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Supervision in Primary Care

Posted By Suzanne Bailey, Thursday, February 26, 2015

This is the first in a two-part series on supervision in integrated care. Check back in two weeks for the second part.

As the demand for behavioral health providers skilled in the provision of brief, targeted, and population-based assessment and intervention within primary care continues to grow, so does the need for a model of supervision that promotes the acquisition of clinical skills and professional development in this area.   At Cherokee Health Systems, a comprehensive community care organization, we have a longstanding commitment to train psychologists and other healthcare providers for work in integrated primary care and have experience in a model of supervision to support this commitment.  


I vividly remember my first day working in primary care as a BHC in training, now almost a decade ago.  I saw nine patients that day, four of which were warm-handoffs, and all of whom had significant behavioral health and medical comorbidities.  Having no experience with integrated care and limited exposure to co-located models I was immediately impressed with both the pace and pathology of primary care.  I felt excited and overwhelmed as I began to hike a very steep learning curve.

Anticipating the steep learning curve trainees new to primary care commonly experience, we utilize a developmental approach to supervision.  Initially, trainees exhibit both high motivation and high anxiety and supervision must respond to the anxiety and dependence of trainees with support and prescriptive instruction.  Early in training, strategic emphasis is placed on providing repeated opportunities for observation and practice in an effort to build a foundational understanding of the structure and operational aspects of primary care.  Shadowing PCPs and BHCs allows trainees to develop a schema for work in primary care.    Heavy emphasis on structured readings and didactic teaching assists trainees in developing primary care content knowledge (e.g., basic labs, common health conditions and comorbidities, behavioral medicine, etc.). 


Mid-level trainees exhibit variable levels of confidence and rapidly growing competence.  During this developmental period, trainees have established a foundation of clinical skills, an understanding of primary and population-based care, and are beginning to develop practice management abilities.  We often tell our trainees, “You learn to do it, then you learn to do it well, and then you learn to do it quickly.”  Mid-level trainees have “learned to do it well” and supervision works to refine their clinical and practice management skills such that they are able to match the pace of work flow in primary care.  Advanced trainees exhibit increased autonomy, clinical skillset and practice management abilities, and exhibit the ability to think critically and “on their feet.”  Supervision of advanced trainees encourages this autonomy and becomes increasingly collaborative and less directive, with increased emphasis on professional development.




Supervision doesn’t just happen in the sacred supervision hour

The structure and content of supervision in primary care mirrors the pace and structure of the primary care setting.  With regard to the structure of primary care supervision a current intern explained, “Supervision doesn’t just happen in the sacred supervision hour.”   Supervision in primary care is flexible, dynamic, and capitalizes on teachable moments.  Real-time, on-the-fly consultations are a routine component of primary care and resemble precepting models of medical training.  Examples of on-the-fly supervisory consultations include questions regarding diagnostic clarification, treatment planning, care coordination, appropriate triage, and practice management.  The supervisor’s role is to listen to the trainee’s brief case presentation (30-60 seconds), ask clarifying questions, and offer prescriptive guidance.


The content of supervision in primary care is not strictly about the treatment of patients.  Working in primary care adds layers of complexity to interprofessional practice, ethics, and practice management.  Thus, supervision must balance strategic emphasis on patient care with more abstract issues related to professional development.    “The sacred supervision hour” is didactic, directive, targeted, solution-focused, and fast paced.   It is common for twenty to thirty patients to be discussed during a one hour supervision meeting.  With each patient, the supervisor targets diagnostic clarification, the development of a unified primary care treatment plan, a defined target for treatment, the selection of best-practice interventions, and coordination of care with the primary care team.  A current intern described, “A large portion of my supervision in primary care has been on how to translate my conceptualization, language, and training as a psychologist in training to serve the primary care team.” 


Supervision in primary care requires supervisors to simultaneously play the roles of teacher, consultant, and counselor.  It is complex, difficult, and immensely rewarding work.  After all, the best way to promote integrated models of healthcare delivery is to train talented trainees who may spend their careers implementing the model and doing great work.  



Suzanne Bailey, Psy.D. is a Licensed Clinical Psychologist and Behavioral Health Consultant at Cherokee Health Systems.  She earned her doctorate in Clinical Psychology at Xavier University in Cincinnati, Ohio.  As the lead Behavioral Health Consultant, Dr. Bailey practices in an integrated primary care clinic in Knoxville, TN.  Dr. Bailey is a member of the training faculty of both Cherokee’s APA Accredited Predoctoral Psychology Internship Program and APPIC member Health Psychology Post-Doctoral Fellowship.


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