Inter-professional Training in FamilyCentered Integrated Healthcare for the
Underserved Population of Children:
Organizational/Implementation Issues
Integrated
Health
Care
Family
Systems
Cultural
Competence
1
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
2
Learning Objectives
Articulate the relationship between inter-professional
training and integrated health care delivery.

List three reasons children’s 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.

3
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)
4
Key Elements of UT-GPEP
Trainee Preferred Criteria
 Spanish-speaking
 Ethnic minority
 Clinical, Counseling, or
School Psychology (doctoral
only)
 Interest in serving children
& families
 Doctoral level
 2-4th year of training
Training Requirements
 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
5
Training in Family-Centered Care
Training Goals

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
Training Modalities

Interdisciplinary seminar

Individual and group supervision

Training experiences in family
assessment, family therapy, and
family-centered care

Family case study presentations
6
Training in Integrated Health Care
Training Goals
Models
Training Modalities
of integrated health care
How to integrate
physical and

Interdisciplinary seminar

Training experiences in
integrated health care
settings/FQHCs

Policy involvement

Site visits

Research
behavioral health
Barriers
to implementation
Knowledge of integrated health
care initiatives across the nation
7
Training in Culturally and
Linguistically Competent Care
Training Goals
Role of
Training Modalities
culture and language in the
delivery of services

Interdisciplinary seminar
Emphasis on Spanish-speaking and

Bilingual/multicultural
supervision

Training experiences in settings
serving diverse populations

Research
Latino families
Development of knowledge, skills,
and awareness in providing care for
diverse populations
Understanding
among children
of health disparities
8
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
9
The Ideal:
Keys 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
10
The Reality:
Challenges 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
11
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 one’s professional group and tendency to overdifferentiate 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
12
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
13
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
14
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

15
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
16
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?
17
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
18
The Ideal:
Family 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
19
The Training Setting

Mental health collaboration between University of
Texas and Dell Children’s Medical Center



Trainees providing therapy services
Outpatient clinic: collaboration between psychology and
psychiatry
Children’s Hospital
• Trainees embedded within
interdisciplinary teams of
pediatric subspecialty
services (oncology, obesity)
20
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
21
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

22
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
23
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?
24
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.)
25
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
Program
development
Managing
technology
26
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
27
The Reality: Challenges and Barriers
to Training in FQHCs
28
Brainstorming solutions for
training in FQHCs
What is the value-added to FQHCs to have trainees?
Partial Answers:
1. Recruitment and retention
2. Expanding access
3. Professional development for staff
4. Interdisciplinary student training
5. Program development
6. Research
29
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.
30
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.
31
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.
32
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.
33
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?
34
Keith Research & Evaluation, LLC
www.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:
Survey
Data
beginning, core areas, and closure
development: peer review & number of items
analysis and reflections
Mid-course
(formative results) influence on training
35
Seminar evaluation results - Year 1
Keith Research
& Evaluation
Family Therapy
Statistically significant increase in knowledge, comfort, and abilities
Integrated Health Care
Statistically significant increase in
knowledge and abilities
No increase in comfort
Multicultural Competence/ Cultural Competencies
Statistically significant increase in knowledge, comfort, and abilities
36
Seminar evaluation results – Year 1
Areas 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
37
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
38
Seminar evaluation results – Year 2
Keith Research
& Evaluation
Family Therapy
Statistically significant increase in knowledge, comfort, and abilities
Integrated Health Care
Statistically significant increase in knowledge, comfort, and abilities
Multicultural Competence/Cultural Competencies
Statistically significant increase in
knowledge and comfort
No increase in abilities
39
Qualitative evaluation results - Year 2
 “Buy-in” from participants was
Keith Research
& Evaluation
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
40
Using evaluation results to inform
course development
What evaluation results from
improvement in Year 3?
Year 2 are targets for
Keith Research
& Evaluation
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 interprofessional collaboration be addressed?
How
can scheduling challenges across training programs
be addressed?
41
Questions?
,
42