Cutting-Edge Health Care Approach Gains Momentum at UT

By Roy Varney
For Reporting Texas and the Austin American-Statesman

The doctor at Dell Children’s Medical Center sensed that he wasn’t getting through to an 11-year-old boy who showed signs of prediabetes. The boy needed to change his diet, and he was resisting.

The doctor turned to Elizabeth Walsh, a graduate student in psychology at the University of Texas at Austin. Using videos from the American Diabetes Association, she explained to the boy how failure to eat differently might lead to Type 2 diabetes. Then she devised quizzes to test his understanding.

The boy “didn’t really have a lot of buy-in,” Walsh said. But when he understood, ” ‘Oh, this could mean in five years I’m taking insulin shots,’ that really brought it home.”

Walsh worked with the boys while she was enrolled in a UT program designed to train psychologists in integrated health care, in which teams of specialists deliver comprehensive services to patients in a one-stop setting. Proponents say it’s the most efficient, economical and effective way to care for patients. The UT program trains psychologists to work with physicians, social workers and other specialists to help the whole patient, body and mind.

Integrated care, also called interprofessional care, is not a new concept, and the professional teams don’t always include a psychologist. But President Barack Obama’s health care program, the Affordable Care Act, embraces integrated care as a tool to achieve one of its primary goals — expanded preventive care.  The people behind Walsh’s program hope to embed the integrated care approach, including the focus on mental health, in UT-Austin’s new medical school and, by doing so, to improve care for the millions of Texans without insurance and regular health care.

Money for Walsh’s training comes from the Health Resources and Services Administration, the federal agency that takes the lead in figuring out ways to improve health care for people who are uninsured or otherwise at risk of bad care. The UT College of Education has received two training grants, worth nearly $800,000, as part of the agency’s effort to promote integrated care.

Walsh is sold on the idea. “Promoting healthy living is something everyone should have access to,” she said, comparing it to the right to public education. Additionally, Walsh said, preventing the boy’s condition from deteriorating is cheaper than treating complications of diabetes later in life.

Cindy Carlson, chair of the Department of Educational Psychology, oversees the grants and believes integrated care gives poorer populations access to premium health care.

“The exciting thing that’s happening in health care right now are these structures, physical and organizationally, that are getting set up that work hard to treat the whole patient, with all of the providers in a single setting and accessible to the patient, and sharing an electronic record and working together as a team to provide for the patient’s needs,” Carlson said.

Treating patients multiple issues in a single stop is especially important for poor people, who often lack access to transportation or don’t have a flexible work schedule, she said.

The emphasis on integrated care at UT has its roots in research done at the Hogg Foundation for Mental Health, which promotes the approach as part of its mission to improve mental health care in Texas. In 2006, it awarded seven clinics around the state grants totaling $2.6 million to start integrated care programs.

The foundation then hired a research company to study the effectiveness of depression treatment at the clinics. The researchers determined that after three years, at least half the patients at six of the clinics showed some improvement and more than 40 percent of patients at five clinics achieved depression remission. It credited the success to the integrated care approach.

A 2012 report from the foundation found that integrated care helped patients manage health issues, such as depression and diabetes, which are more likely to afflict less affluent people.

The first grant program started in 2010 and trained nine psychology doctoral students to work with children in an integrated-care setting. The program featured four specialized courses and upwards of 20 hours of weekly clinical training. Carlson’s latest grant is paying to train 15 students to treat adults with mental health issues.

Kiara Alvarez participated in the first grant program and is now completing a one-year internship at Boston Children’s Hospital, the pediatric teaching hospital for Harvard Medical School. While studying at UT, Alvarez also helped treat low-income families at People’s Community Clinic, where she used her integrated training to help children dealing with diabetes and depression.

“I had the opportunity to see how pediatricians approach mental health issues and behavioral health issues in the context of this practice where they’re seeing so many patients every day,” Alvarez said. “That’s really different than the traditional psychology practice where you’re seeing someone for 50 minutes at a time.”

The workload Alvarez experienced is common at community health centers, which are designed to give low-cost assistance to impoverished communities. The Affordable Care Act will put $11 billion into building more community health centers across the country.

Kathryn Cook, a spokeswoman for HRSA, said integrated care is a primary focus of the act.

“The big push now in community health centers around the country is that interprofessional care is really going to help tremendously the underserved populations,” Cook said.

The grant money is critical. A 2012 study by the Colorado Health Foundation found that revenue generation covered only 21 percent of the costs associated with providing integrated care at primary providers in that state.  Many of the professionals interviewed expressed concern that integrated care is built on grant dollars and that it is financially unsustainable.

“The current payment structure.. in almost all states doesn’t really support integrated care, and it doesn’t support it because of the way services are paid for,” said Ben Miller, director of integrated health care research at the University of Colorado School of Medicine.

For psychology students in the UT program, there’s plenty of opportunity to test the benefits of integrated care at the 69 community health centers already operating in Texas and others that could emerge. Only 33 percent of adults with mental illness in Texas receive care, and one-third of Texas counties do no have a licensed psychologist.

Barbara Jones, an associate professor of social work at UT, trains participants in the grant programs to work in teams. Twenty-five students from five disciplines — social work, nursing, medicine, pharmacy and psychology — are taking her course.

In a recent class exercise designed to improve communication, she divided students into groups and directed them to create a structure using uncooked spaghetti and marshmallows. Each group received different instructions, and only certain members could carry out certain tasks. A class discussion revealed that the challenge forced the students into unfamiliar roles. They learned how to contribute to their group’s progress, despite restrictions on their methods of communication. Members of different professions gained new respect for their peers.

Jones said the HRSA grants are small, given the demand for people trained in integrated care.

“There needs to be more funding for mental health training in both social work and psychology in Texas, specifically. That is my very strong belief. But it’s a start,” Jones said.

Jones, a member of the interprofessional educational subcommittee of the new UT Dell Medical School, said the school will feature a “real dedication” to interprofessional training.

“What’s nice about what’s happening with the Dell Medical School is we can build it from the ground up. So it’s not like trying to now put interprofessional education on top of a system that’s run a certain way… and I think that’s a great opportunity,” Jones said. “It’s really going to be the way of the future.”