by patients. At about the same time I was contacted by the Development Director of a federally qualified health center who wanted to apply for a Rural Workforce Development Grant and hoped to use the grant to expand their provision of behavioral health services.  
These two collaborative efforts have led to a popular advanced practicum placement site at the free clinic and an internship site at the FQHC. Even more, these sites are helping to provide training and experience that our students will be able to take with them as they move into their first jobs while also filling some significant needs in these Health Professional Shortage Areas.


For those of us in rural
areas, the challenge may
be
especially important to
meet because of the
difficulty recruiting and
retaining professionals
in these communities.

Based on the facts that one of the American Psychological Association's three strategic goals is to expand psychology's role in healthcare, that the Affordable Care Act promotes interprofessional care, and that insurance payments for psychological services are falling in many locations, I am convinced that psychology graduate students must receive the training necessary to work in integrated care settings. I am fully aware of the challenges associated with setting up these types of training sites but I believe faculty will need to be proactive in finding or creating sites in order to ensure their graduates will be employable. This may mean that faculty members will have to go into the community and provide supervision for students at sites that do not have psychologists or other mental health professionals on site. We need to expand the types of sites that we have considered for practicum and internship to include physician offices, emergency rooms, and university health centers.

For those of us in rural areas, the challenge may be especially important to meet because of the difficulty recruiting and retaining professionals in these communities. Even with the National Health Service Corps loan repayment program available for psychologists and other providers, many outlying areas do not have access to sufficient numbers of mental health professionals. However, if we can get trainees into these areas and provide them with learning opportunities, especially on internship, we have a greater chance that they will stay. Setting up a private practice in a rural area may not be feasible but continuing to work at a FQHC or in a community mental health center that has begun to recruit medical personnel or at a VA's community-based outpatient clinic could provide employment options.

On a related note, I have noticed that in our FQHC training sites, where both psychology and social work interns have begun providing primary care-based services, we have uncovered other needs in the community. The most obvious ones are referrals for traditional mental health services and psychological assessment. Our behavioral health providers in these rural clinics have ended up having to move away from the typical brief behavioral approach to more of a blended model where they also provide longer-term sessions on a weekly basis because there are no referral options, or at least no options without a several month waitlist. The need for assessment, especially neuropsychological assessment, is even greater. Without university-based training clinics that operate on sliding scales and sometimes waive fees entirely, many people would not be able to get the testing needed for appropriate care. Thus, appropriately trained behavioral health professionals could collaborate with clinics to provide these additional services.

One final area that has been increasingly on my mind as I have thought about training psychology graduate students for the future and about the needs of rural communities is the contentious matter of prescription privileges for psychologists. The military and Public Health Service as well as the states of New Mexico and Louisiana allow properly trained psychologists to prescribe (or unprescribe) psychotropic medications. This is a hotly contested issue and until I started practicing in a rural area where there are virtually no psychiatrists or psychiatric nurse practitioners, I did not think I would ever be interested in this if it were to become a reality in my state.

However, I have changed my mind and now think that if I and my psychologist-colleagues had the appropriate training and our state law allowed it, we could provide significant help to patients as well as the medical providers who are reluctant to prescribe these medications. In fact, I think that hospitals, FQHCs, free clinics, and other primary care practices would be perfect places for pilot programs because of the collaborative relationships with medical personnel. Thus, I hope that psychology trainees will receive significant training in psychopharmacology and that psychologists and medical providers in rural areas can work together for policy change in order to expand the numbers of trained personnel who can meet the psychiatric needs of underserved individuals.

In conclusion, I hope that we will see more graduate programs in behavioral health preparing their students for practice in integrated care settings. Within some programs, such as psychology, this would also include ensuring sufficient training in psychopharmacology. If this happens, then perhaps at least some of the significant needs of people living in rural areas would be met through collaborative efforts between training programs and health care facilities.

 

James L. Werth, Jr., Ph.D., ABPP is currently Director of the Psy.D. Program in Counseling Psychology at Radford University (located in Southwest Virginia). For the past several years he has been collaborating with Stone Mountain Health Services, an FQHC in the Westernmost counties of Virginia and is leaving Radford this fall to become Stone Mountain's Psychology Director. He may be reached at jwerth@radford.edu

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