In 2001, as a pediatric psychologist, W. Douglas Tynan, PhD, noticed some troubling trends: More than half of patients’ visits to their primary-care physicians were driven
by psychological problems, such as anxiety, panic, depression
and stress. In addition, while many patients were referred to a
mental health provider for treatment, few patients followed up.
“Even though some of our primary-care clinics were less
than three miles away from the hospital where the outpatient
behavioral health office was, we’d get referrals and the patients
wouldn’t come,” remembers Tynan, who at the time worked at
Nemours/Alfred I. duPont
Hospital for Children in
Wilmington, Delaware.
To help make mental
and behavioral health
services more accessible,
Tynan developed a
federally funded program
that trains pediatric and
psychology residents to
work together to assess
and treat child behavior
problems in primary-care
settings.
“Among low-income,
difficult-to-reach
populations, this is the
most effective way for
people to get their mental
health services,” says
Tynan, who in May joined
APA staff as director of
integrated health care.
The program Tynan
developed proved
revolutionary for the
Nemours system. By
educating physicians and
patients about the benefits
of psychological treatment and co-locating psychologists in
primary-care offices, the program sharply reduced the number
of patient no-shows for outpatient mental health care, decreased
the stigma associated with seeing a psychologist and improved
access to care for behavioral issues, such as attention-deficit
hyperactivity disorder, says Hal Byck, MD, a pediatrician at
Nemours’s Jessup Street Clinic.
“The fact that they’re part of our office makes seeing a
psychologist more palatable for a lot of patients,” Byck says. Plus,
the psychologists have been able to help primary-care providers
and other staff handle the psychological stress that comes with
their jobs. “It’s been a win-win for everyone working here.”
Today, as one of the nation’s largest integrated pediatric
health systems, Nemours treats 250,000 children a year — many
of whom are minorities or located in health-provider shortage
areas — through its children’s hospitals in Wilmington and
Orlando and its pediatric specialty clinics in Delaware, Florida,
New Jersey and Pennsylvania.
Six of the system’s 10 primary-care clinics are pursuing
NCQA recognition
as a patient-centered
medical home (see
article on page 38), and
Nemours continues to see
improvements in patient
care and outcomes as a
result of the integration of
psychologists into primary
care, says Cheyenne
Hughes-Reid, PhD, a
pediatric psychologist with
Nemours.
“It’s about increasing
communication across
providers, making sure
we’re following up on
referrals and making sure
we’re addressing barriers
many families face,”
Hughes-Reid says.
The system is also
working to develop
customized care plans
for every patient seen by
a Nemours primary-care
physician. Those plans
would include several
treatment or wellness goals
that the patient develops with help from his or her care team.
It’s a way to make sure all of the health-care professionals
a patient sees are on the same page and following the same
treatment protocol, and it helps the patient feel more in control
of his or her health, Hughes-Reid says. “That’s particularly
important for the population that we work with because of all
the needs they have and the challenges they face,” she says.
In addition to providing therapy and brief interventions
with patients in primary-care practices, Nemours primary-care
“Rather than leading more
formal seminars, our
psychologists are more
focused on shadowing
and on-the-spot training
opportunities with their
colleagues. It’s much more
effective at that level because
it’s not just hypothetical.”
JENNIFER SCHROFF PENDLEY, PHD
Nemours/Alfred I. duPont Hospital for Children in
Wilmington, Delaware
