As psychology becomes increasingly involved in providing primary health care, it is absolutely essential to establish collaborative relationships with other health professions to ensure that the critical psychosocial-cultural-economic gradient of care becomes incorporated into society's definition of "quality care." This is best accomplished during one's early training years, and it is important to appreciate the unique opportunities for training and expanded practice provided by our nation's community health centers (CHCs).
The CHC movement was an integral component of President Lyndon Johnson's "War on Poverty" and is distinct from the community mental health center initiative associated with President John F. Kennedy. The CHCs represent our nation's true "safety net," and the current administration has requested nearly $2 billion for the coming year in order to significantly expand access points and services through 1,200 additional sites across the nation.
Serving the most vulnerable
CHCs operate at the local community level and provide high quality, family-oriented, comprehensive primary and preventive health care (including mental health care), regardless of patients' ability to pay. Approximately 14.1 million patients are seen annually, of whom 63.6 percent are ethnic minorities; 59 percent are female; 25 percent are children under the age of 12; 44 percent live in rural America; and more than 795,000 are homeless. Twenty-nine percent of patients are best served in a language other than English or with sign language. Approximately 38 percent of health center patients are on Medicaid or other public programs; 7.5 percent are on Medicare; and nearly 40 percent are uninsured. CHCs serve our nation's most vulnerable citizens, including those with low incomes and from minority populations that experience significantly higher rates of many diseases, including diabetes, asthma, high blood pressure, cancer and HIV/AIDS.
For those of our colleagues who are concerned about developing viable strategies for reducing health disparities, CHCs provide an unsurpassed opportunity. Of interest to psychology faculty and graduate students, CHCs possess the potential for providing exciting training experiences and are deemed Health Professional Shortage Areas for fulfilling federal loan-repayment requirements (see page 23 for more information). And, for those practitioners willing to provide pro bono services to the community, what better place, for example, to demonstrate the efficacy of biofeedback care for a wide range of clinical problems?
Hawaii's prescriptive authority legislation is based upon practicing within CHCs, and as the state's bill notes: "(P)sychologists at the Waianae Coast Comprehensive Health Center completed approximately three thousand eight hundred forty patient encounters in 2004; seventy percent of these patients received necessary psychotropic medication for the treatment of mental illness." We would rhetorically ask: What better place for those seeking postdoctoral clinical psychopharmacological experiences than at their local community health center?
Integrating behavioral and physical care
Within CHCs, psychology trainees learn to participate on multidisciplinary health provider teams, stressing coordinated and integrated care. This early socialization in an interdisciplinary approach will provide our next generation of clinicians with an understanding of the nuances of the 21st Century health-care environment, including using electronic records, providing telehealth care and emphasizing preventive care. Students also discover the unique knowledge and skills they bring from the discipline of psychology to the health-care team. They see for themselves, and demonstrate to others, how health care is improved and how patients benefit from the integration of behavioral and physical health care. By learning how to practice in new formats--such as brief consultations with nurses and physicians, one to three sessions with patients and families and routine behavioral health screenings--students discover the potential for applying their skills in new and beneficial ways in the ever-changing world of health care. They also are exposed to patients they might not otherwise see: those individuals who do not enter mental health care systems because of issues related to stigma, lack of awareness, access or affordability, but who need and can benefit from behavioral health services. The skills of collaboration and obtaining an in-depth appreciation for the clinical contributions of other disciplines stands in sharp contrast to psychology's (and other health professions') traditional silo-oriented, isolated models of training and treatment. As health-care systems move to collaborative care models, educators must find ways to incorporate this learning early on in the training sequence. At present, only a handful of the 3,745 CHCs include psychology training; we must do better.
The importance of the biopsychosocial approach to health care with a wide range of patients becomes more central as psychology gains increasing recognition as one of our nation's health-care professions, rather than as an exclusively mental health profession. The CHCs are an excellent venue for fostering this approach and for demonstrating to society our essential role in quality health care.
Patrick H. DeLeon, PhD, MPH, JD, served as APA's president in 2000. Mary Beth Kenkel, PhD, is dean of the College of Psychology and Liberal Arts at the Florida Institute of Technology. Cynthia Belar, PhD, is executive director of APA's Education Directorate.
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