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Integrated Care, Residency, and PCMH: A Basic How To Start

Posted By Lisa Zak-Hunter, Wednesday, December 12, 2012
Updated: Tuesday, December 11, 2012
New Faculty Forum

Lisa ZakHunter's blog is the second post in a month-long series from recent graduates in their first semester of a faculty or junior faculty position.

Please check back
each week.


Since the end of June, I have been serving as behavioral science faculty within the second largest family medicine residency in the country. It is three times the size of the residency where I completed my doctoral internship-yikes! The program has been taking steps toward becoming a Patient Centered Medical Home (PCMH). What an opportune time to introduce integrated healthcare! But, how??

My original intent was to try to answer that question in this post. After some investigating, I have few answers, but more and more avenues of investigation. Simultaneously, I’ve had personal and professional experiences with colleagues that have reminded me of the struggles mental health professionals face entering the fast-paced, hierarchical world of medicine. Therefore, what I offer are starting points for new professionals to become better integrated within medical training programs as they drive toward the PCMH.

stages of change

Even though you might already be burgeoning with ideas and energy better suited for a preparation or action stage, the program may be precontemplative or contemplative.

 When You Start

  • Create your own job description: Include roles and responsibilities that are specific to your personal strengths, talents, and interests. Note what types of psychotherapy you provide, your clinical and research interests and specializations, populations you like to work with, specific ways you plan to attend to resident education, languages you speak, other skills etc. Get used to repeatedly being asked what you do, what types of concerns or diagnoses you’ll see, and different ways you can help the residents (personally and professionally). Spending time to write this down will help you answer these directly and succinctly. You can also turn this into a brief ‘advertisement’ to put at the nurses stations, resident lounge, and precepting room, complete with your business cards or contact information.
  • Get visible within the residency AND the clinic: Join committees; attend any and all faculty AND staff meetings (even if you feel out of place at both!); get to know the nursing, front desk, and management staff; hold brief one-on-one meetings with residents and faculty; volunteer to help on projects such as resident observations or meeting with residents who are struggling; be involved with interviewees; present at noon conference; host a ‘get to know the behaviorist’ luncheon; precept (even if you don’t really know how!). Sit near the preceptor so you can listen to the cases for opportunities to offer the classic "how do you think this patient’s depression is affecting his diabetes management?” or "have you screened that patient for past abuse?”. Then you can offer suggestions to the treatment plan or to meet with the patient/s during the visit. Practice being brief, to the point, and straightforward.
  • Don’t move too fast and be persistent! Take time to understand the culture of the program, how faculty and residents interact with each other and the clinical staff, and how patients are perceived. Ask, what is the residency known for? What are its strengths and what draws students to it? Within that, what has been the role of behavioral medicine? What was their vision in hiring you? How do you work within and enhance the culture while simultaneously respecting it? This will help you determine how and who to approach with your ideas. Remember than medical systems move slowly and are much more complicated than you are aware. Think in terms of 1, 3, and 5 year plans, and, metaphorically speaking, prepare to swim through molasses for a while.

Introducing Integrated Healthcare within PCMH

  • Familiarize yourself with Patient Centered Medical Home Standards: In 2011, NCQA outlined new standards for PCMH. There are also principles for medical education in the PCMH. These will help you understand both the clinical and educational aspects of PCMH that a residency will be trying to accommodate.
  • Meet the program where it’s at: Think Prochaska’s stages of change. Even though you might already be burgeoning with ideas and energy better suited for a preparation or action stage, the program may be precontemplative or contemplative. Recall the traditional role of behavioral medicine at your facility. Talk with your office manager, program director, chief residents, and faculty one on one. Learn what they have already done for PCMH and whether they want NCQA’s accreditation. The fact that PCMH encourages integrated and streamlined behavioral healthcare works in your favor!
  • Identify and include all angles and stake holders: This would include clinic operations (management, scheduling, referrals etc), faculty leaders and liaisons, patient education groups or protocols for certain diagnoses, residents, nurse practitioners or physician assistants, those in charge of your EHR system, potential collaborators in other departments (e.g., psychiatry, pharmacy) or other institutions (e.g., social work, family therapy, psychology graduate programs). Speak with them frequently and offer small bits of information on integrated care each time. Consider additional training that all staff (including yourself and other behavioral health specialists) may need to understand integrated care and how to carry it out. You may think your ideas are the best thing since sliced bread, but they (and possibly your reputation) will fall flat if you only consider your own perspective, role, and talents.
  • Get familiar with billing! It can be challenging to charge for integrated care since in some states is illegal to charge for same day service. As you think of different models of care, they must be sustainable. Management and clinic operations will be interested in fine print, so be prepared to try to give it to them! Additionally, the Current Procedural Terminology (CPT) codes (i.e., the billing codes) for psychotherapy and psychiatry are changing in 2013. Investigate Medicaid’s Health Behavior Assessment and Intervention (HBAI) codes to determine if they can be used at your site. Understand what mental health services CMS (Centers for Medicare and Medicaid Services) reimburses such as depression and substance abuse screening. Once you’re familiar with these, I suggest setting up an appointment with someone in your organization’s main business office and compliance. The last thing you want to do is begin creating or implementing a model that is non-compliant!
  • Remember this is a training program! Whatever model of integrated care gets established must dually enhance patient care AND resident education. If your role is more educational than clinical, make certain the model does not have you involved in clinical work that detracts from your teaching.
  • Determine your role. Do you want to lead or develop the entire model? Do you want to form a committee to help? Which of your stakeholders should be part of the committee?


Personal Sanity

  • Stay connected: Talk with your mentors, seek connections with similar providers in your community or department in your medical school, and other new professionals. In my personal experience, I’ve found I was a little sheltered in my safe little collaborative care bubble. I was aware my supervisor faced challenges with faculty and upper administration. However, I didn’t know all the details and I was never solely responsible for addressing them.
  • Be patient. Be persistent.

Overall, know that some of the struggles and suggestions for addressing them that are outlined in the seminal collaborative care and medical family therapy texts are very applicable. My ideas are reflective of where I am in the process of settling into a new community and introducing integrated care. I welcome further comments, suggestions and the opportunity to normalize experiences for others new to medicine or new to life after graduate school!

Some helpful websites:


Lisa Zak-Hunter

Lisa Zak-Hunter, PhD, LMFT is behavioral science faculty with the Via Christi Family Medicine Residency and Clinical Instructor with the University of Kansas School of Medicine-Wichita ,in KS. She earned her PhD in Child and Family Development, specializing in Marriage and Family Therapy, from the University of Georgia. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.

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Comments on this post...

Randall Reitz says...
Posted Wednesday, December 12, 2012
Lisa, Thanks for this post. You have a lot of excellent ideas here. I totally agree that building a PCMH model in a residency provides an excellent window of opportunity to also implement integrated care. As you describe here, often the key is having (or being) a Johnny-on-the-spot behavioral science faculty who can make the case that doing so will make the NCQA application and everyone's jobs easier.

You are a Johnny (Jenny?).
Permalink to this Comment }

Rick Kellerman says...
Posted Wednesday, December 12, 2012
Lisa's post should be required reading for all behavioral science faculty . . . in fact, faculty in all disciplines . . . who are new to the residency education environment and as we move toward PCMH models of care.
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