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A SWOT Analysis for Psychology in Primary Care Settings
Douglas Tynan, PhD, ABPP, American Psychological Association, Integrated Primary Care SIG member
With the rapid changes in health care, many providers will be displaced and we will tend to try to hang on to our familiar ways of doing business. But to be successful, psychologists need to understand how the systems are changing and judge-as a profession-our strengths, weaknesses, opportunities, and threats (a SWOT analysis).
Of all the mental health professions, psychology has one of the longest track records of working with primary care providers. More than 50 years ago, in 1964, the president of the American Academy of Pediatrics, in his presidential address, opined that every pediatrician should have a child psychologist working in his or her office. On the adult side, there has been active research and clinical literature in health psychology dating back to the 1960s. One of our great strengths is data collection. In this new era of health care with an emphasis on payment for value, which is defined as the outcomes achieved for the money spent, there is a growing emphasis on collecting data on individual patients in order to evaluate effectiveness of treatment approaches for both health and mental health conditions. Psychologists are very good at measuring health behavior, whether it is number of steps taken, or adherence to a medication regimen, or keeping a sleep diary. We have expertise in measurement that is highly valued. In addition, with the surge of questionnaires now being implemented online for patients, we also have the expertise on gathering reliable and valid data.
Another strength is the emphasis on evidence-based approaches. In the current, rapidly shifting environment, many approaches are being attempted, and it is our professional scientific rigor that will help sort out what works from what doesn't work.
Work in primary care draws upon the basic skills of being a good psychologist. These include forming relationships with patients and health care providers, implementing evidence-based treatment in clinic settings, and adapting treatments to a primary care environment. It requires specific training on how to work on a team within a health care environment, a very different experience than that of a solo practitioner. The skills to adapt psychological interventions in primary care are currently taught late in training. Moving this earlier in graduate school curriculum could help with the supply. For psychologists in practice, there is a need to re-train in primary care skills, and those opportunities are in short supply. So while the skills and competencies have been identified (McDaniel et al. 2014), training opportunities are hard to find. For those working in primary care, their professional identity is new, and at clinic, county, state, and national levels it is important to develop connections with other primary care psychologists.
Under the Affordable Care Act, within health prevention services, there are mandated screenings for depression, child development milestones, domestic violence, substance abuse, and risky sexual behaviors. Under prevention services there is also counseling for obesity, smoking cessation, alcohol misuse, and HIV risk prevention. While these are mandated to be done by primary care providers and currently psychologists are not reimbursed for those services in the fee-for-service system, as we move to a system that will be paying those providers in a bundled per-member-per-month payment, it may well be possible for psychologists to provide those services. Also, in the current environment, nearly all insurance plans have mental health benefits so psychologists can bill in primary care settings. Last, as the health care system changes, physicians will be reimbursed if their patient populations do better on common measures such as blood pressure, blood glucose levels, and cholesterol levels as well as patient satisfaction. Existing research would suggest that psychological interventions can have an impact on those outcome variables. When engaging physicians in discussions of cooperation, it is helpful to remind them that the work we do often significantly impacts those measures.
A number of other professions are now working in the area of health behavior and in mental health domains. The most common new provider is the "health coach," who can range from a licensed professional (e.g. nurse, social worker) who has been through a formal university-based training program with supervised practicum experience, to someone who has completed a weekend workshop or relatively brief online training. Certificates in health coaching abound, and those with such certificates are perceived as a lower cost alternative provider. In a health care team setting, psychologists can help consult with and at times supervise health coaches and can help define which patients are appropriate for coaching and which ones need a higher level of service. Health coaches are not developed to replace psychologists; they are present to help patients target specific health-related behaviors and achieve goals. While some perceive health coaching as a threat, one may think of it as an opportunity. A clinic with health coaching is focused on behavior, and it is in that environment that psychology has an opportunity to thrive. Working with health educators and health coaches and developing consistent effective programs for health behavior change can be an opportunity for psychology, if we take it. If we don't, someone else will take it.
Overall, the future looks good, as long as we maintain our strengths, work to overcome our weaknesses, and most importantly work with the perceived threats by other providers as an opportunity to creatively lead and improve health care teams. The future is potentially very bright, but we have to be proactive and vigilant in adapting to changes in the health care system. Our best supports as we move forward are groups of psychologists who are successfully engaged in this work: For instance, our fellow members of the Integrated Primary Care SIG. As each of us deals with contracts, billing, scheduling, types of services provided, new opportunities, or new difficulties, we need to share that information in real time with our peers. We in the IPC SIG are our own best resource, so we should actively share our experiences in dealing with the threats, and leverage our strengths by collaborating on research that furthers our aims.
McDaniel, S. et al (2014) Competencies for psychology practice in primary care. American Psychologist 69, (4), 409-429 DOI: 10.1037/a0036072