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An ambulatory care residency with a psychiatric focus reviews integration of behavioral health training in primary care, including advantages and considerations for residents.

Tera Moore, PharmD, BCPS, BCACP
PGY2 Ambulatory Care Residency Program Director
South Texas Veterans Health Care System

In the primary care veteran population, a significant proportion of patients with chronic comorbidities such as diabetes mellitus, hypertension, or cardiovascular disease have concomitant mental health disorders such as depression, anxiety, or post traumatic stress disorder (PTSD). These mental health disorders can negatively impact management and compliance of chronic medical disease states. Therefore the need to integrate behavioral health training into primary care was identified and a novel PGY2 Ambulatory Care/Behavioral Health Pharmacy Residency Program was established at the South Texas Veterans Health Care System. The residency program is designed to give the resident learning opportunities in primary care and mental health, particularly focusing in behavioral health. The goal of the residency program is to train a clinical pharmacy specialist (CPS) to manage anxiety, depression, PTSD and be a resource for psychopharmacology as a component of ambulatory care within the Patient Aligned Care Team (PACT) model.

The resident’s curriculum involves a mixture of longitudinal, concentrated and rotational learning experiences in both primary care and mental health clinics. The longitudinal experiences take place in both Primary Care CPS clinics and Behavioral Health CPS clinics. Experiences in shared medical appointments, done in collaboration with other disciplines such as Nutrition and Behavioral Health Psychology, are valuable for the resident. This serves to foster interdisciplinary collaboration and further the goal of true integrated care.

Advantages

Having a clinical pharmacy specialist (CPS) with psychiatric training can help improve outcomes for patients with depression, anxiety, and PTSD in the primary care setting. Also, a resident who is trained in both ambulatory care and behavioral health can help to facilitate communication and collaboration amongst primary care and mental health. In addition since the resident has training in both ambulatory care and behavioral health, he or she may have more job opportunities than a resident who is trained only in ambulatory care. For example, the resident may qualify for a Primary Care CPS position that provides management of depression and anxiety, along with chronic disease state management or a Behavioral Health CPS that has no mental health cross-coverage for inpatient or specialty mental health clinics. 

Considerations

A resident completing a dual ambulatory care/behavioral health residency has limited exposure to management of patients with serious mental illness (i.e. bipolar disorder, schizophrenia, acute psychosis) in the specialty mental health clinics. With the focus of the training in primary care and behavioral health, he or she may not have the skill set for a position in specialty mental health with the more severe mental health disorders. When applying for a post-residency position, the resident must clearly communicate in their application material a description of their training and competencies. This is important to ensure that the prospective employer understands the resident received adequate training to meet the knowledge, skills, and abilities for the job they are applying for.

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