Two years ago, the Chiefs of Medicine at Kaiser in Northern California redesigned the delivery of services in Adult Primary Care, both to improve the quality of care for patients, and to respond to the heightened stress levels among primary care physicians, whose volume of practice was described as "unsustainable." The redesign provided for each medical "module" of six physicians and two nurse practitioners to also include a full time Behavioral Medicine Specialist and a Clinical Health Educator. Since there are currently about 85 primary care modules in Kaiser's Northern California Region, the redesign represents a significant innovation in the delivery of health care services. Dr. Tulkin was the one Behavioral Medicine Specialist among the 50 members of the redesign group, and Dr. Guzman is currently Chair of the regional group of Behavioral Medicine Chiefs from each of 22 facilities. In this report, we would like to summarize some of the systems issues brought up by this project, and discuss some of the types of clinical cases we are encountering in primary care.

The job responsibilities for the Behavioral Medicine Specialist include:

1. Evaluate patients in primary care who have mental disorders or behavioral problems which affect their medical condition, or are a consequence of their medical condition;
2. Co-manage medical conditions through the use of nonpharmacologic and behavioral interventions;
3. Collaborate with physicians in screening and evaluating patients for psychotropic medications within the scope of practice;
4. Provide consultation and training to other members of the primary care team in the areas of mental health, behavioral medicine, and health psychology;
5. Provide consultation on program development, and conducts program evaluation and outcome assessment as needed;
6. Independently conduct evaluations in State Disability and Workers Compensation cases.

Undertaking a change of this magnitude is certain to produce objections and resistance from a number of fronts. In order to understand physician attitudes, we conducted focus groups prior to implementation of the new model at the Hayward Medical Center. While many welcomed the new team members, others voiced concern that they would "no longer be given time to deal with the human aspects of the doctor-patient relationship," which, one physician said, "is why I became a doctor in the first place." Others were concerned that "administration is only doing this so they can tell us to see more and more patients. We'll end up even more stressed than before." Empathic response to their concerns, and our commitment to "build the team" so that it met everybody's needs was helpful in getting through some of the initial resistance. More important, however, has been our ongoing sensitivity to these feelings as we have worked on the team with our new colleagues, who, themselves, had nothing to do with redesigning the system and bringing us "outsiders" on to the team. We are continually aware that we are "newcomers" in their territory, and while we are not hesitant to share what we know, we understand that it will take time for us to be accepted as partners.

A particular group of physicians which was upset about the new model was psychiatrists, who voiced concern about the expectation that Behavioral Medicine Specialists were going to be "co-managing medical conditions" and 'collaborating with physicians' regarding psychotropic medications. Some even said that such activities were illegal. In response to these concerns, the governance structure for Behavioral Medicine Specialists was designed to include a Quality Assurance Committee which would include a psychiatrist, and also to recommend that a specific psychiatrist be appointed as a liaison to the Behavioral Medicine Specialists so that consultation would be readily available for complex cases. We were also active in the campaign for passage of a "Psychopharmacol-ogy Education" bill in the California legislature. That bill, which was signed into law in September, specifies the importance for psychologists to understand psychopharmacology and to discuss medication issues with patients and physicians. Specifically, the bill notes the role of psychologists in evaluating the patient's need for medication, as well as the patient's response to psychotropic compounds including side effects. This bill clarifies the legal status, but the political issues still remain.

Another important group of resisters has been our fellow psychologists, some of whom feel that we are undermining the value of psychotherapy by working in primary care, seeing patients for two or three 30-minute appointments, referring them to "educational" classes rather than group therapy, and participating in the decision that medication and brief cognitive reframing can be an effective treatment for conditions such as depression. Even psychologists who believe in the model have had difficulty overcoming their own biases and training when they enter the primary care setting to work as a Behavioral Medicine Specialist. Our response is to remind our colleagues about the differences between primary, secondary and tertiary prevention, and to assure them that we are doing assessments and triage, sending those who need more intensive treatment to specialty mental health providers. Specific recommendations were developed by a Psychiatry-Primary Care Interface Committee for referral criteria for the eleven most common psychiatric diagnoses. However, there are still many colleagues who feel that we have betrayed them and are furthering the demise of professional psychology. We respond that we believe there needs to be more than one approach to treatment, and that behavioral medicine in primary care serves as an important primary and secondary prevention intervention, which does not reduce the need for psychologists to offer longer term therapy for those who need that treatment.

Some of the patients referred to Behavioral Medicine have symptoms of depression or anxiety. For example:

1) A 60 year old man whose wife had died of cancer within the past month. He stated "It's more difficult than I had anticipated." He did not have many friends, and was concerned about his isolation. His concentration was poor, his energy was low, and he could not sleep, even on the 25 mg of Elavil that has been prescribed by his internist. We discussed the normal process of grieving; he accepted a referral to Medical Social Work to discuss a spousal bereavement group, and his internist raised his Elavil to 50 mg. He will see me again in a month when he returns to see his internist again.

2. A 50 year old male referred because of symptoms of anxiety, stated that he had been anxious since his early 20's. It was now getting worse and he reported having palpitations, difficulty swallowing, shortness of breath, and feeling like he will faint. I discussed with him that these were indications of a panic attack. We practiced diaphragmatic breathing, and he accepted a referral to a behavioral health class on anxiety and panic. His internist prescribed Paxil, starting at 10 mg daily for one week and increasing to 20 mg daily thereafter. The patient will see me again after the class, or earlier if necessary.

Sometimes, however, cases are more complicated, for example:

A 59 year old man with diabetes was referred because of symptoms of depression: decreased energy, decreased appetite, sleep problems, and problems with memory and concentration. On examination, however, he stated that he never had problems like this before. He also reported that he had a "bad taste" in his mouth, had kinesthetic distortions (car was moving when it had actually stopped), and felt that people were spying on him. I told the internist that the problem might be organic. After investigating various possibilities, the internist concluded that the symptoms were a reaction to Glucophage (Metformin), and after the patient stopped the medication, he no longer had the symptoms.

Other patients are referred because of overuse of narcotic or sedative hypnotic medications. We are asked to talk with patient who may be chemically dependent (a significant percentage of primary care patients), or to make a differential diagnosis between somatization and chemical dependency. After making a diagnosis, we can explain to patients how they could improve their physical as well as psychological condition by participating in a program or class. We have developed "Mind-Body Medicine" classes, as well as Pain Management and Healthy Living with Chronic Conditions. Each Medical Center has Behavioral Health Coordinator with the responsibility of developing classes to serve primary care and psychiatry patients.

Sometimes, patients are manipulative or noncompliant, and physicians simply need consultation and reinforcement for setting limits and dealing with patients' anger or rejection. In cases like this, the Behavioral Medicine Specialist will often see the patient along with the physician or nurse practitioner--and model the limit setting or negotiation behavior. In-service training sessions are also being planned to teach physicians and nurse practitioners skills in negotiation and limit setting.

Monitoring of outcomes is critically important for evaluating the success of this redesign. We will be assessing patient satisfaction, changes in quality of life and health status, changes in medical utilization, and impact on physician morale. We feel that the implementation of this redesign of primary care services is important for psychology, and for health psychology in particular. It is an example of how research has had an impact on health care policy and practice. We are indebted to researchers who have demonstrated that stress affects the immune system, that stress makes somatic symptoms worse, that "health locus of control" (being able to understand and have some effect over health) is related to better health outcomes, and that a significant percentage of primary care visits relate in some way to psychological factors. It is this psychological research which forms the platform on which Kaiser's redesign has occurred. We hope to be able to now provide data on the successes and failures of this large scale system change.

Drs. Tulkin and Guzman invite feedback from the readers of this article. You may contact Dr. Tulkin at Steven.Tulkin@ncal.kaiperm.org, and Dr. Guzman at John.Guzman@ncal.kaiperm.org.

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