Identifying core curricular components for behavioral health training in internal medicine residency: Qualitative interviews with residents, faculty, and behavioral health clinicians

Objective Behavioral health services frequently delivered by primary care providers include care for mental health and substance abuse disorders and assistance with behavioral risk factor reduction. Internal medicine residencies in the United States lack formal expectations regarding training in behavioral health for residents. This qualitative study aimed to determine learners’ and teachers’ perceptions about appropriate behavioral health curricular components for internal medicine residents. Method Focus groups and interviews were conducted with the following individuals from the Duke Outpatient Clinic: residents with continuity practice (n = 27), advanced practice providers (n = 2), internal medicine attending physicians (n = 4), internal medicine/psychiatry attending physicians (n = 2), and behavioral health clinicians (n = 4). A focus group leader asked regarding residents’ successes and challenges in managing behavioral health issues and about specific learning components considered necessary to understand and manage these behavioral health conditions. Transcripts were coded using an editing analysis style to identify central themes and concordance/discordance between groups. Results Regarding mental health management (Theme 1), residents emphasized a need for better care coordination with specialty mental health, while attendings and behavioral health clinicians gave priority to residents’ skills in primary management of mental health. Residents, attendings, and behavioral health clinicians all emphasized advanced interviewing skills (Theme 2) with subthemes: eliciting the patient’s perspective, managing time in encounters, improving patients’ understanding, and patient counseling. Conclusions Internal medicine residents, attendings, and behavioral health clinicians may differ significantly in their perceptions of primary care’s role in mental health care. Future internal medicine behavioral health curricula should specifically address these attitudinal differences. Curricula should also emphasize interview skills training as an essential component of behavioral health learning.

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VitalSign6: A Primary Care First (PCP-First) Model for Universal Screening and Measurement-Based Care for Depression

Pharmaceuticals ◽

10.3390/ph12020071 ◽

2019 ◽

Vol 12 (2) ◽

pp. 71 ◽

Cited By ~ 9

Author(s):

Madhukar Trivedi ◽

Manish Jha ◽

Farra Kahalnik ◽

Ronny Pipes ◽

Sara Levinson ◽

...

Keyword(s):

Mental Health ◽

Primary Care ◽

Mental Health Professionals ◽

Health Professionals ◽

Universal Screening ◽

Primary Care Providers ◽

The United States ◽

Care Providers ◽

Similar Treatment ◽

Measurement Based Care

Major depressive disorder affects one in five adults in the United States. While practice guidelines recommend universal screening for depression in primary care settings, clinical outcomes suffer in the absence of optimal models to manage those who screen positive for depression. The current practice of employing additional mental health professionals perpetuates the assumption that primary care providers (PCP) cannot effectively manage depression, which is not feasible, due to the added costs and shortage of mental health professionals. We have extended our previous work, which demonstrated similar treatment outcomes for depression in primary care and psychiatric settings, using measurement-based care (MBC) by developing a model, called Primary Care First (PCP-First), that empowers PCPs to effectively manage depression in their patients. This model incorporates health information technology tools, through an electronic health records (EHR) integrated web-application and facilitates the following five components: (1) Screening (2) diagnosis (3) treatment selection (4) treatment implementation and (5) treatment revision. We have implemented this model as part of a quality improvement project, called VitalSign6, and will measure its success using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework. In this report, we provide the background and rationale of the PCP-First model and the operationalization of VitalSign6 project.

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The Digital Revolution in Behavioral Health

Journal of the American Psychiatric Nurses Association ◽

10.1177/1078390319879750 ◽

2019 ◽

Vol 26 (1) ◽

pp. 102-111 ◽

Cited By ~ 3

Author(s):

Michael J Hasselberg

Keyword(s):

Mental Health ◽

Health Care ◽

Mental Health Care ◽

Behavioral Health ◽

Digital Health ◽

Behavioral Health Care ◽

The United States ◽

Care Providers ◽

Digital Revolution ◽

The University

BACKGROUND: Technology is disrupting every modern industry, from supermarkets to car manufacturing, and is now entering the health care space. Technological innovations in psychiatry include the opportunity for conducting therapy via two-way video conferencing, providing electronic consultations, and telementoring and education of community health care providers. Use of mobile health applications is also an expanding area of interest and promise. OBJECTIVE: The purpose of this article is to review the evolution and pros and cons of technology-enabled health care since the digital movement in psychiatry began more than 50 years ago as well as describe the University of Rochester’s innovative digital behavioral health care model. METHODS: A review of the literature and recent reports on innovations in digital behavioral health care was conducted, along with a review of the University of Rochester’s model to describe the current state of digital behavioral health care. RESULTS: Given the lack of access to care and mental health professional shortages in many parts of the United States, particularly rural areas, digital behavioral health care will be an increasingly important strategy for managing mental health care needs. However, there are numerous hurdles to be overcome in adopting digital health care, including provider resistance and knowledge gaps, lack of reimbursement parity, restrictive credentialing and privileging, and overregulation at both the state and federal levels. CONCLUSIONS: Digital health innovations are transforming the delivery of mental health care services and psychiatric mental health nurses can be on the forefront of this important digital revolution.

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How Are You?: A Culturally Sensitive Group Therapy Program for Latinos

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.1767 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S482-S482

Author(s):

M. Paris ◽

M. Lopez ◽

L. León-Quismondo ◽

M. Silva ◽

L. Añez

Keyword(s):

Mental Health ◽

Behavioral Health ◽

Doctoral Students ◽

Local Community ◽

Psychiatric Symptoms ◽

Skills Training ◽

The United States ◽

Group Program ◽

Spanish Speaking ◽

Alternative To Hospitalization

IntroductionAn ongoing challenge for the behavioral health field in the United States is ensuring access to culturally and linguistically responsive treatments for the growing number of monolingual Spanish speakers. The limited availability of services further compromises mental health outcomes given the unique psychosocial stressors often experienced in this population, such as language barriers, family separation and inadequate social support, unemployment, trauma, and poverty.ObjectiveIn response to the local demand for services, the authors describe a specialized group program for monolingual Spanish speaking adults with chronic and persistent mental illness.AimsThe program aims are two-fold:– to reduce exacerbation of psychiatric symptoms for individuals presenting in an acute state of distress through the provision of recovery-oriented mental health services in a familiar setting and preferred language;– to offer a specialized behavioral health training experience for bilingual psychology doctoral students.MethodsThe group is led by the psychology fellow and is offered twice per week for a total of six hours, and includes elements of interpersonal and cognitive behavioral therapy; motivational interviewing; spirituality; coping skills training; and art/music.ResultsThe described mental health group program is the only one available in Spanish in the local community and has reduced utilization of the hospital emergency room. Consequently, it fills an important gap in the service system and offers care that would otherwise be unavailable for individuals in need.ConclusionsThe program is a cost-effective alternative to hospitalization for Spanish speaking Latinos and a unique professional experience for psychologists in-training interested in a career in the public sector.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Attitudes, Practices, and Barriers to Adolescent Suicide and Mental Health Screening

Journal of Primary Care & Community Health ◽

10.1177/2150131911417878 ◽

2011 ◽

Vol 3 (1) ◽

pp. 29-35 ◽

Cited By ~ 13

Author(s):

Guy S. Diamond ◽

Alana O’Malley ◽

Matthew B. Wintersteen ◽

Sherry Peters ◽

Suzanne Yunghans ◽

...

Keyword(s):

Mental Health ◽

Primary Care ◽

Health Services ◽

Behavioral Health ◽

Suicide Risk ◽

Primary Care Providers ◽

Mental Health Screening ◽

Care Providers ◽

Behavioral Health Services ◽

Suicide Screening

Objective: To determine primary care providers’ rates of screening for suicide and mental health problems in adolescents and the factors that promote or discourage this practice. Patients and Methods: Overall, 671 medical professionals (ie, pediatricians, family physicians, nurse practitioners, physician assistants) completed an electronic survey. The 53 items focused on (1) attitudes, knowledge, and comfort with general psychosocial and suicide screening and (2) current practices and barriers regarding screening and referrals to behavioral health services. Results: Forty percent had a patient attempt suicide in the past year, and 7.7% had 6 or more patients attempt suicide. At a well visit, 67% screened for mental health, and 35.2% screened for suicide risk. Most (61.1%) primary care providers rarely screened for suicide or only when it was indicated. Only 14.2% of primary care providers often used a standardized suicide screening tool. Factors associated with screening were being knowledgeable about suicide risk, being female, working in an urban setting, and having had a suicidal patient. Only 3.0% reported adequate compensation for these practices, and 44% agreed that primary care providers frequently use physical health billing codes for behavioral health services. Nearly 90% said parent involvement was needed if adolescents were to follow through with referrals to mental health services. Only 21% frequently heard back from the behavioral health providers after a referral was made. Conclusion: Policy that promotes mental health education for primary care providers, provides reimbursement for mental health screening, and encourages better service integration could increase suicide screening and save healthcare costs and patients’ lives.

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Expanding Telehealth Competencies in Primary Care: A Longitudinal Interdisciplinary Simulation to Train Internal Medicine Residents in Complex Patient Care

Journal of Graduate Medical Education ◽

10.4300/jgme-d-20-00030.1 ◽

2020 ◽

Vol 12 (6) ◽

pp. 745-752

Author(s):

Rachel Wong ◽

Patricia Ng ◽

Tracey Spinnato ◽

Erin Taub ◽

Amit Kaushal ◽

...

Keyword(s):

Internal Medicine ◽

Primary Care ◽

Patient Care ◽

Primary Care Providers ◽

Interdisciplinary Care ◽

Care Providers ◽

Coordinated Care ◽

Post Intervention ◽

Complex Patient ◽

Internal Medicine Residents

ABSTRACT Background Despite increasing use of telehealth, there are limited published curricula training primary care providers in utilizing telehealth to deliver complex interdisciplinary care. Objective To describe and evaluate a telehealth curriculum with a longitudinal objective structured clinical examination (OSCE) to improve internal medicine residents' confidence and skills in coordinating complex interdisciplinary primary care via televisits, electronic consultation, and teleconferencing. Methods In 2019, 56 first- and third-year residents participated in a 3-part, 5-week OSCE training them to use telehealth to manage complex primary care. Learners conducted a standardized patient (SP) televisit in session 1, coordinated care via inter-visit e-messaging, and led a simulated interdisciplinary teleconference in session 2. Surveys measured confidence before session 1 (pre), post-session 1 (post-1), and post-session 2 (post-2). SP televisit checklists and investigators' assessment of e-messages evaluated residents' telehealth skills. Results Response rates were pre 100%, post-1 95% (53 of 56), and post-2 100%. Post-intervention, more residents were “confident/very confident” in adjusting their camera (33%, 95% CI 20–45 vs 85%, 95% CI 75–95, P < .0001), e-messaging (pre 36%, 95% CI 24–49 vs post-2 80%, 95% CI 70–91, P < .0001), and coordinating interdisciplinary care (pre 35%, 95% CI 22–47 vs post-2 84%, 95% CI 74–94, P < .0001). More residents were “likely/very likely” to use telemedicine in the future (pre 56%, 95% CI 43–69, vs post-2 79%, 95% CI 68–89, P = .001). Conclusions A longitudinal, interdisciplinary telehealth simulation is feasible and can improve residents' confidence in using telemedicine to provide complex patient care.

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PrEParing for Preexposure Prophylaxis

Journal of Doctoral Nursing Practice ◽

10.1891/2380-9418.jdnp-d-19-00033 ◽

2020 ◽

Vol 13 (1) ◽

pp. 3-8

Author(s):

Michelle Peters Zappas ◽

Ruth Madden Foreman

Keyword(s):

Primary Care ◽

Side Effects ◽

Nurse Practitioners ◽

Risk Groups ◽

Primary Care Providers ◽

The United States ◽

Care Providers ◽

Patient Counseling ◽

Preexposure Prophylaxis ◽

Substantial Decline

BackgroundIn 2012 the Food and Drug Administration (FDA) approved Truvada (emtricitabine [FTC] 200 mg/tenofovir disoproxil fumarate [TDF] 300 mg) for preexposure prophylaxis (PrEP) against HIV. There was a substantial decline in new HIV diagnoses which has since stabilized.ObjectiveThe plateau is thought to be because preventative efforts are not reaching high-risk groups. About 1.2 million adults in the United States could benefit from PrEP but only 80,000 individuals are taking it. This article aims to increase provider awareness of PrEP so primary care providers feel confident discussing risk reduction options, initiating, and monitoring PrEP.MethodsA case based approached is used to achieve the objective.ResultsTarget populations, baseline labs, follow up labs and monitoring parameters, and side effects of medication will be reviewed. Patient counseling with regards to dosing, administration, side effects and adverse events will be discussed.ConclusionsHIV prevention is an integral public health goal. PrEP is a way to achiveeve continued reduction in HIV incidence. PCPs should be offering PrEP to at risk individuals.Implications for NursingMany nurse practitioners work as primary care providers, this article hopes to increase the confidence of PCPs in prescribing PrEP to those who would benefit from it.

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Effects of the mental health parity and addictions equality act on depression treatment choice in primary care facilities

The International Journal of Psychiatry in Medicine ◽

10.1177/0091217417703289 ◽

2017 ◽

Vol 52 (1) ◽

pp. 34-47 ◽

Cited By ~ 5

Author(s):

Daniel M. Goldberg ◽

Hsien-Chang Lin

Keyword(s):

Mental Health ◽

Primary Care ◽

Primary Care Physicians ◽

Primary Care Providers ◽

The United States ◽

Depression Treatment ◽

Mental Health Parity ◽

Care Providers ◽

Multinomial Regression ◽

Care Facilities

Objective The Mental Health Parity and Addictions Equality Act (MHPAEA) of 2010 in the United States sought to expand mental health insurance benefits on par with medical benefits. As primary care facilities are often the first step in identifying mental health concerns, it is essential to examine the association of this policy with primary care physicians’ choice on depression treatment. Method A retrospective cross-sectional study was conducted using data from the 2007–2012 National Ambulatory Medical Care Survey, including a weighted total of 162,699,930 depression patients. Using the Heckman two-step selection procedure, a logistic and a multinomial regression were conducted to examine the association of the MHPAEA with physicians’ two-step process of deciding whether and which type of treatment was prescribed. Sociological factors were controlled. Results Treatment was significantly more likely to be provided after the MHPAEA. Psychotherapy was used for treatment for 10.0% of the sample while medication was used for 75.0% of the sample. Patient race/ethnicity, practice setting, physician specialty, and primary source of payment were associated with diverging likelihood of being prescribed depression treatment. Non-Hispanic White patients were more likely to be provided treatment than non-Hispanic Black patients. Patients were less likely to be prescribed only medication than only psychotherapy after the MHPAEA enactment. Conclusions The MHPAEA was associated with primary care providers’ decision and choice on depression treatment. Educational and policy interventions aimed at improving physician’s understanding of their own treatment tendencies and decreasing barriers to depression treatment may impact the disparities in underserved, minority, and older populations.

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Development of an Ambulatory Geriatrics Knowledge Examination for Internal Medicine Residents

Journal of Graduate Medical Education ◽

10.4300/jgme-d-13-00123.1 ◽

2013 ◽

Vol 5 (4) ◽

pp. 678-680 ◽

Cited By ~ 2

Author(s):

Jessica L. Kalender-Rich ◽

Jonathan D. Mahnken ◽

Lei Dong ◽

Anthony M. Paolo ◽

Deon Cox Hayley ◽

...

Keyword(s):

Internal Medicine ◽

Older Adults ◽

Primary Care ◽

Medical Students ◽

Assessment Tool ◽

Primary Care Providers ◽

Basic Knowledge ◽

Care Providers ◽

Internal Medicine Residents ◽

Fourth Year Medical Students

Abstract Background The number of older adults needing primary care exceeds the capacity of trained geriatricians to accommodate them. All physicians should have basic knowledge of optimal outpatient care of older adults to enhance the capacity of the system to serve this patient group. To date, there is no knowledge-assessment tool that focuses specifically on geriatric ambulatory care. Objective We developed an examination to assess internal medicine residents' knowledge of ambulatory geriatrics. Methods A consensus panel developed a 30-question examination based on topics in the American Board of Internal Medicine (ABIM) Certification Examination Blueprint, the ABIM in-training examinations, and the American Geriatrics Society Goals and Objectives. Questions were reviewed, edited, and then administered to medical students, internal medicine residents, primary care providers, and geriatricians. Results Ninety-eight individuals (20 fourth-year medical students, 57 internal medicine residents, 11 primary care faculty members, and 10 geriatrics fellowship-trained physicians) took the examination. Based on psychometric analysis of the results, 5 questions were deleted because of poor discriminatory power. The Cronbach α coefficient of the remaining 25 questions was 0.48; however, assessment of interitem consistency may not be an appropriate measure, given the variety of clinical topics on which questions were based. Scores increased with higher levels of training in geriatrics (P < .001). Conclusion Our preliminary study suggests that the examination we developed is a reasonably valid method to assess knowledge of ambulatory geriatric care and may be useful in assessing residents.

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