Sixteen-year-old Kyle* and his mother visited the Geisinger

Health System primary-care clinic in Pottsville, Pennsylvania,

last winter in search of treatment for Kyle's chronic acne.
Toward the end of the visit, Kyle's mother told the doctor,
William Gianfagna, MD, that Kyle seemed sad of late and
uninterested in some of his favorite activities. Gianfagna spoke
with Kyle for a few minutes and discovered he was depressed
and even having suicidal thoughts.
"In the past, I honestly would have tried to bail and sent him
to the emergency room;' Gianfagna says.
But times have changed at the clinic, one of more than SO
Geisinger community practice sites serving 2.6 million patients
in central and northeastern Pennsylvania. That's because
Geisinger is now focused on integrated care. Three years ago,
the facility was one of three pediatric community centers
selected to pilot an integrated-care program in which primarycare physicians, psychologists, nurses and other medical
professionals work together to diagnose and treat physical and
psychological health problems.
Gianfagna and other physicians learned how to screen for
depression, anxiety, attention deficit hyperactivity disorder
and several other mental health conditions, and now have a
full-time psychologist and several psychology residents down
the hall available for one-on-one and group therapy or for
consultations on a variety of mental and behavioral health
conditions.
Armed with those skills, Gianfagna was able to spot the
depression and get Kyle in to see a psychologist that night.
"When I called the next morning, they already had a pretty
good plan in place to treat him;' Gianfagna says.
His eagerness and comfort level with using this mental
health screening is one of several signs that Geisinger's
integrated approach is working, says Tawnya Meadows, PhD,
a pediatric psychologist at Geisinger's primary-care clinic in
Selinsgrove, Pennsylvania.
"Anecdotal reports show that our physicians are feeling less
stressed and more prepared because they have the screening
instruments they need and our guidance," she says.
Preliminary data indicate that the approach is also reducing
health-care costs and improving patient care, says Paul
Kettlewell, PhD, Geisinger's chief pediatric psychologist. The
system's health insurance company, Geisinger Health Plan,
reports a statistically significant reduction in total pharmacy
expenses for children in the integrated-care pediatric primarycare settings compared with non-interventions sites. In
addition, the average length of treatment is shorter in integrated
care: approximately 4.5 sessions, compared with 19 sessions at
Geisinger's traditional behavioral health outpatient clinic.
Perhaps most important, the program is increasing access
to behavioral health services, says Shelley Hosterman, PhD, a
pediatric psychologist at the Pottsville clinic.
"I see families who have been referred by their primary-care
physician to outpatient behavioral health clinics four, five, six
48

times and they have never gotten in touch with services because
there's just too many barriers - distance, travel, making
the scheduling calls - it just involves all this extra work;'
Hosterman says. "Now, those families who really need care are
just passed down the hall to us and they start getting quality
services right away."

A reputation for excellence

Geisinger Health System serves mostly rural Pennsylvanians,
providing health-care services ranging from primary care to
complex medical subspecialties such as pediatric endocrinology
and urogynecology. Geisinger also uses a state-of-the-art
electronic medical records system to track patients throughout
its 1,000-member multi-specialty group practice, seven hospital
campuses, two research centers and dozens of community
practice locations.
Psychologists are part of many medical teams throughout
the system, says Charlotte Collins, PhD, chief of behavioral
medicine and adult psychology at Geisinger. They work
with many different medical populations, including those
undergoing bariatric surgery, diabetics in need of help
managing their medical regimen, cancer patients and those
experiencing chronic pain, she says.
"From the very beginning, Geisinger was a collaborative
group practice where the staff cooperated for the good of the
patient, and psychologists have always been ranked as part of
the professional staff;' Collins says.
It also helps that psychologists are part of the system's
psychiatry division, and the two groups support and celebrate
each other's successes, Collins says. Maintaining a cooperative
relationship with psychiatry is part of why Geisinger's
psychologists are so well-respected, says Randy Phelps, PhD,
director of APA's Office for Health Care Financing.
"Geisinger doesn't have psychiatry versus psychology turf
issues," Phelps says. "They respect each other there, and if health
care is really moving toward integrated, team-based care, that's
absolutely essential:'
Geisinger is the only hospital in the state in which
psychologists have hospital privileges. That shows the system
values them at the same level as their medical colleagues,
Kettlewell says. But getting there took a lot of small steps by
psychologists to show their worth, including offering to provide
a mental health consult in the emergency room, and then
taking the steps needed to make more systematic changes such
as getting added to the on-call schedule for after-hours ER
coverage, where decisions on hospital admission were needed.
"We're now in the process of using this same small wins
strategy to try to change our culture so that psychologists and
other behavioral health providers are an integral part of all of
our primary care clinics;' Kettlewell says.
A natural fit
Geisinger has also reduced its pharmacy expenses, according

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This spring, APA's Dr. Randy Phelps met with Geisinger psychologists and physician leaders, and leaders of the Geisinger Health Plan.
Back row standing, from left to right, are Eric Hill, Dr. Chris Chew, Dr. Tawnya Meadows, Dr. Laura Campbell, Dr. Erica Walles,
Ed Madalis, Richard Bitting, Dr. Thomas Graf, Dr. Cathy Schuman, Dr. Fred Bloom and Mark Basinger. Front row sitting, from left to
right, are Dr. Paul Kettlewell, Dr. Charlotte Collins, Dr. Randy Phelps, Dr. Shelley Hosterman, Dr. Heather Hoover and Dr. Nicole Quinlan.

to data from the pediatric primary-care pilot study.

Kettlewell believes the reduction is due in part to the fact
that pediatricians now have more tools in their toolbox than
medication alone.
"Primary-care physicians feel lots of pressure to take
action when a parent or patient makes a request for help;'
he says. "Referring the parent to a psychologist for further
discussion and assessment represents a wise action-step, and
results in a more thorough assessment so that the right children
get medication."
Geisinger is now piloting integrating psychologists and
psychology residents into adult primary care at four community
sites, Collins says. If the data show Geisinger is successful, the
hope is that other medical centers recognize the benefits of
putting psychologists on site in primary care and follow suit,
which would help improve the health of Americans nationwide,
says APA's CEO Norman B. Anderson, PhD.
"Research clearly shows that psychological, behavioral and
social factors are key dri~ers of health problems seen in the primary-care settings;' Anderson says. "Incorporating psychologists
directly into these settings can help ensure that health professionals are working together to treat the whole person."
The bottom line, Kettlewell says, is that as America attempts
to redesign health care, behavioral health services should
be expected to demonstrate cost savings, and the possibility

exists when integrated care models like the one that Geisinger
has implemented are put in place. He notes, however, that
behavioral health services continue to be an underfunded area
of health-care, and shouldn't only be considered valuable if
adding these services into a health-care model demonstrates
total cost-offset.
"Nobody providing comprehensive behavioral health
services has a healthy return-on-investment using the feefor-service model," Kettlewell says. "But there are profound
consequences to society, including added legal, educational
and unemployment expenses, because we are not adequately
addressing serious behavioral health needs." Gianfagna also
notes that working in tandem with behavioral health experts
h~s helped him be a better physician. Knowing he has a
partner who is keeping up with a child's behavioral health
needs keeps him focused on the rest of the patient's care.
"It allows me to do what I do best, rather than playing
part pediatrician, part psychologist, pa.rt social worker,
part information gatherer, part research assistant;' he says.
"Incorporating psychology into primary care is just a natural
fit."

*Pseudonym used to protect patient privacy.

Amy Novotney is a journalist in Chicago.

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