Individuals who take our online course, Primary Care Behavioral Health are asked to fill out a retrospective pre/post evaluation after the course. We ask them to measure the change in their competency as behavioral health providers working in primary care before and after the course. The competencies we use are referred to as the “Colorado competencies” after this report published by the Farley Center in 2017.
But until now, there has been no list of essential skills for medical residents who are learning about integrated care. Recently the journal Family Medicine published Essential Skills for Family Medicine Residents Practicing Integrated Behavioral Health: A Delphi Study. Lead author, Matt Martin, Ph.D., LMFT has been a colleague of CIPC faculty and generously agreed to be interviewed for this post. CIPC faculty member Amber Hewitt Cahill is also part of the distinguished team that authored this study.
Matt Martin is a clinical assistant professor in the Integrated Behavioral Health program at Arizona State University. He teaches classes on quality improvement, interprofessional leadership, and motivational interviewing. His research interests include integration measurement, family-centered care, and workforce development. Before coming to ASU, Matt was a behavioral medicine educator at a family medicine residency program in North Carolina. He is also a licensed marriage and family therapist.
CIPC: As lead author, what in your opinion is the most revelatory finding in the study? What surprised you or was unexpected?
Martin: My greatest hope and I believe I speak for all the team, is that the list of essential skills published in this work and derived using the Delphi methodology will guide residency programs in their own curriculum development.
Let me talk more about the curriculum our team created. The actual point of our entire project was to create a curriculum for family medicine residents, but we quickly realized we had no “end zone” for our target. There were no competencies specific to integrated care. That’s what led us to spend a year using the Delphi method to develop a solid list of skills necessary for family medicine physicians working in integrated settings.
CIPC: Had you used the Delphi methodology before this study? If yes, can you briefly describe that instance? How critical do you think using this method to evolve the IBH competencies has been?
Martin: This was my first time using the Delphi survey method, but I had heard about it before starting our study. I looked at several examples in the literature for guidance.
The purpose of the Delphi design is to target content experts, minimize the impact of strong personalities, and create a bi-directional learning process. We learned from the participants just as they were learning from us. That process is described in our paper. The Delphi method was very critical for the success of our study. The only alternative would have been to get all the content experts on a conference call or into the same room. That can be very expensive and challenging to schedule; moreover, you may have certain personalities dominate the conversation.
During our work, I was most surprised by the specific physician role reflected in the list of skills. Our survey participants were pretty clear about what physicians should and should not be doing.
For example, most of our participants believed that it is not the role of the physician to conduct comprehensive assessments, manage behavioral health crises, or regularly implement process improvement strategies. Participants were on the fence about other skills like explaining services to the patient and directing the collaboration of team members. I think our participants believed that integrated care should clearly shift certain responsibilities from the medical provider to the rest of the team, including the behavioral health clinician.
CIPC: How well do you anticipate the acceptance of these competencies in Family Medicine residency education will be?
Martin: During the second year, we used the competencies as a foundation to build a curriculum that includes both online learning and a live workshop. We started a pilot at the end of 2018 to test this residency curriculum. The pilot is ongoing right now with eight residency programs testing the curriculum for us. The preliminary results show that knowledge and confidence increased post-training.
When we started recruiting for the pilot, we got a pretty strong response from several programs that were interested in participating. I think there are many programs out there that want a structured curriculum to prepare all their residents for team-based, whole-patient care. Our curriculum can help fill that void for programs.
CIPC: If there is anything in the Family Medicine article that you would have liked to expand upon—please feel free to do so here.
Martin: We created a list of behavioral health anchors (also known as entrustable professional activities) as discrete demonstrations of skill that residency faculty can track and observe. The original list of competencies is a good starting point, but we realized that some programs may not know how to measure or evaluate residents on some of the skills. Unfortunately, there was no room in the article to add the list of anchors.
A second thing I’ll mention refers to the general role of the medical provider on the care team. Physicians, physician assistants, and nurse practitioners play important roles on the care team; but most of them may need training in task delegation, team communication, accountability management, and other team-based skills. I think those skills are vital for integrated care to work.
The next step after the pilot is to expand our competencies and curriculum to include other primary care medical disciplines.
