Training and Education in Clinical Psychology in the Context of the Patient Protection and...

Training and Education in Clinical Psychology in the

Context of the Patient Protection and Affordable Care Act

Ka Ho Brian Chor, Su-chin Serene Olin, and Kimberly Eaton Hoagwood, Department of Child

and Adolescent Psychiatry, New York University School of Medicine

The Patient Protection and Affordable Care Act of 2010

(ACA) is revamping the access, quality, and financing of

the health and mental health systems. However, its

impact on training and education in clinical psychology is

unclear. This article aims to identify specific components

of the ACA, in particular the Mental and Behavioral

Health Education and Training Grants, that are expected

to affect training and education in the field. The article

further connects the ACA with four paradigm shifts in

clinical psychology that have broad implications for train-

ing and education—evidence-based practices, research

methodology, interprofessionalism, and the quality indi-

cator movement. The overarching goal of this article is to

begin timely discussions on the future directions of the

field under the current healthcare reform.

Key words: clinical psychology, education, healthcare

reform, Patient Protection and Affordable Care Act,

training. [Clin Psychol Sci Prac 21: 91–105, 2014]

The Patient Protection and Affordable Care Act of 2010

(ACA; P.L. 111-148) is restructuring the U.S. health and

mental health systems. It embraces the triple aims of the

Institute for Healthcare Improvement—improving pop-

ulation health, improving patient experience of care, and

reducing total healthcare costs (Katon & Un€utzer, 2013).

It specifically focuses on the following (Rozensky,

2012):

1. Provision of accountable, efficient, and effective

health care.

2. Integration of health and mental health care.

3. Expansion of an interprofessionally focused

healthcare workforce to provide team-based,

coordinated quality services.

4. Monitoring and reporting of outcomes.

In turn, these ACA foci are accelerating several key

healthcare trends (Katon & Un€utzer, 2013; Rozensky,

2012). Provider accountability is being established

through innovative models for regionalizing and net-

working service providers, such as accountable care

organizations (ACOs), to share access, quality, and cost

(Center for Medicare & Medicaid Services, 2013).

Patient-centered medical homes (PCMHs) and colocat-

ed primary care and specialty care are being set up to

improve the integration and coordination of health and

mental health services (Mechanic, 2012). This entails

interprofessional health care, which entrusts primary

care physicians as treatment leaders to provide continu-

ous, comprehensive care and coordinate with other

professionals (e.g., mental health professionals; Gabel,

2010). Performance measures such as quality indicators,

patient outcome measurements, credentialing, and

accreditation of providers are becoming standards for

justifying and incentivizing provider networks

(Hoagwood, 2013; Zima et al., 2013). Also, electronic

medical record (EMR) is becoming the standard plat-

form that facilitates communications among providers

for care coordination and reporting quality measures to

states and healthcare systems (Kelleher, 2010).

Despite available information about the tenets of

the ACA and national attention to its impact on

Address correspondence to Ka Ho Brian Chor, Department

of Child and Adolescent Psychiatry, New York University

School of Medicine, 1 Park Avenue, 7th Floor, New York,

NY, 10016. E-mail: [email protected].

© 2014 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.All rights reserved. For permissions, please email: [email protected]. 91

the healthcare system, the 906-page ACA proves to be a

formidable tome to decipher. With pragmatic issues such

as state health exchanges and insurer eligibility at the

forefront of the ACA (Barry, Weiner, Lemke, & Busch,

2012; Golberstein & Busch, 2013), much less is known

about how professional health disciplines, including clin-

ical psychology, will adapt to the new standards of

healthcare reform. The goals of this article are to distill

the specific components of the ACA that are expected

to impact training and education in clinical psychology

and to describe four paradigm shifts in the field that have

broad implications for training and education.

THE ACA MENTAL AND BEHAVIORAL HEALTH EDUCATION

AND TRAINING GRANTS (MBHETG)

Building on the Paul Wellstone and Pete Domenici

Mental Health Equity and Addictions Parity Act of

2008 (MHEAPA; P.L. 110-343), the ACA requires

mental health coverage to be part of the essential health

benefits package. This ensures affordable access to and

comprehensive coverage of quality mental health care

for individuals with a preexisting condition (Garfield &

Druss, 2012; Golberstein & Busch, 2013). The ACA

incorporates “mental health” and “behavioral health”

professionals throughout relevant sections on the deliv-

ery of quality and efficient care, inclusion in health

teams, interdisciplinary teams, PCMHs, and ACOs

(e.g., Sec. 2703, 3502, 5301, and 5604). Only in Title

V on the “Health Care Workforce” does the ACA

address how the workforce can meet the healthcare

needs of the populations. The ACA’s mission to

improve training and education is described in Subtitle

B, “Innovations in the Health Care Workforce” —Sec. 5101 on the “National Health Care Workforce

Commission.” This section states that the “. . .mental

and behavioral health care workforce capacity at all

levels” is a high priority with respect to “. . .education

and training capacity, projected demands, and integra-

tion with the health care delivery system.”

Subtitle D “Enhancing Health Care Workforce

Education and Training” — Sec. 5306 on the “Mental

and Behavioral Health Education and Training Grants”

(MBHETG) contains the clearest directives. As an

amendment to Sec. 756 of the Public Health Service

Act of 1944 (PHSA; P.L. 78-410), the MBHETG is

the only new ACA-funded initiative focused on

improving the training and education of the behavioral

health workforce. Its scope is broader than the

Graduate Psychology Education (GPE) initiative,

which has been separately funded by Sec. 750 and 755

of the PHSA since 2002 (Reid-Arndt, Stucky, Cheak-

Zamora, DeLeon, & Frank, 2010). Specifically, Sec.

5306 MBHETG of the ACA states:

“(a) Support the recruitment of students for, and education

and clinical experience of the students in. . .

“(2) accredited master’s, doctoral, internship, and post-

doctoral residency programs of psychology for the develop-

ment and implementation of interdisciplinary training of

psychology graduate students for providing behavioral and

mental health services, including substance abuse preven-

tion and treatment services;

“(3) accredited institutions of higher education or accredited

professional training programs that are establishing or

expanding internships or other field placement programs in

child and adolescent mental health in psychiatry, psychol-

ogy, school psychology, behavioral pediatrics, psychiatric

nursing, social work, school social work, substance abuse

prevention and treatment, marriage and family therapy,

school counseling, or professional counseling; and

“(4) State-licensed mental health nonprofit and for-profit

organizations to enable such organizations to pay for

programs for preservice or in-service training of paraprofes-

sional child and adolescent mental health workers.

Thus, the ACA supports education and training in

clinical psychology across advanced degrees and post-

master’s/doctoral experiences. The institutional selec-

tion criteria for the training grants are consistent with

the broad aims of the ACA:

“(d) Priority. . .

“(2) In selecting the grant recipients in graduate psychol-

ogy under subsection (a)(2), the Secretary shall give pri-

ority to institutions in which training focuses on the

needs of vulnerable groups such as older adults and chil-

dren, individuals with mental health or substance-related

disorders, victims of abuse or trauma and of combat stress

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE � V21 N2, JUNE 2014 92

disorders such as posttraumatic stress disorder and trau-

matic brain injuries, homeless individuals, chronically ill

persons, and their families.

“(3) In selecting the grant recipients in training programs

in child and adolescent mental health under subsections (a)

(3) and (a)(4), the Secretary shall give priority to appli-

cants that

“(A) have demonstrated the ability to collect data on

the number of students trained in child and adolescent

mental health and the populations served by such stu-

dents after graduation or completion of preservice or

in-service training;

“(B) have demonstrated familiarity with evidence-based

methods in child and adolescent mental health services,

including substance abuse prevention and treatment ser-

vices;

“(C) have programs designed to increase the number of pro-

fessionals and paraprofessionals serving high-priority popula-

tions and to applicants who come from high-priority

communities and plan to serve medically underserved popula-

tions, in health professional shortage areas, or in medically

underserved areas;

“(D) offer curriculum taught collaboratively with a family

on the consumer and family lived experience or the

importance of family-professional or family-paraprofes-

sional partnerships; and

“(E) provide services through a community mental health

program described in section 1913(b)(1).

These funding criteria address population needs (i.e.,

serving vulnerable and high-priority groups), account-

ability and quality measurement (i.e., tracking data on

the number of students trained, populations served, and

demonstration of evidence-based treatments), patient-

centeredness, and collaborative care (i.e., involving

families and consumers).

The ACA is financially committed to the aforemen-

tioned education and training areas:

“(e) Authorization of Appropriation. . .

“(2) $12,000,000 for training in graduate psychology

in subsection (a)(2), of which not less than

$10,000,000 shall be allocated for doctoral, postdoctoral,

and internship level training;

“(3) $10,000,000 for training in professional child and

adolescent mental health in subsection (a)(3); and

“(4) $5,000,000 for training in paraprofessional child

and adolescent work in subsection (a)(4).

In FY 2012, the ACA Prevention and Public Health

Fund awarded $9.8 million to 24 institutions for 3-year

grants as authorized under the above subsections (U.S.

Department of Health & Human Services, 2012).

Among the MBHETG awardees, 13 are social work

programs and 11 are psychology programs. The grants

stipulate that 75% of the funding must be used as

stipends to support clinical training in field placements,

and the remaining 25% is to support recruitment of

prospective students interested in pursuing clinical

work with special populations and to implement didac-

tic and field placement curriculum focused on “inter-

disciplinary training and integrating behavioral health

with primary care and/or public health” (Catalog of

Federal Domestic Assistance, 2012b).

Table 1 describes the 11 MBHETG-funded grantees

in psychology that represent 10 states (U.S. Depart-

ment of Health & Human Services, 2012, 2013). All

funded programs consist of a psychology internship

accredited by the American Psychological Association

(APA). Six programs are based at a university, two at a

hospital, two at a research institute, and one at a state-

wide internship consortium. All programs meet the

ACA funding requirements in multiple ways. Clinical

training targets the needs of diverse vulnerable popula-

tions, from children, chronically and medically ill

patients, to veterans and trauma victims, especially

those in underserved and rural areas. Increasing the

number of qualified mental health professionals to

decrease workforce shortage is also a shared objective.

Beyond didactics and supervision, the funded programs

outline key training components that address the

MBHETG funding criteria—interdisciplinary/multidis-

ciplinary consultation, interprofessional collaboration in

multiple settings (e.g., school, primary care), telehealth

TRAINING IN CLINICAL PSYCHOLOGY AND THE ACA � CHOR ET AL. 93

Table 1. Grantees in psychology funded by the Affordable Care Act under Sec. 5306 “Mental and Behavioral Health Education and Training Grants”(U.S. Department of Health & Human Services, 2012, 2013)

Grantee StateAwardAmount

APAInternship Project Goals

Western InterstateCommission forHigher Education

AL $354,253 Yes • Recruit and retain qualified psychologists in rural areas.

• Increase the capacity to address unmet needs by providing quality behavioral healthservices.

• Expand internship positions to generate highly skilled psychologists to reduce stateworkforce shortages across behavioral health professions.

• FY 2012 funding was used for hiring a project director, intern recruitment, selectingthree additional training sites for three additional interns, and additionaladministrative and supervisory support.

University of Florida FL $251,999 Yes • Expand internship training positions to serve rural and medically underservedareas.

• Create seamless training experience: graded series of didactic, direct clinicaland interdisciplinary team-based experiences, and direct interprofessionalcollaboration.

• Focus training for underserved populations: children, chronically ill, and olderadults.

Conduct formal competency-based evaluations of interns.

• Disseminate the design and implementation of the training model.

• FY 2012 funding was used to support the recruitment of prospective interns for theunderserved/interprofessional slots, and the dissemination of interprofessionaltraining to a multidisciplinary group of physicians, physician assistants, medicalresidents and fellows, and psychology students and interns.

University of Hawaii HI $331,201 Yes • Increase the number of interns and scientist-practitioner clinical psychologists whouse culturally sensitive evidence-based psychological services and telehealth servicesto treat ethnically diverse populations in underserved, rural areas.

• Develop a training model that consists of supervised clinical and consultativeexperiences in multidisciplinary patient care settings, use of telehealth, didacticinstruction, research, guided rehearsal, modeling, and mentoring around targetedprofessional goals.

• Evaluate training goals in relation to service and patient outcomes.

• FY 2012 funding was used for program planning and stipend support beginning inthe second quarter of the federal fiscal year and beyond.

University of KansasMedical Center ResearchInstitute, Inc.

KS $240,000 Yes • Increase the number of highly qualified interns and well-trained mental healthprofessionals in medically underserved areas.

• Develop a training model that focuses on health and mental health disparities, servicesto patients with reduced access to specialty mental health, and use of statewidetelehealth system to diagnose and treat individuals with a full range of mentalhealth issues.

• Evaluate the objectives and success of the training model.

• FY 2012 funding was used for program planning and stipend support beginningin the second quarter of the federal fiscal year and beyond.

Hugo W. Moser ResearchInstitute at KennedyKrieger Institute

MD $121,096 Yes • Offer specialized training to future psychologists to provide culturally and linguisticallycompetent clinical services to meet the needs of children affected by hearing lossor deafness.

• Provide rotational clinical training within the Department of Neuropsychology and thePediatric Psychology Clinic and Consultation Program.

• FY 2012 funding was used for program planning, recruiting and interviewing trainees,and stipend support beginning in the second quarter of the federal fiscal year andbeyond.

(Continued)


Table 1. (Continued)

Grantee StateAwardAmount

APAInternship Project Goals

University of MissouriSystem

MO $474,174 Yes • Strengthen clinical field competencies of psychologists who work with individualswith chronic illnesses in rural areas.

• Increase the number of interns and qualified psychologists, and evaluate their culturaland linguistic competencies.

• Develop a training model that consists of curriculum/experiential training throughrotations, didactics, grand rounds, journal clubs, and supervision by diverse facultymembers.

• FY 2012 funding was used for hiring five interns to complete the standard majorrotations, provide telehealth psychological services to active duty military soldiers,and travels to rural areas to provide neuropsychological evaluations to statevocational rehabilitation clients with traumatic brain injury.

University of Nebraska NE $480,000 Yes • Increase the number of interns, residents, and mental health practitioners inunderserved rural areas.

• Develop an integrated behavioral health internship model that provides interdisciplinarytraining, “learning through service” clinical skills, and supervision in rural primarycare settings.

• FY 2012 funding was used for recruitment of psychology interns, supplies and logistics,and support for supervisors at rural primary care sites.

Mount Sinai Schoolof Medicine

NY $225,570 Yes • Increase the number of psychologists specialized in neurorehabilitation, specializedassessment, and treatment for individuals with traumatic brain injury, stroke, spinalcord injury, and amputation.

• Develop a training model that consists of competency-based training, supervision,and interprofessional clinical learning experiences.

• FY 2012 funding was used for transportation and training on applying to internshipfor externs and prospective interns from a neighbor university.

Yeshiva University NY $470,862 Yes • Create an innovative training model for graduate students and interns that issequential and graded in interdisciplinary training, and comprehensive in theassessment and treatment of the severely and persistently mentally illpopulation.

• Disseminate training strategy to other graduate clinical programs and internshipsites.

• FY 2012 funding was used for program planning and stipend support beginning in thesecond quarter of the federal fiscal year and beyond.

Children’s Hospitalof Philadelphia

PA $192,000 Yes • Prepare interns and fellows for careers in serving children with or at risk for mentalhealth disorders, especially those from underrepresented minority and low-incomegroups.

• Develop a sustainable training model of leadership in providing innovative clinical care;increasing competencies in assessment, intervention, consultation, and preventionservices; implementing experiential training in primary care and schools; and creatinga progressive series of didactic seminars.

• FY 2012 funding was used for program planning and stipend support beginning inthe second quarter of the federal fiscal year and beyond.

Medical Universityof South Carolina

SC $469,404 Yes • Increase the supply of well-trained psychologists specialized in working with veteranand civilian trauma victims.

• Develop a training model that combines evidence-based practicum experience incommunity settings and via telehealth technology, didactics, and interdisciplinarypatient management.

• Reduce health disparities among trauma victims and improve trainees’ readiness towork with these populations.

• FY 2012 funding was used for hiring a project director to engage in recruitment oftrainees for the next academic year.


assessment and treatment, and competency-based train-

ing and evaluation. Two grantees, University of Florida

and Yeshiva University, further propose to disseminate

the design and implementation of their training models

to other graduate clinical programs and internship sites.

Only one year into the FY 2012 funding cycle, how-

ever, most programs to date have allocated their fund-

ing to hiring a project director, creating new intern

positions, and covering the logistics of training activi-

ties.

FOUR PARADIGM SHIFTS IMPACTING TRAINING AND

EDUCATION IN CLINICAL PSYCHOLOGY

Healthcare reform and concomitant public policy

changes provide an opportunity for the field of clinical

psychology to evolve (Cubic, Mance, Turgesen, &

Lamanna, 2012; Reid-Arndt et al., 2010). To shape

future directions in training and education, the ACA-

funded MBHETG initiative is a crucial start. In addition

to its specific directives, there are now opportunities to

expand the training and education paradigm in four

areas: evidence-based practices, research methodology,

interprofessionalism, and quality indicators. We describe

the relevance of each area to specific ACA sections and

the broader implications for future training and educa-

tion in clinical psychology.

TRAINING IN EVIDENCE-BASED PRACTICES: FROM STAND-

ALONE EBPS TO MODULAR, TRANSDIAGNOSTIC, AND

SCALABLE EBPS

The ACA emphasizes evidence-based practices (EBPs)

in research (Sec. 10410), prevention (Sec. 4108 and

4301), quality care (Sec. 5405), and training programs

(Sec. 5301 and 5306). EBPs in the healthcare reform

are means toward effective care and outcome monitor-

ing, although their translation into mainstream, profes-

sional care is a challenge.

In clinical psychology, EBPs are generally incorpo-

rated into standard training and education models.

Two issues, however, arise from the uptake of individ-

ual EBPs to improve population mental health. First,

although the knowledge base of EBPs has advanced

tremendously in the past 40 years (Comer & Barlow,

2013), it is disproportional to the finite amount of time

for education and training that a typical clinical

psychologist receives (Runyan, 2011). It is also ineffi-

cient to learn each separate EBP to cover the needs of

the population as a whole (Chorpita, Bernstein, &

Daleiden, 2011; Comer & Barlow, 2013). This

approach is inconsistent with the ACA’s emphasis on

population-based clinical and community prevention

services (Sec. 4003), removal of barriers, and improve-

ment of population access to quality care (Sec. 4203;

Kelleher, 2010).

Second, the ACA prioritizes the identification of

“health care providers. . .that deliver high-quality,

efficient health care services, employ best practices that

are adaptable and scalable to diverse health care

settings” (Sec. 3501). Unfortunately, the adaptability

and scalability of mental health EBPs across states have

not been promising (Bruns & Hoagwood, 2008;

McHugh & Barlow, 2010) due to insufficient attention

to system contexts, including barriers and facilitators for

organizations, for practitioners, and for each particular

EBP (Comer & Barlow, 2013; Wisdom, Chor, Hoag-

wood, & Horwitz, 2013). The tension between the

sanctity of EBP fidelity and the societal need for popu-

lation uptake of EBPs heightens within the ACA and

throughout the field (Kazdin, 2013). This tension needs

to be resolved with scalable EBP training.

Broad Implications for Training and Education in Clinical

Psychology

Under the directives of the ACA, models for training

and education need to integrate the growing knowl-

edge base of EBPs to benefit a wider population. In

both child and adult mental health, promising training

models have emerged to extract shared evidence-based

mechanisms, improve clinical decision making, and

facilitate the scalability of EBPs.

Clinical training needs to meet the growing

demands for EBP elements that are adaptable across

diagnoses (Chorpita et al., 2011; Mitchell, 2011; Sex-

ton, Chamberlin, Landsverk, Ortiz, & Schoenwald,

2010). When psychiatric diagnoses are conceptualized

as a constellation of shared problems, common EBP

elements emerge (Ellard, Fairholme, Boisseau, Farchi-

one, & Barlow, 2010; Garland, Hawley, Brookman-

Frazee, & Hurlburt, 2008). After the identification of

common elements, the learning process should extend

to the effective organization, selection, and delivery of

these elements for neighboring diagnostic groups


through a modular or a transdiagnostic approach

(Comer & Barlow, 2013). Key examples include trans-

diagnostic cognitive behavioral therapy (CBT) for adult

mood, anxiety, and eating disorders (Ellard et al., 2010;

Fairburn et al., 2009); the Modular Approach to Ther-

apy for Children with anxiety, depression, trauma, or

conduct problems (MATCH-ADTC; Chorpita & We-

isz, 2009; Weisz et al., 2012); and the Managing and

Adapting Practice (MAP) tool, which provides clini-

cians with access to up-to-date scientific treatment

information and recommendations for specific problems

(Southam-Gerow et al., 2013).

Because of their training and education, clinical

psychologists play key roles in directing and training

other mental health providers on EBPs in several

large-scale training initiatives that have demonstrated

the scalability and adaptability of EBP training. The

Veteran Health Administration (VHA) has trained over

6,400 mental health staff in EBPs for depression, anxi-

ety, and posttraumatic stress disorder (Karlin & Agar-

wal, 2013; Karlin et al., 2012; Ruzek, Karlin, & Zeiss,

2012). The Improving Access to Psychological Thera-

pies (IAPT) initiative in the United Kingdom has

nationally trained over 3,600 cognitive behavioral

therapists (McManus, Westbrook, Vazquez-Montes,

Fennell, & Kennerley, 2010). Through collaboration

among multiple stakeholders, Los Angeles County has

trained more than 1,700 practitioners in local mental

health agencies on the MAP tool (Southam-Gerow

et al., 2013). Further, the New York State–funded

Evidence-Based Treatment Dissemination Center (EB-

TDC) has trained over 1,300 clinicians and 200 super-

visors on cognitive behavioral health therapy for

depression, anxiety, trauma, and disruptive behavior

disorders (Gleacher et al., 2011). New York State is

building on the successful implementation of MAP in

Los Angeles County to offer statewide training of

MAP. Psychologists serve as expert MAP trainers for

over 150 master’s-level frontline clinicians and supervi-

sors from outpatient mental health clinics (Hoagwood

et al., 2014).

These initiatives provide a blueprint for scaling EBPs

and highlight the important role of psychologists in

scaling EBPs. To prepare them for such a role, skills in

training, didactics, workshops, consultation, supervi-

sion, and technical assistance should be added as core

components of graduate training (Comer & Barlow,

2013; Edmunds, Beidas, & Kendall, 2013; Leffler,

Jackson, West, McCarty, & Atkins, 2013). Sustained

mastery of EBPs and evidence-based decision making

will also rely on session-to-session clinical feedback on

treatment progress and treatment process using standard

measures (Bickman, Kelley, & Athay, 2012). A remain-

ing challenge, however, is that the success of scaling in

training is usually limited to specific EBPs within a

closed system. Clinical psychologists need to be

prepared to ensure such efforts are extended across

coordinated systems.

RESEARCH METHODOLOGY: FROM TREATMENT

DEVELOPMENT TO DISSEMINATION AND IMPLEMENTATION

The ACA emphasizes dissemination and implementa-

tion of outcomes research (Sec. 6301), EBPs in preven-

tion (Sec. 4108), in healthcare settings (Sec. 3501), and

in the national agenda to improve quality of care (Sec.

3011). In mental health, this means developing tailored

research methodologies in dissemination and imple-

mentation to evaluate the large-scale trainings in EBPs

described above.

Hybrid designs are one approach to this. They com-

bine elements of efficacy, effectiveness, and implemen-

tation to examine multiple aspects of treatment

development and population uptake (Curran, Bauer,

Mittman, Pyne, & Stetler, 2012). They represent a

new approach that can enhance the level of public

health impact supported by the ACA. Hybrid designs

provide flexibility to support multiple and concurrent

testing of scientific questions, such as decision making

to test a clinical intervention (e.g., EBP), gathering

implementation data (e.g., rates of adoption), or testing

an implementation intervention (e.g., enhancing adop-

tion).

Hybrid type 1 is a model for testing a clinical inter-

vention and gathering implementation data at the same

time, to reduce the time lag between efficacy and

effectiveness research. A Hybrid type 1 study may

involve a randomized controlled trial (RCT) of a

clinical intervention (e.g., EBP) at the individual or

organizational level to assess clinical effectiveness (e.g.,

symptom reduction); simultaneously, it may involve

qualitative evaluation of multiple stakeholders on

potential barriers and facilitators to implementation.


Hybrid type 2 is a model to test a clinical intervention

and an implementation intervention to produce rapid

translation. A Hybrid type 2 study may involve a

multisite RCT of an EBP that is supported by an

implementation intervention (e.g., quality improve-

ment teams) that facilitates adoption. Its utility also

depends on the implementation momentum (e.g., lead-

ership) within the settings (e.g., veteran administration

clinics). Hybrid type 3 focuses on testing a feasible and

supportable implementation intervention while gather-

ing observational data on a clinical intervention that

may vary in effectiveness across settings. A Hybrid type

3 study may randomize an implementation intervention

(e.g., stakeholder engagement, performance feedback)

to support integrated primary care and mental health

across sites, while comparing sites on implementation

outcomes (e.g., adoption) and clinical outcomes (e.g.,

depression score). In summary, hybrid designs offer

flexible methodological strategies that are compatible

with the ACA’s public health mission.


Psychology

The foundation of research methodology forms in

one’s graduate studies and expands in one’s career. In

the past two decades, however, self-reported knowl-

edge of research methods from graduate students and

professionals has focused on traditional techniques such

as RCT designs, test reliability, effect size, and basic

regressions, indicative of a slow incorporation of

newer techniques into the curriculum (Aiken et al.,

1990; Berke, Rozell, Hogan, Norcross, & Karpiak,

2011). These findings call for an update and expansion

of training and education in research methods. Krat-

ochwill (2007) identified related areas of training

needs and recommends an expansion in graduate cur-

riculum to cover methods and conceptual models for

appraising EBP studies, efficacy studies (i.e., RCTs),

transportability studies (to account for contextual

issues), dissemination studies (i.e., protocols deployed

in applied settings), and system evaluation studies

(postdissemination; Chorpita, 2003). The APA has

formed a task force to expand such methodologies in

school psychology programs, which would guide other

graduate training programs (Kratochwill, 2007).

National training initiatives for early career interdisci-

plinary researchers include the Training Institute for

Dissemination and Implementation Research in Health

(TIDIRH) and the Implementation Research Institute

(IRI). Both institutes focus on methods and

approaches (e.g., research design, measurement, system

dynamics) that have not been taught in most graduate

programs (Meissner et al., 2013). Ultimately, building

a stronger real-world research methods base can bol-

ster psychologists’ roles in developing evidence-based

policies relevant to decision makers (Rozensky, 2012),

such as why, when, and under what circumstances an

EBP fails to make an impact on the delivery of qual-

ity care.

BALANCING INTERPROFESSIONALISM, PRIMARY CARE

INTEGRATION, AND SPECIALTY CARE

The ACA emphasizes interprofessionalism to support

primary care in ACOs on the system level (Sec. 3022)

and PCMHs on the individual level (e.g., health

home teams; Sec. 3502). Interprofessionalism in

patient care has potential fiscal benefit. When

improved patient outcomes are aligned with efficient

and effective practices among ACOs and PCMHs,

participating providers will receive shared saving

incentives. To advance interprofessionalism in work-

force training and professional education, the ACA

(Sec. 5301 and 5309) is funding a $4 million, 5-year

Coordinating Center for Interprofessional Education

and Collaborative Practice:

provide an infrastructure for leadership, expertise,

and support to enhance the coordination and capac-

ity building. . .among health professions across the

U.S. and particularly in medically underserved areas.

Through innovative program coordination, scholarly

activities, and analytic data collection efforts, the

coordinating center will raise the visibility of high-

quality, coordinated, team-based care that is well-

informed by interprofessional education and best

practice models. (Catalog of Federal Domestic Assis-

tance, 2012a)

The foundation of interprofessionalism is pooled com-

petencies. It begins in education and training across

disciplines so that trainees can overcome the mentality

of working in silos (Rozensky & Janicke, 2012). Under


federal policies, interprofessionalism not only involves

student and faculty training, but it also focuses on

curriculum development, competency development,

program evaluation, and use of technology (Wilson,

Rozensky, & Weiss, 2010).

Interprofessionalism also entails communication

among service providers, including mental health pro-

viders (Sec. 3502). In this regard, the use of valid diag-

nostic tools serves two goals: enhancement of

interprofessional communications and facilitation of

payments and reimbursements. This is particularly

important in integrated primary care and mental health

settings where patients may present with comorbid

health and mental health problems. In these integrated

settings, the new Diagnostic and Statistical Manual of

Mental Disorders (5th ed.; DMS-5) and the International

Classification of Disease (ICD-10; currently under revi-

sion for the release of ICD-11 in 2015) will remain the

main clinical tools for health and mental health diagno-

ses (Cuthbert & Insel, 2013).

With overlapping listing of disorders to streamline

clinical communications, the DSM and ICD are also

intertwined with payments and reimbursements in the

health and mental health services system (Duke, Gu-

ion, Freeman, Wilson, & Harris, 2012; Noll & Fi-

scher, 2004). Since 2004, the introduction of health

and behavior Current Procedural Terminology (CPT)

codes (i.e., 96150-96155) has facilitated billing for

mental health services for individuals with a medical

diagnosis (McAuliffe Lines, Tynan, Angalet, & Shroff

Pendley, 2012). For example, in pediatric psychology,

the use of health and behavior (H&B) codes has

expanded psychologists’ roles in medical care by

framing psychological services around health, preven-

tion, and collaborative treatment with primary care

services. This workaround has somewhat relieved the

requirement of a mental health diagnosis for tradi-

tional psychological assessment or psychotherapy ser-

vices (i.e., CPT codes 90801-90899). Nevertheless,

H&B codes are less useful in standard mental health

settings (e.g., community mental health centers) and

are often associated with lower reimbursement rates

and greater difficulty in obtaining authorization by

insurance companies, which may result in more barri-

ers to providing quality mental health care (Duke

et al., 2012).


Psychology

There are three ways the field can develop interprofes-

sionalism to substantiate the viability of the field and

contribution to quality care. First, curriculum revisions

and prerequisites for interprofessional competencies can

be made consistent with ACA standards (Rozensky &

Janicke, 2012). Developing interprofessional competen-

cies should begin in graduate studies so that students

from different health and mental health disciplines can

join together for collaborative training and education

(Belar, 2012; Cubic et al., 2012; Rozensky, 2011). In

particular, the breadth and depth of primary care psy-

chology education (e.g., defining behavioral healthcare

role to patients, medical literacy and pharmacology

knowledge, interventions implementable by other

health professionals, and effective consultation and

referral) will shape interprofessional competencies for

future clinical psychologists (Cubic et al., 2012;

Runyan, 2011). Second, the ACA emphasizes collabo-

rative treatment and coordinated care for individuals

with mental disorders who might also have comorbid

medical or chronic diseases. Practicum and internship

sites at colocated primary and specialty care in commu-

nity-based mental health settings (Sec. 5604) and

interdisciplinary hospitals will provide valuable inter-

professional supervision and training experiences

(Cubic et al., 2012). APA training standards such as the

practicum competencies outline (Hatcher & Lassiter,

2007) and the competency benchmarks (Fouad et al.,

2009; Hatcher et al., 2013) can ensure the continuity

of training in current diagnostic systems (e.g., aware-

ness of DSM in relation to ICD) that are crucial to

communications and payments in these integrated set-

tings. Third, as participating providers in PCMHs and

ACOs, clinical psychologists can capitalize on their

unique position to provide timely expert consultation

and mental health services. This effort can demonstrate

psychologists’ roles in integrated, interprofessional care.

Despite the importance of interprofessionalism and

integrated primary care in healthcare reform, the field

must retain training and education in specialty mental

health (Cubic et al., 2012). Mental health professionals

in integrated primary care settings are well equipped

to treat individuals with common mental health prob-

lems, but they are not necessarily trained to treat those


with specific or low-rate psychiatric diagnoses. In

these cases, referrals should be made to appropriate

mental health specialists (Comer & Barlow, 2013). For

generalists, the focus of training and education is then

on the identification and referral of individuals who

need specialty mental health care. Conversely, for spe-

cialists, maintaining their availability and linkages to

integrated primary care is critical. Developing innova-

tive models of specialty care delivery (e.g., telehealth

care, coaching, consultation, and training) that bridge

generalists and specialists will be important to the

future of the field (Belar, 2012; Comer & Barlow,

2013; Schoenwald, Hoagwood, Atkins, Evans, &

Ringeisen, 2010).

QUALITY INDICATORS: FROM “I’M FEELING BETTER” TO

OUTCOME MEASUREMENT

In the ACA, quality measures (Sec. 3014) will become

the basis for demonstrating quality of care in adult

health (Sec. 2701), hospital providers (Sec. 3004), and

PCMHs (Sec. 3502) through EMR technology (Sec.

3002), as well as financial accountability and incentives

of ACOs (Sec. 3022). Toward this goal, a top priority

is the development of data-driven quality measures

(Sec. 3013) to assess efficiency and effectiveness of

health outcomes, patient functioning, coordination

of patient-centered care, and the use of health informa-

tion technology. Beyond the traditional measurement

of clinical outcomes (Rozensky, 2012), the ACA is

invested in the measurement of health behaviors (Sec.

4201–4207) and prevention (Sec. 4301–4306) to

improve quality and reduce costs. In this respect, men-

tal health has lagged behind general health care in the

effort to standardize and implement quality measures,

especially among vulnerable populations such as

children and adolescents (Pincus, Spaeth-Rublee, &

Watkins, 2011; Zima & Mangione-Smith, 2011). From

the provider’s perspective, it is important that quality

measurement not interfere with routine practices or

encroach upon billable service hours. Similar efforts to

integrate mental health into primary care practice in the

past were met with resistance due to inability to bill for

services (e.g., in telepsychiatry; Palmer et al., 2010).

However, progress is being made. In the Children’s

Health Insurance Program Reauthorization Act of

2009 (CHIPRA), the Agency for Healthcare Research

and Quality (AHRQ) funded seven Centers of

Excellence to standardize quality measures and quality

indicators specifically for children (Hoagwood, 2013;

Zima & Mangione-Smith, 2011; Zima et al., 2013).

Quality indicators are being developed for adolescent

depression (Lewandowski et al., 2013) and prescribing

practices, particularly for the use of atypical antipsy-

chotics (Kealey et al., 2013). An implication of the

emphasis on quality indicator development is that out-

comes shown in laboratory settings through RCTs

must now be demonstrated across treatment settings.

Similarly, scalable treatments will need to be justified

with measurable outcomes on other levels beyond the

patient, including the system level (Hoagwood et al.,

2012). A comprehensive, population-based focus of the

ACA will become synonymous with high-quality, sus-

tainable care (Kelleher, 2010).

Although outcome data communicate accountabil-

ity, they also need to inform decision making and

improve population care (Daleiden & Chorpita, 2005;

Torda & Tinoco, 2013). As EMR technology, quality

measures, and quality indicators become standardized

under the ACA, monitoring of outcomes on the

healthcare system level can identify potential

population needs (e.g., gaps in quality of care, patient-

centeredness) to inform future interventions. For exam-

ple, EMR-based quality measures can be used to

identify trends and patterns in clinical data that may

vary by, for example, ACO (Torda & Tinoco, 2013).

Similar to quality improvement on the organizational

level (Hermann, Chan, Zazzali, & Lerner, 2006), qual-

ity improvement on the system level will enable

intended audiences such as policymakers to use quality

indicators for decision making (Zima et al., 2013).


Psychology

A typical psychologist licensing examination question

asks how to know whether treatment works in practice;

the typical answer is through consistent and continuous

assessment of client outcomes. Under the ACA, consis-

tent and continuous quality measurement is mandated.

On the system level, payers, accreditors, and other reg-

ulatory entities often impose requirements on providers

to demonstrate outcomes, which include measurement

of structures and processes of care (Hermann et al.,


2006). For psychologist training, the link between mea-

surement of the effectiveness of care and decision mak-

ing is critical. Training focus needs to expand beyond

individual client outcomes to other quality measures

important to the ACA. While outcome measurement is

embedded in research training (e.g., program evalua-

tion, quality assurance, measures development) and in

practice (e.g., ability to link observable behaviors to

evidence of quality care), how to foster and expand

these skills early and throughout training will be chal-

lenging. There are few training models that compre-

hensively address needs assessment, program evaluation,

and multilevel collaborations tied to public health poli-

cies (Chu et al., 2012). As these skills are likely to be

framed in an integrated care model, they reinforce the

relevance of training in clinical health psychology

(Grus, 2011) and primary care or health psychology

(Runyan, 2011). In short, ensuring patients are “feeling

better” (i.e., from-the-neck-above; Runyan, 2011) is a

narrow end goal of clinical training that is quickly

becoming obsolete.

CONCLUSION

This article describes the broad aims of the ACA and

identifies its specific components, namely, the

MBHETG initiative, which explicitly invests in the

training and education for clinical psychology. To pre-

pare future clinical psychology training and education

for healthcare reform, this article describes four para-

digm shifts relevant to EBPs, research methodology,

interprofessionalism, and quality indicators. Because

MBHETG and the ACA are very recent initiatives, it

is premature to provide definitive recommendations.

Rather, this article provides a roadmap for change.

Although new funding opportunities for graduate

training in psychology now exist (Reid-Arndt et al.,

2010), graduate curriculum and APA accreditation

standards can be difficult, if not impossible, to alter

systematically without extending graduate studies

(Runyan, 2011). Thus, there is incentive to continue

to fund these programs to deliver the same training as

in the past. Change is hard. The feasibility of adding

new modules (e.g., training and coursework in collabo-

rative health, modular EBPs, etc.) will depend in part

on the extent to which specialized versus general train-

ing is currently robust and defined. Federally funded

training initiatives such as the MBHETG initiative

generally target the internship and postdoctoral training

as opposed to the academic years in which graduate

programs would have to make structural changes to

their curriculum (e.g., in diagnosis, EBP orientation,

and research methodology).

The four paradigm shifts described here do not

simply add new responsibilities in a cumulative sense.

Instead, they suggest that for the field to evolve and

adapt to healthcare changes, a new set of training pri-

orities is needed (Cubic et al., 2012; Reid-Arndt

et al., 2010). With their strong background in EBP

training and measurement, clinical psychologists can

be better positioned to improve population health

through EBP scaling and to apply their measurement

expertise in the development of quality measures.

While interprofessionalism and primary care integra-

tion are neither novel nor atypical, the ACA has

legitimized and incentivized these ideas. Direct impli-

cations will be seen in the networking of mental

health providers with health providers within an

ACO. By the same token, the ACA is testing differ-

ent forms of quality measurement and accountability

across demonstration projects (e.g., Sec. 2704) and

payment models (e.g., Sec. 2705). If the field does

not develop a stronger workforce of psychologists

with expanded competencies to work within the

healthcare system, it will become marginalized and

nonessential (Rozensky, 2012; Runyan, 2011).

To align training and education in clinical psychol-

ogy with healthcare reform, the field needs to repriori-

tize its areas of emphasis. With top-down support from

the reform and bottom-up preparation from the field

(e.g., students, faculty, graduate programs, researchers,

clinicians, the APA), new training models will emerge

to support the public health vision that underpins both

psychology and health care.

ACKNOWLEDGMENT

This study was funded by the National Institute of Mental

Health (P30 MH090322, PI: Hoagwood).

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Received August 12, 2013; revised December 11, 2013;

accepted December 23, 2013.


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