Since the emergence of the Patient Protection and Affordable Care Act of 2010, we have been hearing a great deal about the transformation in healthcare and the central role that primary care medicine plays in the new healthcare system. As you may recall from earlier communications and our Fall 2014 survey, SCN has been examining the role that neuropsychologists play in interdisciplinary “patient centered” care settings. The idea of patient care settings is that patients are more likely to receive the behavioral health services they need if all specialists are either “co-located” or fully integrated (“embedded”) into one “medical home” setting. In this new healthcare world, primary care physicians (PCPs; including pediatricians and family medicine physicians) are expected to perform behavioral health and cognitive wellness screenings or work within a system where other disciplines provide those services to the patient in the same clinic. Indeed, there are incentives for performing these behavioral health (including cognitive) screenings and potential penalties when they are not addressed (can anyone spell PQRS?).
What would clinical neuropsychology be like in a primary care setting? While Health Psychology easily fits into this embedded model of care delivery through providing consultation to PCPs or health and behavior services for issues such as sleep disorders, obesity management and treatment for pain conditions, where do neuropsychologists fit into a model where primary care is the place where service is delivered? When trying to apply this model of work to clinical neuropsychology, it doesn’t seem easy to conceptualize. After all, if the neuropsychologist is expected to be available for consultation or supervision in real-time in the clinic, it's problematic to start and then interrupt testing or treatment sessions once they begin. Yet, to not be willing to change means very simply that we will be replaced by inexpensive computer programs promising diagnoses of Alzheimer’s disease or ADHD in 10 minutes or less. Therefore, I have been extremely interested in hearing from neuropsychologists who are already working in primary care settings in order to understand how they are functioning, what kind of services they provide and what administrative or supervisory role they play as a part of an integrated healthcare team.
So what is primary care Neuropsychology and how does it differ from typical “silo” service delivery? Let's turn to Dr. Josette Harris, a longtime colleague and friend who until recently was working in a primary care setting at the University of Colorado. According to Dr. Harris, the primary care clinic provides broad wellbeing screeners for cognition, anxiety, depression, bipolar disorder and substance abuse. According to Dr. Harris, the physicians don't typically want nor have the time to perform cognitive screenings on their own, so doctoral level neuropsychologists teach medical residents and other clinic trainees how to give screeners like the Montreal Cognitive Assessment (MoCA) in the clinic. Those patients who are suspected of having cognitive impairment are then introduced to the neuropsychologist (who is also physically present in clinic) for further interview and possible evaluation (sometimes called the “warm handoff”). Those patients with suspected cognitive impairment from the MoCA are given an abbreviated battery in clinic that involves an expanded mini-mental state exam, RBANS or Dementia Rating Scale to determine if further (comprehensive) assessment is needed. Additionally, as a member of the care team, Dr. Harris also attended case conferences in the clinic and contributed to the education of team members including physicians, physician assistants and nurses on detection of neuropsychological issues among other clinical concerns. In general, Dr. Harris in her role made herself available to provide in the moment input to team members in clinic and was considered a valuable and essential team member. Her presence helped others to see the important role that neuropsychology can play in the overall care of the patient. I would welcome hearing from other neuropsychologists about their experiences in integrated primary care settings (firstname.lastname@example.org).
Finally, it is worth noting that the primary care world is most concerned about those patients who are the highest utilizers of medical services. Indeed, chronic diseases accounted for 75% (or $1.9 trillion) of the nation’s healthcare costs in 2009, and national data suggest that 25% of Medicare beneficiaries were responsible for 85% of Medicare costs that same year. Identification of cognitive and emotional barriers to treatment that contribute to the frequent users of the healthcare system represent an important role that neuropsychologists can play in the primary care setting.
My advice to early career psychologists is come out of the silo.
Be prepared to utilize shorter test batteries. In these settings, don't take an extensive history and do more targeted testing. Become comfortable in the role of consultant, as many of our psychiatrist colleagues already have. Train and be trained to work using shorter batteries in addition to the longer and more formal assessments we typically perform. To those #dinosaurs out there (like me), don't be afraid of technology and be prepared to start looking at the role that handheld devices can play in our work. I strongly believe that our specialty needs to remain relevant in this new healthcare world and that means being willing to adapt or prepare to be replaced with less overtly costly options. Neuropsychologists are used to working within treatment teams to achieve better outcomes for patients. We now have to expand the settings where we work. It might also mean reconsidering the kind of work product that we produce. After all, I have heard from many physician colleagues over the years how they "skip to the end of the report to learn the final results" and how many of our non-psychologist colleagues are unable to understand and appreciate the nuances of test results sections when we use our own special language that is not well understood outside of our profession with terms such as “prepotent responses”, “failure to maintain set”, and even executive function. We must embrace our new role in the capitated healthcare world and be prepared to demonstrate our utility and relevance based on the unique information we provide. There will be more formal communications and publications forthcoming regarding the results of the survey later this year.
Best wishes to all for a healthy and prosperous summer.