The Health Psychologist

Kathleen  Ashton, PhD, ABPP
Director of Behavioral Health
Breast Center
Cleveland Clinic

Amy Walters, PhD
Director of Behavioral Health Services for St. Luke’s Humphreys Diabetes Center

Erin F. Swedish, Ph.D., MBA
Director, Health Integration

Diana L. Prescott, Ph.D.
Clinical Psychologist
Hampden Psychological Consultation, PLLC

Amy Van Arsdale, PhD

Laurie Ivey, PsyD
Professor,
Director of Psychology Education and Postdoctoral Training,
Office of Psychological Science and Practice (OPSP),
Department of Psychiatry, University of Colorado School of Medicine

Starting work in a new practice area can be overwhelming. Below are some expert tips from psychologists working in integrated specialty medical settings about how to start and sustain a practice:

1. Identify a medical population with psychological needs. Whether you work in a medical center, community mental health center or private practice, you likely encounter patients with chronic or unique medical conditions.  You may notice referrals with common presenting conditions (i.e., diabetes, cardiac disease, COPD, sleep, obesity, etc.).  Many medical specialties are eager to incorporate psychological services into their practice.  Nationwide, integrated psychologists have been incorporated into the following medical specialties: oncology, bariatrics, endocrinology, sleep medicine, multiple sclerosis clinic, gastrointestinal disorders, pain management, movement disorders, pediatric integrative medicine and many others.
2. Find a physician champion. Psychologists looking to integrate into a medical practice will do well to find a physician leader who understands and supports the unique role a psychologist can play on their team.  They can serve as the catalyst for seeking financial support, hiring, as well as being an ambassador for integrating the psychologist into the medical team and promote their role in patient care.
3. Develop a business plan. In health care you may hear the saying “Without money we have no mission.”  It’s important to consider the business side of care, in addition to clinical services.  Remember, you will be making a pitch to an administrative team, so consider referral base, access to care, and billing parameters in your plan.  Be realistic about what you can offer and consider workflow for new patients, established patients, groups, and shared medical appointments. Be prepared to discuss value added for non-billable time (case consultations, trainings, curriculum development, program support, data analysis) and how psychologists help support the quadruple aim and improve provider satisfaction.  Understand the relevant CPT codes and what you might expect the clinic to bill and collect on fee-for-service visits.  Be clear about the differences between general mental health and the specialty level of care you are proposing to provide (different level of training and consultative interactions with the medical team).
4. Don’t be afraid to start small. Sometimes medical groups are hesitant to go “all in” with behavioral health integration.  It’s okay to start with a day or two per week and increase as demand grows. If your practice grows too quickly, be prepared to narrow referral criteria or ask for additional hours or support.  Be clear from the beginning about payment arrangements (e.g., salary, hourly, paid for scheduled patients or only patients seen) and plan for non-clinical time as well (meetings, emails, trainings, consults and documentation).
5. Establish your credentials as a doctoral level scientist-practitioner. Psychologists are seen as important team members based on their unique training in evidence-based treatments, science and research background, and ability to synthesize information at a high level to provide expert consultation. They have specialized training in behavior, motivation, cognition and learning. Psychologists should have medical staff level benefits and privileges within the medical system and academic appointments. This should be negotiated before accepting a position.  Education and research activities are a natural fit for psychologists in academic medical centers and can add to your prestige and recognition.  Consider becoming board certified in clinical health psychology, getting an academic appointment, presenting at regional, state and national meetings or applying for fellowship status in a relevant professional society.
6. Understand the specialty medical issue and the psychological implications. Psychologists in specialty integrated care should have a strong understanding of the medical issue they treat and the impact it has on social-emotional health and quality of life.  For early career psychologists this may take place on internship or postdoctoral fellowship, while mid to late career psychologists may consider shadowing the medical team, reading the relevant literature, attending medical continuing education on the topic, and/or obtaining mentoring and consultation with a psychologist expert in the specialty. Psychologists should have the opportunity to attend the state or national conference for their medical specialty to further their knowledge and to connect to other allied health professionals working in the field.  Psychologists are also encouraged to work with their state licensing boards or APA to obtain credit for medical CE.
7. Make yourself visible and market your services. Talk to team members about different challenges you can address (e.g., coping, sleep, pain management, medication adherence) to support their patients. This can help build a referral base.  Consider presenting at grand rounds and in-service trainings, media interviews (both internal and external), or community presentations.  Use social media to help people get to know you and how psychological services might benefit their patients.  Be prepared with business cards and print media which referral sources can easily hand to their patients. The American Psychological Association also has public education materials you can order free of charge to help support marketing of your services.
8. Build the infrastructure. Make sure you have a reliable means of scheduling new and established patients.  Ask your IT team to help create an easy-to-use referral option in your electronic health record (EHR) system.  Build a strong relationship with the administrative staff who manage the scheduling template and talk to your patients.  Make sure they understand the services you provide and your workflow so that they can keep your schedule accurate and full.  Consider how to use administrative or nursing support to maximize your professional time and delegate tasks that are not practicing at the top of your license.  Realize that it is as important to educate the staff about what you do as it is the referring medical providers!
9. Listen to patient needs.  Discuss their challenges with the healthcare team and offer to support these challenges to help reduce provider burnout.  If you notice a particular issue coming up repeatedly, consider building a specific program to address it.  If the team has an ongoing issue with psychological implications, think about how you can provide consultation.
10. Be flexible. Be willing to see patients with a range of presenting issues, in a variety of settings, and as your services are needed. Your space may be an exam room, inpatient room, hallway consultation, warm handoff after a provider visit, or jumping in first if a provider is running behind. Your goal is to support your team and remove barriers to patient access.
11. Be brief. The pace of medical care is much faster than the pace of traditional mental health services. You need to learn to match the needs of your team and be brief and efficient in your intervention and communication. In many integrated settings, 15–20-minute consults are the norm.  It is important to become skilled and comfortable with brief interventions and learn to report your conceptualization and recommendations in a concise way.  Establish a strong clinical foundation in motivational interviewing, contextual interviewing, CBT, ACT, solution-focused, behavior modification and other brief therapies to provide evidence-based interventions in an efficient manner.
12. Consider a population-based model. Remember the modal number of sessions is 1, so work towards a consultation model (1-4 visits) and try to adopt a single session mindset. Population health favors a small amount of intervention for many patients over a large amount of intervention for a few. Be careful how you label your services (consultation vs. therapy), as patients will expect what they are promised by other providers who refer to you.  The more you promise to each patient, the fewer patients you will reach.  The public is very interested in mental health services and access is hard.  Work with your practice to get assistance from patient navigators or other staff around helping patients with referrals to traditional mental health services in the community so that you can focus on the specialty problem.
13. Ethics: Be clear about confidentiality limits with team-based care and charting in the medical record. Make sure to connect with your patient’s other providers (including mental health therapists and other specialists) to provide team-based, collaborative care.  Discuss your portion of the work with the patient to ensure that they are clear about each provider’s role.  Ensure the primary therapist is aware that you have been consulted by the medical team and are not trying to replace their role.  Create a process to deal with crisis situations (which may require patient or provider support) and agree with your team on the best method of contact (cell phone, pager, staff message in EHR, Teams message, etc.).
14. Adapt to the culture and be sensitive. Adopt the language and culture of your clinic in your verbal and written communications (e.g., patient vs. client; visit vs. session, know terms associated with the medical condition and its treatment). If you are using an EHR, be aware that in many systems your note will be visible to all providers and the patient.  Make sure to include this in your informed consent with your patient at the first visit.  Be objective in your documentation and include necessary information, while balancing patient confidentiality and privacy needs. You may choose to be more general in your documentation of abuse history, relationship conflict, and other areas than you might have been including in more detail in a traditional mental health setting or choose to share this verbally with the treating provider when possible.  Remember that your note is a communication tool with the team and is used for billing purposes.  Think about and include the most salient information to achieve these goals.
15. Stay connected. Stay connected to the medical team through interprofessional meetings and spend time in workrooms or other clinical spaces. Communicate with providers after patient encounters verbally or through the EHR to “close the loop” and facilitate collaboration. Seek out opportunities for face-to-face time with providers and staff to build relationships and trust. Connect with other wellness and behavioral health professionals in your system or community.  Building relationships, maintaining communication and working together helps mobilize resources and improve patient care.
16. Stay current and be creative. Information, workflows and best practices evolve rapidly in medicine. Attend continuing medical education, staff meetings, and specialty meetings to ensure your knowledge remains current. Consider joining professional societies that align with your population (e.g., oncology, bariatrics, lifestyle medicine). Be alert about new trends and opportunities to offer services to specialty populations.
17. Measure what you do.  Hospital and health system administrators love data. Keep track of the number of referrals, patients served, appointments completed, and patient progress monitoring (e.g., BP, A1C, lab values).  Provide outcome data on the efficacy of your treatments and the impact on medical outcomes.  Consider patient and provider satisfaction surveys to help quantify the impact of your services.
18. Be ready to expand.  Know when it is time to add additional staff or include a trainee to help increase access for your patient population.  Every six months reassess your access and capacity, plan for growth and account for the time required in hiring new staff (in many health systems professional credentialing may take three months or more).
19. Be responsive. Think about ways to provide good customer service to your team and your patients. Return emails promptly, accept meeting invitations, show up to team events, and complete tasks you have been assigned in a timely manner.  Respond quickly to team members’ requests for help and find ways to support your team. Being known as someone who gets things done in a timely fashion is essential to building trust and teamwork.  Psychologists can be unknown quantities in the medical world, so establishing a reliable and responsive style goes a long way to being a valued member of the team.
20. Establish best practices. As your behavioral team grows, be prepared to establish best practices. It is helpful to create written guidelines for care, templates for documentation and handouts that can be used by all health staff to maintain continuity of care. These materials are very helpful for training additional staff and students. These might include “care pathways” that the typical patient would be offered based on their presentation that are grounded in the empirical literature and clinical expertise of the program.  Be clear about referral criteria for your services and create a policy about whether you will treat team members or their families.

This tip sheet was adapted from the original work of Dr. Kathleen Aston and edited by Dr. Amy Walters to include additional ideas from the APA ISC committee members.