Hogg Foundation for Mental Health

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Inter-professional Training in Family-Centered
Integrated Healthcare for the Underserved
Population of Children Organizational/Implementat
ion Issues
Integrated Health Care
Family Systems
Cultural Competence
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Presenters

• Cindy Carlson, Ph.D.
  Margie Gurley Seay Professor and Department
  Chair 
  The University of Texas at Austin
• Jane Ripperger-Suhler, M.D. Program Director,
  Child and Adolescent Psychiatry University of
  Texas Southwestern at
  Seton Family of Hospitals,
  Austin
• Jane Gray, Ph.D.
• Psychologist  Director of Psychology
  Training, Texas Child Study Center
• Director of Behavioral Health
• Texas Center for the Prevention and
  Treatment of Childhood Obesity
• Greg Jensen, LCSW
• Vice-President of Behavioral Health
• Lone Star Circle of Care
• Elizabeth Minne, Ph.D.
• Psychologist, Lone Star Circle of Care
• Referral Center at Crockett High School

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Learning Objectives

• Articulate the relationship between
  inter-professional
• training and integrated health care delivery.
• List three reasons childrens services should be
• family-centered, culturally/linguistically
  competent,
• and integrated.
• Identify three barriers and three solutions to
• inter-professional training implementation.
• Provide two examples of how evaluation data
  inform
• organizational/implementation issues.

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UT Graduate Psychology Education (UT-GPE) Program

• Goal Foster interdisciplinary teamwork in the
  provision of evidence-based, culturally
  linguistically competent, family-centered
  treatment of children.
• How? Trainees (doctoral psychology students)
  participate in interdisciplinary training with
  psychiatrists and other health professionals,
  including seminar participation, clinical service
  delivery, and field placements at integrated
  health care sites that permit collaboration.
• (HRSA Award D40HP19644/Graduate Psychology
  Education Programs. Project director C.Carlson)

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Key Elements of UT-GPEP

• Trainee Preferred Criteria

• Training Requirements

• Spanish-speaking
• Ethnic minority
• Clinical, Counseling, or School Psychology
  (doctoral only)
• Interest in serving children families
• Doctoral level
• 2-4th year of training

• 2 years sequential
• Initial year evidence-based practice in Texas
  Child Study Center
• 2nd year FQHC or FQHC-like setting
• Engagement in research
• Engagement in policy

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Training in Family-Centered Care

• Training Goals

• Training Modalities

• Systems theory
• The family health and illness cycle
• Family functioning and child health
• Family-centered care principles
• Family assessment methods
• Evidence-based family intervention and parent
  training

• Interdisciplinary seminar
• Individual and group supervision
• Training experiences in family assessment, family
  therapy, and family-centered care
• Family case study presentations

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Training in Integrated Health Care

• Training Goals

• Training Modalities

• Interdisciplinary seminar
• Training experiences in integrated health care
  settings/FQHCs
• Policy involvement
• Site visits
• Research

• Models of integrated health care
• How to integrate physical and behavioral health
• Barriers to implementation
• Knowledge of integrated health care initiatives
  across the nation

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Training in Culturally and Linguistically
Competent Care

• Training Goals

• Training Modalities

• Role of culture and language in the delivery of
  services
• Emphasis on Spanish-speaking and Latino families
• Development of knowledge, skills, and awareness
  in providing care for diverse populations
• Understanding of health disparities among children

• Interdisciplinary seminar
• Bilingual/multicultural supervision
• Training experiences in settings serving diverse
  populations
• Research

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Why Inter-professional Education (IPE) is
Essential

• Integrated health care places patients, families,
  and communities at the center of health care
  provision served by point-of-delivery teams of
  professionals.
• Inter-professional education is recommended to
• Reduce ignorance of roles and duties
• Reduce professional prejudices
• Increase understanding knowledge
• Increase team-work collaborative skill

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The IdealKeys to success in IPE

• Early exposure
• Learn about colleagues professional culture
• Spend time in classroom and socially
• Learn about own professional culture and be able
  to articulate this to others
• Recognize own biases and assumptions
• Leadership from each culture teaching and
  learning
• Enthusiastic and skilled facilitators

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The RealityChallenges and Barriers in IPE

• Few models exist that are accepted and
  operationalized successfully
• Logistical barriers
• semester length
• grading requirements
• practice style
• Profession-centrism and social identity theory

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The Reality Predictions about IPE prior to
implementation

• Integration would be challenging
• Differences in background, approach, value
  systems
• Prejudice about the other
• Fragile identities uncertainty and insecurity
  about identity as members of ones professional
  group and tendency to over-differentiate groups
  to consolidate identity
• We will need to address the cultures of the
  professional groups
• Integrating across professions may
• help them understand cultural barriers with
  patients (clients)
• introduce new ideas for working styles
• enhance their ability to work with other
  disciplines as well

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The Reality Taking the Plunge in Year One

• Met together in two hour blocks
• On psychiatry turf
• Instructors came from psychiatry, public health,
  business, counseling psychology, and school
  psychology backgrounds
• None from within employed clinical faculty of
  psychiatry or from clinical psychology faculty
• New roles and new professional
  partnerships

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The Reality Mistakes in Year One

• I did not attend lectures so no parent
  representative for psychiatry
• Attempts to address interprofessional cultural
  differences came late in the year
• Expectations of teachers for group function
  further sequestered groups because it did not
  match the groups expectations

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The Reality Corrections in Year Two and
Outcomes

• Corrections
• Child psychiatry at every class (almost)
• Compared training backgrounds in first session
• Presented expectation of group project early
• (family therapy together)
• Outcomes
• More engagement of all groups
• inter-professionally in discussion
• Only one dyad attempted and
• presented conjoint family therapy experience

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The Reality New Challenges in Year Three

• Larger and more diverse group
• More formal structure
• Some participants
• getting credit/grades
• Semester requirement
• All participants do not work in clinic together

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Brainstorming Solutions for IPE

• Every situation will present its own challenges
  but some seem to be universal
• Identity issues
• Learning/teaching styles
• Goal differences
• How do we transcend identity and prejudice issues
  to facilitate teamwork?
• How do we provide learning opportunities that
  match expected styles?
• How do we encourage collaboration in diverse
  groups who have different goals and motivations?

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Importance of Family-centered Collaborative Care

• Families increasingly involved in care as
  medicine advances
• Complexity of medical plans puts demand on
  families
• Psychosocial issues at the family level are
  related to higher healthcare costs
• Family system is relevant in health behaviors
• Family-centered collaborative care acknowledges
  ecosystemic view
• Provider is part of the ecosystem

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The IdealFamily Centered Collaborative Care

• Partnership between patients, families, and
  healthcare professionals
• Collaboration among disciplines
• Medicine, nursing, behavioral health, among
  others
• Inclusion of family as crucial part of team
• Biopsychosocial model
• with equal importance of
• each element

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The Training Setting

• Mental health collaboration between University of
  Texas and Dell Childrens Medical Center
• Trainees providing therapy services
• Outpatient clinic collaboration between
  psychology and psychiatry
• Childrens Hospital
• Trainees embedded within
• interdisciplinary teams of
• pediatric subspecialty
• services (oncology, obesity)

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The Reality Successes in Family Centered Care

• Parents engaged as collaborators in treatment
• Assessment of family system, including strengths
• Many examples of effective collaboration among
  disciplines
• Multiple disciplines of mental health within
  teams
• Trainees display high skill level in
  collaborative behaviors

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The Reality Challenges and Barriers in Family
Centered Care

• Setting
• Collaboration across disciplines
• Awareness of roles and skills
• Overlap in content and techniques
• Financial support for time spent on
• collaboration
• Limited availability of
• bilingual supervision on site

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The Reality Challenges and Barriers in Family
Centered Care

• Communication systems/EMR
• Billing and diagnosis
• Challenges to family therapy efforts
• Referral challenges
• Availability of family members
• Supervision

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Brainstorming Solutions for Family Centered Care

• How do we create more effective collaboration
  across disciplines?
• How do we successfully implement family therapy
  within these types of settings?

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Importance of training in FQHCs

• An Institute of Medicine report in 2005
  concluded that the only way to achieve true
  quality (and equality) in the health care system
  is to integrate primary care with mental health
  care and substance abuse services.
• (Institute of Medicine, Improving the Quality
  of Health Care for Mental and Substance-Use
  Conditions Quality Chasm Series, November 1,
  2005.)

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The Ideal Training in FQHCs
Providing holistic care by diagnosing and
treating physical AND mental conditions
together
Training in BH medical clinics
Embedding BH students in medical clinics
Interdisciplinary training
Managing technology
Program development
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The Reality Challenges and Barriers to Training
in FQHCs

• Lack of Clarity re Value Added
• Financial Impact of Trainees
• Ability to bill
• Demand for training slots
• Service Delivery vs. Academic Culture

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The Reality Challenges and Barriers to Training
in FQHCs
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Brainstorming solutions for training in FQHCs

• What is the value-added to FQHCs to have
  trainees?
• Partial Answers
• Recruitment and retention
• Expanding access
• Professional development for staff
• Interdisciplinary student training
• Program development
• Research

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Importance of cultural and linguistic competence
(CLC) in collaborative care

• There is a growing presence of diverse
  ethnic/cultural groups in society. Latinos
  comprise one of the fastest growing minority
  groups.
• Health care providers are increasingly challenged
  to address the needs of a linguistically and
  culturally diverse clientele.
• Providers and trainees in agencies that cater to
  underserved populations are especially likely to
  interact frequently with diverse groups.

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The Ideal CLC in Collaborative Care

• The training agency must uphold the delivery of
  culturally competent care as a core value.
• Effective multicultural training Providing
  trainees exposure to a diverse client group,
  including minority clients
• Effective multicultural training Opportunities
  to train with ethnically diverse faculty
• Culturally Competent Supervision
• Establishing a broad definition of culture and
  appreciating the heterogeneity within a cultural
  group.
• Encouraging self-awareness in supervision.
• The value of bilingual supervision.

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The Reality Challenges and Barriers in CLC in
Collaborative Care

• Recruiting clinicians and trainees from diverse
  backgrounds can be tricky.
• Lack of bilingual clinicians makes it difficult
  to serve non-English speakers.
• Cultural competence training for staff Budget
  and time constraints.
• Overcoming barriers to accessibility of services
  for underserved populations.

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The Reality Challenges and Barriers in CLC in
Collaborative Care

• Issues in providing culturally competent
  supervision
• Lack of bilingual supervisors places limits on
  the linguistic development of trainees.
• Supervisors often do not get guidance on how to
  be a culturally competent supervisor.
• Supervision Making incorrect
• assumptions about the type
• of training experiences
• that minority students
• desire.

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Brainstorming solutions for CLC in Collaborative
Care

• How might a healthcare agency go about
  demonstrating a core value in culturally
  competent care?
• How do we become more accessible and connected to
  the communities we serve?
• How do we enhance cultural competency in the
  healthcare setting?
• What are some areas for growth in providing
  multicultural supervision of trainees?

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Keith Research Evaluation, LLCwww.keithresearch
.com
Keith Research Evaluation

• First Year (Cohort 1) Psychiatry Residents (8),
  Doctoral Psychology Interns (2), and GPEP
  Trainees (3 Spanish-speaking)
• Second Year (Cohort 2) Psychiatry Residents (3),
  Doctoral Psychology Interns (2), and GPEP
  trainees (2 Spanish-speaking)
• Evaluation Methods
• Data Collection Outcomes (pre- mid-course, post
  surveys) feedback (mid-course, end of course)
• Observations beginning, core areas, and closure
• Survey development peer review number of items
• Data analysis and reflections
• Mid-course (formative results) influence on
  training

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Seminar evaluation results - Year 1
Keith Research Evaluation
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Seminar evaluation results Year 1Areas for
improvement
Keith Research Evaluation

• Several participants reported that the
  multicultural content was too focused on
  Spanish-speaking/Hispanic populations (however,
  the grant goal was to focus on these populations)
• There were varying reactions to course content
  and expectations, with some participants feeling
  the reading load was too heavy or repeated
  information that they had learned previously
• Overall, not all participants seemed to be aware
  of the goals of the seminar or how it fit into
  their training program
• Inter-professional collaboration was difficult to
  accomplish

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Year 2 Modifications based on evaluation results
Keith Research Evaluation

• Site visits to integrated health care settings
  were added to seminar in order to address comfort
  with these settings
• All training directors and seminar instructors
  attended the first class in order to ensure
  buy-in from attendees and explain the goals of
  the course within their training program
• Overview of the grant program was more formalized
  in the first class in order to clarify seminar
  focus and goals
• A collaborative project (case study) was added to
  increase inter-professional collaboration between
  psychology and psychiatry

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Seminar evaluation results Year 2
Keith Research Evaluation
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Qualitative evaluation results - Year 2
Keith Research Evaluation

• Buy-in from participants was reflected in
  increased participation within seminar and
  increased cohesion among seminar participants
• Case study collaboration faced logistical
  barriers in terms of finding cases, though
  participants did work at collaboration and some
  were able to present cases to the class
• Attendance requirements were different for
  different training programs due to scheduling
  constraints - this was an evaluation challenge
  and led to different levels of exposure to course
  topics among course participants

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Using evaluation results to inform course
development
Keith Research Evaluation

• What evaluation results from Year 2 are targets
  for improvement in Year 3?
• What can be changed in Year 3 to improve
  participants abilities in the multicultural/
  cultural competencies area?
• Given the logistical challenge of completing the
  case study assignment, how else can the goal of
  increasing inter-professional collaboration be
  addressed?
• How can scheduling challenges across training
  programs be addressed?

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Questions?

• ,