GOOD PRACTICE FALL 2019 How Powerful These Accreditation Bodies Psychology Master’S Degrees, Or Degrees Director of Forensic Studies at DU

TOOLS AND INFORMATION FOR PROFESSIONAL PSYCHOLOGISTS FALL 2019

CBD in Practice What Psychologists Need to Know PAGE 18

Practitioners Who Offer More Than Psychotherapy PAGE 8

Get More of Your Claims Accepted PAGE 12

Treating Chronic Pain PAGE 22 From Author Samuel O. Ortiz, Ph.D.

Fair – Accurate – Digital

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MHS.com/OrtizPVAT FALL 2019

CONTENTS

CHIEF OF PROFESSIONAL PRACTICE Jared L. Skillings, PhD, ABPP LEGAL AND REGULATORY ISSUES CHIEF COMMUNICATIONS OFFICER Alicia C. Aebersold 2 APA Seeks to Accredit Master’s Programs EDITOR-IN-CHIEF Sara Martin 26 Thinking of Retirement?

EDITOR Jewel Edwards-Ashman LET’S GET TECHNICAL CONTRIBUTORS Tori DeAngelis Meghann Dugan-Haas Connie Galietti, JD 4 Practice Management Software Stacey Larson, JD, PsyD Amy Novotney Nicole Owings-Fonner, MA TRENDS AND OPPORTUNITIES Diane Pedulla, JD 8 Offering More Than Psychotherapy CREATIVE DIRECTOR Bevin Johnston 14 How to Make Your Practice Green GRAPHIC DESIGNER Rachel Semenov 18 CBD in Practice: What Psychologists Need to Know

Good Practice magazine is a resource for APA members who are licensed, REIMBURSEMENT practicing psychologists. Editorial offices are located in the Practice Directorate of the American Psychological Association at 750 First St. NE, 12 Claim Accepted Washington, D.C. 20002-4242

Email [email protected] PRACTITIONER PROFILES Web apaservices.org/practice Practitioner Helpline 800.374.2723 22 Treating Chronic Pain

programs and accrediting them could increase the numbers of clinicians trained APA SEEKS TO ACCREDIT in the science of psychology practice at the master’s level and increase access to psychological services for consumers,” says Lynn Bufka, PhD, APA’s senior director PSYCHOLOGY MASTER’S for practice research and policy. A PUSH FOR APA INVOLVEMENT One issue that’s driving APA to accredit PROGRAMS master’s programs is the changes to the standards used by the Council for Accred- itation of Counseling and Related Educa- Increasing demand for psychological services and other tional Programs (CACREP) to accredit master’s-level counseling programs. In factors have led APA to create competencies and offer 2013, CACREP began to require counseling program faculty to have doctoral degrees accreditation to master’s-level psychology programs, in counselor education, not psychology. As a result, some counseling psychology just as it does for doctoral-level programs master’s programs were forced to close, resulting in a smaller pool of future clini- BY STACEY LARSON, JD, PsyD cians available to provide services. Other programs ended up replacing most of their psychology faculty members. PA policy states that the doctorate (MPCAC)—which is not a federally recog- “CACREP standards have affected is the minimum level of education nized accreditor—is the only organization who we can hire,” says Jesse Owen, PhD, required for entry into profes- that accredits master’s-level clinical and a professor in the University of Denver sional practice as a psychologist. counseling psychology programs. There are (DU) counseling psychology department. But several factors—including the more than 30 accredited programs. “Our counseling psychology folks have need to expand access to mental Cathi Grus, PhD, APA’s acting chief been training master’s-level counselors Ahealth care, concerns about current stan- education officer, says accrediting master’s for decades, so it seems odd to have an dards for accrediting master’s-level programs would help APA close a gap accreditation body that excludes an inter- psychology programs and the scope of in the psychology training spectrum and disciplinary approach to training.” practice for master’s-level practitioners— ensure that students graduating from those These types of changes in accreditation have prompted APA to re-examine its programs have the knowledge, skills and standards affect the makeup of graduate stance on accrediting master’s programs. attitudes needed for professional prac- program faculty as well as licensing regula- APA is the only psychology program tice. “Accreditation provides quality assur- tions. State licensing boards rely on outside accreditor recognized by the U.S. Depart- ance for students and is part of protecting organizations, such as MPCAC and CACREP, ment of Education. APA only accredits the public by ensuring students are trained to develop standards for education and doctoral psychology programs, internships in programs that meet standards set by the training leading to licensure for master’s- and postdoctoral programs, although it has profession,” Grus says. level providers of psychological services. developed national standards for high school To continue promoting quality and “CACREP now has more accredited psychology curricula as well as guidelines for excellence in education and training across programs than APA does,” says Owen, the undergraduate psychology major, core all levels of education, in 2018 APA’s who along with several other psycholo- competencies for interprofessional collabora- Council of Representatives approved a gists, faculty and staff from DU is a member tive practice for doctoral-level health service motion to pursue the accreditation of HSP of the DU Licensure Task Force, chaired psychology (HSP) and standards for provid- master’s-level programs, which include by Lynett Henderson Metzger, JD, PsyD, ers of continuing education. clinical, counseling and school psychology. a clinical associate professor and assis- Many master’s programs in psychology Competencies for these programs are now tant director of DU’s master’s in forensic are not accredited. The Masters in Psychol- being developed. psychology program. ogy and Counseling Accreditation Council “Developing competencies for these “Scope of practice is directly tied to

2 GOOD PRACTICE FALL 2019 how powerful these accreditation bodies psychology master’s degrees, or degrees director of forensic studies at DU. are at the national level and the state level, from programs not accredited by CACREP, In addition, APA accreditation would and they can have a major influence on from becoming licensed providers of mental provide a path to accreditation for insurance companies and state licensure health services. Data from APA’s Center for master’s-level psychology programs that boards,” says Owen. Workforce Studies show that 22 percent cannot, or do not want to, pursue CACREP In line with APA’s stance on accredi- of people—more than 130,000 individu- accreditation in counseling. tation of doctoral programs, APA’s Model als—with a master’s degree in psychology Act for State Licensure of Psychologists worked as counselors in 2017. In addition, 15 APA ACTION encourages state licensing boards to percent of those with doctorates in psychol- In February 2019, an APA Board of Educa- recognize the doctorate as the minimum ogy teach at postsecondary programs, tional Affairs task force developed a educational requirement for providing including counseling programs. blueprint for APA to follow in pursu- professional services as a psychologist, but “Master’s-level practitioners typi- ing accreditation of master’s programs in this is not the consensus at the state level. cally work with more underserved clients, health service psychology. Currently, 34 states require practitioners to often in specialized areas, so they are not Based on that blueprint, APA has have a doctorate, while 17 states allow indi- necessarily competing head-to-head with formed a new task force to develop compe- viduals with master’s degrees to practice psychologists for work,” says Henderson tencies for students in master’s-level independently or with supervision. Metzger. “The idea of closing doors to health service psychology programs. The Many of these 17 states require grad- practice seems antithetical to the idea group plans to present their competencies uates to have a master’s degree from a of creating a qualified workforce to meet to APA’s council in 2020. Bufka says that psychology program, or from a related the unmet mental health needs of many group will aim to differentiate the expected field, to apply for licensure. However, there marginalized groups.” competencies of graduates with a master’s is no consistency in the scope of practice APA’s development of competencies degree in health service psychology from of master’s-trained providers or in the titles for HSP master’s programs and its work to those with a doctoral degree. they use for themselves once licensed. expand its accreditation standards will not “APA will continue to monitor devel- “The lack of defined competencies change the state requirements for doctoral opments,” Grus says, “but members and differentiating doctoral-level psychology licensure, Bufka says, “and it will ensure students should also be on the alert for any programs from master’s-level programs that APA continues to maintain relevance in potential changes introduced at the state combined with a lack of defined scope of the field of psychology.” level regarding licensure eligibility.” ● practice and clear title distinction differen- Rehabilitation psychologist and APA tiating master’s and doctoral psychology council member Kim Gorgens, PhD, ABPP, Jewel Edwards-Ashman contributed to this report. providers have led to increased confu- adds that it’s important for APA to have sion among consumers,” says Deborah a voice in master’s-level accreditation Baker, JD, APA’s director of legal and regu- because this issue has major implications for latory policy. For example, in West Virginia, practicing psychologists. “Psychologists’ job Resources American Psychological Association, master’s-level providers can refer to them- security is in APA having a voice and saying Task Force on Guidelines for selves as psychologists. In Kansas, inde- here are the competencies for professional Master’s Programs in Psychology. pendent master’s-level practitioners take practice at the doctoral level and here are (2018). APA guidelines on core the title of licensed clinical psychotherapist. competencies for professional practice at learning goals for master’s degree graduates in psychology. “Without clear delineations specifying the master’s level,” says Gorgens. “If APA the differences in training, title and scope isn’t dictating the competencies required for Grus, C.L. (2019). Accreditation of of practice for a doctoral-level psychologist master’s-level practice, someone else will.” master’s programs in health service psychology. Training and Education versus a master’s-level provider, people Others point out that accrediting in Professional Psychology, 13(2), trying to access psychological services may master’s-level programs could also provide 84–91. be easily confused when trying to select psychologists with a larger pool of candi- Grus, C.L., et al. (2019). The master’s the appropriate provider,” Baker adds. dates to train and mentor, helping psychol- issue advances. PLC 2019 For graduates applying for licensure as a ogists fulfill supervision and consultation presentation. professional counselor (LPC), several states competencies. “Accrediting master’s Report of the BEA Task Force to now have policies requiring that they have programs allows for psychologists to Develop a Blueprint for APA master’s degrees from CACREP-accredited expand on the competencies we already Accreditation of Master’s Programs counseling programs. These statutes disen- have to really be able to own them,” says in Health Service Psychology. (2019). franchise thousands of individuals with Lavita Nadkarni, PhD, associate dean and

GOOD PRACTICE FALL 2019 3 Let's Get Technical PRACTICE PSYCHOLOGIST REVIEW PANEL Kristi K. Phillips, PsyD, is a licensed psychologist and health service provider in Minnesota. She also serves on APA’s Committee on Rural Health. Phillips is dedicated to the removal of barriers to comprehensive health care within rural and remote areas, and she has found that utiliz- ing smartphone-based mental health apps within her prac- MANAGEMENT tice along with other tools can be helpful for her patients to SOFTWARE self-manage mental health symptoms between sessions. JoAnna Romero Cartaya, PhD, is a licensed psychologist and health service provider in Iowa and is the owner of A review of SimplePractice, the Cartaya Clinic in Humanistic and Behavioral Psychol- ogy PLLC, housed at Virtue Medicine, P.C. Cartaya is TherapyNotes and Valant also an adjunct associate professor at the University of Iowa Hospitals and Clinics in the department of psychi- BY NICOLE OWINGS-FONNER, MA atry. Cartaya is an active member of the Iowa Psycholog- ical Association (IPA) and has a specific interest in the integration of technology in clinical practice and ethical considerations.

he right practice management software can help a psychologist be more organized, efficient and even more appealing to clients. Software packages designed for mental and behav- Charmain F. Jackman, PhD, is a licensed psychologist ioral health offer resources for paperless practice, stream- with a doctoral degree in counseling psychology from lined billing and invoicing, and secure and effective client the University of Southern Mississippi. Jackman is the founder and CEO of Innovative Psychological Services communication. “Superior packages make it easy for prac- (InnoPsych), a thriving solo practice in the Boston metro Ttice owners to track key metrics and generate financial reports area. She also offers business development coaching and such as cash flow, productivity, outstanding payments, insurance marketing support to clinicians who are poised to launch aging and accounts receivable … all essential to the financial health or grow their private practices. and growth of any practice,” notes Charmain Jackman, PhD. Our panel of psychologists share their ratings and reviews of three practice management software packages that practitioners may wish to consider for streamlining their practice administration.

Kevin D. Arnold, PhD, ABPP, is a psychologist who is Software was reviewed in June 2019. This article has been edited for length. Visit board certified in behavioral and cognitive psychology. He APAServices.org for more information on the privacy and security risks, evidence serves on the boards of several organizations and is an APA base, cost, business models and user feedback associated with each app. fellow. He is the founder and president/CEO of the Center for Cognitive and Behavioral Therapy in Columbus, Ohio, a Let’s Get Technical is a column that discusses various software and applications avail- large group practice that specializes in cognitive-behavioral able to psychologists for their professional use. The views expressed in this column are the views of the authors and do not reflect the views of the American Psychological Asso- therapy and co-locating in primary-care offices. Arnold has ciation or any of its divisions or subunits. All authors have no financial interests in the apps served as the president of the Ohio Psychological Associ- or software discussed. APA does not recommend or endorse any practitioners, products, ation and the Ohio Board of Psychology, as well as in other procedures, opinions or other information that may be mentioned in this column; those national organizations. who use these applications or products do so at their own risk. Please direct updates and feedback about apps to Communications Office Staff ([email protected]).

4 GOOD PRACTICE FALL 2019 KEY TO PSYCHOLOGIST RATINGS

Categories are rated from 1 to 5, with 5 being the most positive score SimplePractice is a cloud-based practice manage- Do the creators acknowledge ment software designed for health and wellness that providers need to be HIPAA compliant? Is it HIPAA compliant? professionals. The software offers a client portal for Do they offer a Business Associate appointment booking, secure messaging, custom Agreement? Are there other legal/ paperless intake forms and progress notes, elec- regulatory issues to consider? PRIVACY/ tronic claim filing, a template library, free appoint- SECURITY Is there a privacy policy? Is data collected, stored, shared? Is data ment reminders (SMS text, voicemail or email), billing de-identified? Is there a security and invoicing, and integrated telehealth capabilities. policy? Data encryption?

Does the software have all the PHILLIPS ARNOLD features your practice needs? For Privacy/Security 5 5 example: accounting management, AVAILABLE appointment management, billing Available Features 5 4 FEATURES and invoicing, etc. Ease of Use 5 4

Functionality 4 4

Is it easy to navigate? Customer Support 3 4 Is it customizable? EASE OF USE Value for Money 5 5 Overall Rating 4 4

Does it perform well? KRISTI K. PHILLIPS, PsyD Is it web-based? I would recommend the SimplePractice platform to other psychologists. I was very impressed with the privacy and security, extensive features, Is there an app? FUNCTIONALITY ease of use and the functionality that makes the software ideal for providing a psychologist in private practice most everything they might need to run the business side of their practice. I think that SimplePrac- Is customer support responsive tice could be even more effective if they hired trained customer service staff to answer questions regarding the use of the software. when needed? Do they provide multiple support CUSTOMER options? KEVIN D. ARNOLD, PhD, ABPP SUPPORT SimplePractice offers an online subscription-based office management, electronic health record and billing/payment software that provides more than required precautions to protect the privacy of the data. The platform has all the features a practice would normally need. For the Does this software provide good cost, this software is more than adequately functional for groups or value for the money spent? individual offices unless integrated into primary care, where interop- VALUE FOR erability is usually necessary. There were some confusing aspects MONEY to the features when corresponding with the customer service office compared to the company’s website. Overall, though, the software seems well suited to psychologists; however, when migrating data, one would be well-served to be certain of what data will transfer and any Would you recommend this costs associated with cleaning the data set once migrated. software to other psychologists? OVERALL RATING

GOOD PRACTICE FALL 2019 5 Let's Get Technical

TherapyNotes is a cloud-based electronic health Valant offers a fully integrated suite of behavioral record (EHR), practice management and billing soft- health management tools for providers including ware designed for mental health professionals. The certified EHR with secure patient portal, streamlined software can be used for appointment scheduling intake forms, robust reporting for productivity and (by office staff or through a patient portal), to docu- revenue cycle, and a library of automatically scored ment session notes, and to update client records, outcome measures. and to create and submit insurance claims. JACKMAN ARNOLD CARTAYA JACKMAN Privacy/Security 4 5 Privacy/Security 4 4 Available Features 5 5 Available Features 5 4 Ease of Use 3 5 Ease of Use 3 5 Functionality 4 4 Functionality 3 5 Customer Support 4 5 Customer Support 5 5 Value for Money 4 5 Value for Money 3 5 Overall Rating 4 5 Overall Rating 3 4

CHARMAIN F. JACKMAN, PhD * JOANNA ROMERO CARTAYA, PhD Valant goes above and beyond with the features it offers. The finan- TherapyNotes is a visually pleasant software with good security cial and productivity reports are excellent and allow practitioners to measures. It provides multiple integrated functions and ways to understand how the business is doing from a financial perspective. customize its use based on roles or practice features; however, it does The screening tools cut down on wait time in the office as patients not include all services that a psychologist may provide. As Therapy- can complete forms at home. The ability to track patient outcomes Notes is web-based, if there is an issue with their servers or the user’s gives providers data they can use to negotiate better reimbursement internet, the software cannot be used. TherapyNotes provides good rates. One drawback of the Valant platform is the outdated user inter- unlimited phone support as well as online resources. Larger practices face. However, Valant is scheduled to have an update within the next or clinicians who want a one-stop shop for all their practice needs may six months. Valant is ideally suited for group practices and large enter- find the cost reasonable and the software easier to use as current prises. Solo practitioners, especially those interested in understanding third-party companies are integrated within the software rather than their productivity and other financial metrics should weigh the bene- contracting with multiple companies. fits versus costs for their practice of this pricier platform. *Jackman was only able to access and navigate the Valant platform with the support of a team member. CHARMAIN F. JACKMAN, PhD TherapyNotes provides a simple, straight-forward platform for clinicians and group practice. The software is web-based and requires an internet KEVIN D. ARNOLD, PhD, ABPP connection. The software is HIPAA compliant and includes a BAA for I strongly recommend Valant practice management software. The providers. It has all the needed components for clinical documentation, developers have created an online subscription-based office manage- billing, appointment management and some basic revenue and financial ment, electronic health record and billing/payment software that takes reports. You have a free 30-day trial and you can start using the plat- excellent precautions to protect the privacy of the data. Valant is easily form immediately. Customer support is available in English and Spanish. navigated in the desktop mode with intuitive sidebar menus and an TherapyNotes provides a great value and offers reduced fee structures option to enter the user-friendly mobile notes version. Overall, Valant for nonprofits and educational/training settings. I have been using Ther- performs well most of the time; however, there are periods when it is apyNotes for two years and have been satisfied with it. not available for access as it is web-based. For the cost, this software is highly functional for groups or individual offices. The company states it is close to releasing an updated software. Early reports from a pilot site are that it operates even better than the current version.

6 GOOD PRACTICE FALL 2019 WASHINGTON, DC AUGUST 6–9

CONVENTION.APA.ORG/PROPOSALS

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MORE THAN PSYCHOTHERAPY

An increasing number of n 2008, Mitchell Greene, PhD, took a risk that paid off: launching a sport psychology practice in Haverford, Pennsylvania, practitioners are incorporating to fuel a longtime passion for sports. Today, about 80% of his clientele at Greenepsych are either athletes, coaches or both. yoga, meditation or other mind- His work includes speaking engagements and consulting gigs, and his income is about 15% higher than it was when he prac- body therapies into their practices. Iticed traditional clinical psychology. Last year, Greene took another leap: adding holistic services, Here’s how you can, too. such as yoga and mindfulness, to his practice. “The word ‘wellness’ kept floating through my mind, and I BY TORI DEANGELIS thought, ‘Why not have someone in my practice who could inte- grate holistic services into what I’m already doing?’” he says. While the thought was inconceivable to him five years ago, “now these modalities seem to fit under my umbrella,” he says. His practice now includes a yoga instructor and mindfulness coach, as well as a psychology doctoral student with a master’s degree in kinesiology and training in mindfulness techniques.

8 GOOD PRACTICE FALL 2019 Trends and Opportunities

Greene is among a growing number of consultant can help you develop your prac- psychologists who are beginning to incorporate tice vision and strategy, he says, including such services into their practices. Conceptually, your business model, record-keeping and the move makes sense—after all, integrating management, billing, ideal partners, structure mind and body is a key tenet of psychologi- for decision-making and governance, cal health. But you need adequate planning; a and how you will fund your enterprise. good understanding of the legal, ethical and Holistic “You need to work with someone who can regulatory issues involved; the right people and help you do the planning on the front end—who sufficient capital to achieve success. Specialities can help you figure out the basis of your rela- As a veteran consultant to psychologists tionship as potential business partners and the interested in launching a niche practice, Jeff These are some holistic services principles and practices you’ll follow,” he says. you may want to consider when Zimmerman, PhD, ABPP, has seen his share Over time, these professionals can help building a wellness practice. of new-business successes and snafus, espe- you grow and refine the concept of your orga- cially when they involve an idealistic concept nization clinically, administratively and finan- like a wellness practice. “What tends to happen cially, Zimmerman adds. Consultants can help is that [interested providers] get to know each you consider future contingencies—for exam- other and say, ‘Wow, this is a great idea. Let’s ple, determining staff benefits, or how to handle do it,’” he says. “However, they don’t really think payment if one partner makes considerably through the possible ways it could go wrong.” MEDITATION more or less than others—and be on call if prob- To avoid potential pitfalls and to reap the lems or questions emerge. For further help in benefits of running your own wellness practice, some of these areas, visit Apaservices.org, consider these tips from practice consultants which includes information on alternative prac- and seasoned practice owners. tice models, practice management, marketing, financial management and more. Consult with the right experts. First, meet MASSAGE with an attorney who is versed in your state’s Choose a role and a structure that you (and corporate statutes and mental health laws. An others) are comfortable with. Do you want to attorney can help determine whether your be the leader of your practice or a co-owner? state allows you to pursue the kind of prac- Have a full-time staff, hire independent tice you have in mind, says Connie Galietti, JD, contractors or both? Be a sole proprietor, a APA’s director of legal and professional affairs. general partner, a corporation, an independent Several states, for example, only allow psychol- MINDFULNESS practice organization or something else? ogists to co-own a practice or incorporate with Address all of these questions in the beginning, other mental health professionals. In Alabama, advisers say. (See the APA article, “Choosing for instance, professional corporations can be the Best Legal Structure for Your Practice,” at organized “only for the purpose of rendering on.apa.org/practice-legal-structure for more professional services ... within a single profes- on this topic.) sion.” Other states are more lenient but have Greene has developed a system that works varying stipulations, she says. KINESIOLOGY well for him. He is full owner of Greenepsych, Even if your state allows you to include employing independent contractors who receive other practitioners as part of your business, a percentage of what they bring in without “consider starting with a less formal collabora- paying rent. He also meets monthly with a bill- tion,” Galietti adds. This will help to ensure that ing manager who keeps track of client payments all parties are comfortable with your practice and follows up as necessary. and partnership plans before you formalize a ACUPUNCTURE/ Andrew Tatarsky, PhD, founder and owner of business relationship. ACUPRESSURE the Center for Optimal Living, an addiction treat- Once you are clear what’s allowed in ment center and professional corporation in New your state, consider meeting with an experi- York, employs a mix of salaried providers and enced practice consultant who understands independent contractors, including 11 psychother- the mental health field and the nature of apists, a Chinese medicine practitioner and prac- your potential business, Zimmerman notes. A titioners versed in yoga and meditation.

GOOD PRACTICE FALL 2019 9 Trends and Opportunities

He became sole owner of his busi- developed a referral network with New ness after an unsuccessful attempt to With advance planning, York University, The New School and other work with partners. “I’ve come to learn area institutions, which also serve as train- that I operate best when I’m the leader, but a strong vision and input ing pipelines for his center, he says. I bring in a whole team of people who can Meanwhile, Greene chose the greater actively collaborate in developing ideas, from others, a wellness- Philadelphia area because of its access materials and programs,” he says. to college-prep schools. “There are a lot oriented practice can be a of high schools in the area and a lot of Choose your colleagues carefully. While competitive parents with competitive kids credentialing is standardized for psychology, meaningful new direction who are aiming for college scholarships,” that is not the case for complementary and he says. “It’s a prime location to do the alternative practitioners: Some are licensed, for some psychologists. kind of work that I do.” As he launches the some are certified and some are neither. As wellness aspects of his practice, he’s find- a result, choose providers in these domains ing that athletes enjoy adding them to their carefully, advises Pauline Wallin, PhD, a clin- the health of the whole organization in therapy and coaching work, thanks to their ical psychologist in Camp Hill, Pennsylva- mind, Tatarsky says. physical nature. nia, and co-founder with Zimmerman of “If the team isn’t really working The Practice Institute, a behavioral health together—if the chemistry isn’t right, the Manage your time wisely. Before offer- consulting firm. Your practice may be liable communication isn’t right, the culture isn’t ing these different services, decide how for the actions of others and your reputation one that everybody feels a part of—that you will keep and share records, deal with may suffer as a result. becomes a real problem,” he says. “So, net losses or gains, compensate staff and “If you have a practitioner who’s doing it’s important to be really clear about your contractors and address other practical some really fringy stuff—that is not well vision and the people that you invite to aspects of business management. Wallin supported by evidence but is being popular- be part of it.” In fact, colleague dynamics is a big fan of hiring others who can do ized by some celebrity—things can go bad are another reason to consider practicing certain aspects of the job better and less really quickly,” she says. An extreme exam- together informally for a while before creat- expensively than you. ple is a 10-year-old girl who died in 2000 ing a combined legal entity, Galietti notes. “Outsource noncontroversial roles like after being smothered during a “rebirthing,” bookkeeping and reception so that you’re a dubious treatment for attachment disorder. Target your marketing. Gear your market- using your professional time to organize, “You want to make sure that the people ing efforts toward potential clients who reach out, promote your practice—the you’re working with are well respected by are already inclined toward integrative big-picture stuff,” she says. their peers,” she says, “because they’ll be approaches, Wallin suggests. As Tatarsky’s business has grown, part of the face that your practice presents.” “Rather than trying to convince the techniques like these have made a huge Also important? Getting your attor- general population that these services difference in his ability to manage his ney’s input on issues related to informed are good for them,” she says, “target your workload, he says. consent and privacy, Wallin says. For exam- promotion, marketing and messaging to “I’ve put a lot of attention into goal- ple, ask holistic practitioners to create and people who are already invested in well- setting, limit-setting, self-care, being able use their own informed consent forms that ness.” For example, tap owners of health to say no, being able to delegate—to do not implicate you in the effects of their food stores, members of gyms and physi- really manage myself in the midst of grow- treatments. In addition, make sure that the cians who see patients who might be inter- ing interest and success and growth,” he other practitioners will not create issues or ested in these services. “Such people says. He also meets regularly with leaders liability for you under the Health Insurance already appreciate the value of wellness, of similar businesses in order to tap their Portability and Accountability Act (HIPAA) and are more likely to pay for professional expertise and experience. privacy or security rules—something your wellness services,” she says. With advance planning, a strong vision attorney can help to address. Another College students are a big part of and input from others, Tatarsky adds, a good move is consulting with your malprac- Tatarsky’s practice because there’s an wellness-oriented practice can be a mean- tice insurance provider to make sure your abundance of colleges and universities ingful new direction for some psychologists. policy applies to services beyond psychol- in New York, and students tend to be “It’s a leap of faith,” he says, “but if you ogy, as well as to contractors or employees interested in integrative approaches and really believe in it—if you really think the who may not be licensed, Galietti advises. many have insurance that pays for addic- community needs it—I think it’s a leap More generally, choose your staff with tion-related services. As a result, he has worth taking.” ●

10 GOOD PRACTICE FALL 2019 Renew Your APA Membership

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APA-GoodPractice-Ad-Renewal-0919-1.indd 3 9/23/19 1:59 PM Reimbursement CLAIM ACCEPTED Advice for smoother billing and fewer rejected claims

Getting reimbursed for services can be a complex task. Not only do practicing psychologists have to wade through the varying third-party payer plans that cover their patients, they also must determine which health-care service and diagnosis codes they should bill under. As a result, practitioners are bound to make a few mistakes when submitting claims for reimbursement. The chart below lists some of the most common mistakes psychologists make and how to prevent them.

PROBLEM REASON SOLUTION

Putting the wrong provider, Mistakes happen, and so do typos, Double check and reread everything before you submit patient or third-party payer misspelled names and incorrect a claim. Pay close attention to birthdays, addresses information on your claim addresses. Sometimes the wrong infor- and names. form mation can end up on a claim form because it is written or typed in wrong Keep in mind that submitting the wrong patient name from the start and then scanned onto on a claim form may trigger your reporting obligations the claim form from your computer. under the Health Insurance Portability and Account- ability Act (HIPAA) breach notification rule.

Applying the wrong CPT® Using the wrong CPT® code is usually Watch for any changes or updates to CPT® codes rele- code to a service the result of writing the wrong code vant to psychologists. You can read APA’s bimonthly number or wrong combination of PracticeUpdate newsletter for the information on numbers. CPT® codes can also change, changes to billing codes. Each January, the Centers and new codes can be created for for Medicare and Medicaid Services publishes billing services. If you aren't aware of those codes and values for health-care services in the Physi- changes, you could mistakenly use old cian Fee Schedule, available at CMS.gov. Every fall, or incorrect codes. the American Medical Association publishes new and updated codes in the CPT® Professional Edition coding manual.

Using the wrong H&B codes are a specific set of CPT® To use H&B codes, you need to find out which phys- combination of CPT® codes that apply to psychological ical health diagnosis the patient was given from the codes and International services that address behavioral, physician. Classification of Diseases social and psychophysiological condi- (ICD) diagnosis codes for a tions in the treatment or management Ask for a copy of the patient’s diagnosis from the physi- service you provide. of patients diagnosed with physical cian who provided the physical health diagnosis. Use health problems. the diagnosis code that they provide as the reason for A common mistake, for performing an H&B service: You are helping the patient example, is billing a health When you bill for H&B codes, you deal with a physical health diagnosis they received and behavior assessment and are also required to use an ICD code from the physician. Your services may include evalu- intervention (H&B or HBAI) that corresponds to a physical health ation of the patient’s responses to disease, illness or service code with a mental diagnosis. A mental health condition injury; patient adherence to medical treatment; coping health diagnosis code. cannot be the primary diagnosis for strategies; removal of psychological barriers to recov- providing an H&B service. ery; and promotion of functional improvement.

12 GOOD PRACTICE FALL 2019 PROBLEM REASON SOLUTION

Using an incorrect ICD ICD diagnosis codes are usually longer Contact the payer or visit their website and obtain a diagnosis code on the than CPT® codes, so errors may be the copy of their coverage policy to find out which ICD claim form result of missing or incorrect numbers. codes they will reimburse. Practitioners should also be mindful that third-party payers, including Medicare, may not accept all ICD codes. For example, dementia has several ICD codes that correspond to that diagnosis, and not all insurance companies accept every code.

Using a code with a This is a common error with time- Choose the CPT® code closest to the actual time description that does not based services, or services that have a of the service you provide. For example, under the match the service you specific time stated in the code descrip- CPT® time rule, if you provide 16 to 37 minutes of provided. For example, tor. Often, the mistake is due to confu- psychotherapy, bill 90832 (the 30-minute code). If incorrectly billing the sion over the “CPT® time rule.” The rule you provide 38 to 52 minutes of psychotherapy, bill 30-minute CPT® code for a states that “a unit of time is attained 90834 (the 45-minute code). 39-minute session with a when the midpoint is passed.” For patient, instead of using the example, an hour of service time is Keep in mind that some companies have policies that 45-minute code. attained when 31 minutes have elapsed. restrict or discourage the use of the 60-minute code.

Submitting a claim late Late claims submissions can be the Contact the third-party payer to find out the deadlines result of simply being unaware of a and time limits for submitting patient claims. With Medi- payer’s deadlines and time limits on care, for example, you have one year from the date of claims. service to submit the claim.

Improperly calculating the This type of mistake usually happens Review the CPT® code descriptor for the service you number of units billed when there are changes to codes and want to bill. For time-based services, the CPT® time the way they are used, such as the rule (discussed above) will apply. changes to neuropsychological and psychological testing codes that took When billing multiple units of the same service, effect in 2019. combine all units of time per service before rounding up or down. For example, if you are billing several Miscalculations also happen when bill- hours of test administration under 96136/37, combine ing multiple units of the same service. all of the time under 96137 before rounding the number Some practitioners incorrectly round of units up or down. the amount of time up or down for each individual unit. Calculating the proper number of units to be billed requires you to carefully document the time you spent performing each service and converting that time to the proper number of units billed on your claim form.

Incorrectly using base and You can report most procedures Add-on codes can be billed only if the primary service, add-on code pairs using a single code that describes the or base code, is also on the claim form. Add-on codes total service performed. However, in submitted without a base code will be denied. In addi- certain cases, you may have to report tion, add-on codes will be denied if the corresponding two or more codes to completely base code is denied. describe the service. For example, 96130 is a base code that is reported for the first hour of psychological testing evaluation services; but if you are performing evaluation services that go beyond 91 minutes, a second hour may be reported using the add-on code 96131.

Visit the Practice section of APAServices.org for more information on getting reimbursed.

GOOD PRACTICE FALL 2019 13 Trends and Opportunities

14 GOOD PRACTICE FALL 2019 Trends and Opportunities

HOW TO MAKE YOUR PRACTICE GREEN Six ways to run a business that puts less burden on the environment

BY JEWEL EDWARDS-ASHMAN

ore than half (56%) of Americans say that legisla- tors should prioritize protecting the environment and addressing climate change, according to data from the Pew Research Center. That’s an increase from a decade ago, when only 41% of Americans viewed climate change as a top issue. With a growing number Mof Americans worried about the effects of climate change, some psychologists are doing more than helping their patients cope with the anticipated changes: They are creating eco-friendly, or “green,” practices. “For a practice to be green, it’s not about deprivation. It’s about living well as a positive contributor to the systems on which all life depends,” says conservation psychologist John Fraser, PhD, president and chief executive officer of Knology, a nonprofit transdisci- plinary social science think tank. Fraser is also the past president of APA Div. 34 (Society for Environmental, Population and Conser- vation Psychology). “As psychologists, we are the best-equipped people to be self-aware. We can understand how and why we do something and how our actions influence others.” Want to build your own cleaner and greener practice? Follow these six tips:

1. DETERMINE WHY YOU WANT A GREEN PRACTICE Before changing out all the light bulbs in your office to their energy-efficient counterparts, Thomas Doherty, PsyD, recom- mends identifying your environmental values and why it’s important to run a green practice. “People tend to rush to actions, but

GOOD PRACTICE FALL 2019 15 Trends and Opportunities

SMALL CHANGES, BIG IMPACT

There are many ways to Buildings that are certified green Some modes of transportation, must take many factors into account, while fuel efficient, have large affect positive environmental including water use, waste recycling, carbon footprints, like air travel. change, and there are mental appliance energy consumption and benefits that go with them. even the type of paint used.

Physical commuting can reduce Public transportation invigorates Green spaces reduce stress stress and other mental illnesses, community mental health by creating levels and promote positive as well as improve cognitive function opportunities and networks to social interactions. and academic performance. increase community cohesion.

For an in-depth report on mental health and climate change, visit on.apa.org/practice-climate-change.

there’s a preconversation to have,” says How do you get to work? Is your practice paper- Doherty, a licensed psychologist who runs less? Are you recycling and can you do more? Sustainable Self, a practice in Portland, Oregon. Is your office located in a building that uses “Your actions will change as you get more expe- green technologies and energies? Are you using rience, and as technology changes and as the energy efficient lighting? needs of the environment change. But your values will remain fairly stable through your life. 3. USE ELECTRONIC HEALTH Celebrate these and let them be your guide.” RECORDS Doherty says these three sets of values Electronic health records (EHRs) can dramat- tend to influence people’s approach to protect- ically reduce a practice’s paper trail—and ing the environment: some clients prefer it, Piotrowski says. With EHRs, you can keep all your patients’ clini- »» Egocentric: actions that benefit the individ- cal details in one place, track outcomes and ual, their family or inner circle; share information with other providers. Many »» Altruistic: actions that benefit the health and EHRs also help with practice management well-being of people in the community; tasks, like billing and scheduling, without the »» Biocentric: actions that improve nature and added paperwork. the global landscape. 4. MOVE YOUR OFFICE TO 2. CONDUCT A “GREEN AUDIT” A GREEN BUILDING To help decide what you can change, Nancy Use your rent and utilities payments to support Piotrowski, PhD, a San Francisco–based clinical green building programs. Leadership in Energy and consultant psychologist, urges practitioners and Environmental Design (LEED), for exam- to consider the impact their practices have on ple, is one of a number of internationally recog- the planet: What is your carbon footprint—the nized rating systems that examine the green amount of carbon dioxide each person produces components of buildings. LEED buildings are resulting from fossil fuel use in their daily life? rated for their performance in conserving

16 GOOD PRACTICE FALL 2019 Electronic communications like webinars, videoconferences and conference calls are more environmentally friendly than traveling for in-person meetings.

resources and using energy efficiently. APA’s via telephone or videoconferencing. “That’s headquarters in Washington, D.C., received another green savings because I’m not LEED certification in 2013. commuting, and I have a lot more control over According to the U.S. Green Building Coun- my environment.” cil, Illinois, Massachusetts, Washington, New York and Texas top the list of states for LEED 6. SHOW AFFECTED green buildings. COMMUNITIES HOW YOU Fraser says you can also select wind or CAN HELP solar suppliers for your energy utility. Psychology practitioners can also become more green by increasing their outreach to 5. LESSEN YOUR CARBON communities that may need help managing the FOOTPRINT trauma and anxiety related to environmental Due to the nature of their work, most practicing change, says Piotrowski, who lives near Napa psychologists probably have a low carbon foot- Valley, where wildfires raged for weeks in 2017 print. Still, Doherty says, psychologists can be and destroyed nearly 9,000 buildings. mindful of their travel. Doherty lives close to his “Psychologists don’t have to become an office and limits his plane travel, for example. expert on every natural catastrophe, but you Piotrowski encourages teleconferencing with can learn about the potential impact on your colleagues instead of physical meetings. clients,” says Piotrowski, who talks with people “I know a lot of us are hooked on physi- in her community about air quality monitoring, cal meetings. That has value, but I find that we making good health decisions and managing spend a lot of money traveling, and there’s a anxiety when the air-quality is poor. higher carbon footprint with air travel. So, if I “People don’t know that they can talk to a can do something with webinars and confer- psychologist about these issues,” she adds. ence calls and electronic communications, I try “Psychologists can be green just by putting to do that.” themselves in the right place and working with She also provides psychological services their community.” ●

GOOD PRACTICE FALL 2019 17 Trends and Opportunities

18 GOOD PRACTICE FALL 2019 Trends and Opportunities CBD IN PRACTICE WHAT PSYCHOLOGISTS NEED TO KNOW

With more products containing annabidiol, a chemical compound found in the cannabis plant, is springing up nationwide in the cannabidiol flooding the form of oils, salves, teas, edible concoctions and market, here’s how to help more. Popularly known as CBD, the substance is being touted as a cure for sleep disorders, anxiety, patients make good decisions Cpain, epilepsy and even cancer. about their use. CBD became more widely available in 2018, when Congress legalized the growing of hemp, the plant from which CBD is derived. As a result, BY TORI DEANGELIS more patients are asking their psychologists and other health-care providers about CBD, wondering whether they should try it to manage their sleep, anxiety, pain or other conditions. CBD products can easily be purchased online, in medical marijuana dispensaries and in specialty retail stores, including health food outlets and smoke shops, for example. But the legal and regulatory status of CBD remains unclear. And research on the substance is limited and inconclusive, though larger randomized controlled trials are underway. Given CBD’s status as a relatively unvetted substance, how should a psychologist proceed if a patient asks about its use? What’s in the patient’s best interests and within the scope of practice? Here’s some background and advice from the experts.

WHAT DO WE KNOW ABOUT CBD? CBD is one of at least 113 chemical compounds, or cannabinoids, found in cannabis, a genus of flowering plants in the Cannabaceae family, which includes hemp and marijuana. There’s a fuzzy distinction

GOOD PRACTICE FALL 2019 19 Trends and Opportunities

between hemp and marijuana, since both dose and the mode of administration, so it “When you have an industry without are derived from the same plant species, is unclear which types and amounts of CBD standards and with relatively poor regu- but according to federal law: work, how and for whom, says psychologist latory oversight, you have problems,” Ryan Vandrey, PhD, an associate profes- Vandrey notes, among them mislabeling, »» Legal CBD-containing products come sor of psychiatry and behavioral sciences false advertising and contamination. from hemp, which federal law defines as at Johns Hopkins School of Medicine who any plant in the cannabis family contain- studies the effects of cannabis. HOW SHOULD ing less than 0.3% THC—tetrahydro- “You have to treat CBD as a novel ther- PSYCHOLOGISTS PROCEED? cannabinol, the principal psychoactive apeutic and weigh the potential risks and Ethical experts and experienced clinicians component of cannabis. benefits for each individual patient,” he says, provide the following recommendations: »» Marijuana is any cannabis plant contain- “but at the same time recognize that there is Use your professional and scientific ing more than 0.3% THC. growing evidence that it might be helpful for judgment. A good rule of thumb is APA Ethi- people with certain health conditions.” cal Standard 2.04—using your best profes- CBD doesn’t have the same psychoac- To add to the uncertainty, the Food sional and scientific judgment, says Lindsay tive properties as marijuana: Users don’t and Drug Administration (FDA) has not Childress-Beatty, JD, PhD, acting director feel “stoned” when they use it. Instead, yet regulated CBD. At this point, topical of APA’s Ethics Office. Psychologists should research suggests, CBD has mild calm- products including oils and lotions are understand state and federal regulations ing effects. Emerging evidence finds that legally permissible. Foods and beverages related to CBD, examine the latest litera- CBD may help with some health conditions, containing CBD are still considered ille- ture on the safety and efficacy of different including chronic pain, inflammation, anxi- gal, although manufacturers aren’t neces- types of CBD products and the conditions ety, multiple sclerosis and opioid cravings. sarily taking heed. they may treat, and tie that literature to their Research also finds that CBD may interact And while growing hemp is legal, states individual patients. In general, recommend- with other medications, such as the blood still have the power to determine whether ing CBD (for example, a specific product thinner Coumadin, for example, and that it to license local businesses to cultivate and dose) is ill-advised, given that the only has potential side effects such as nausea, hemp or cannabis, though manufactur- FDA-approved version is for epilepsy. fatigue and irritability. ers in nonlicensing states are selling their “Because CBD is a chemical substance The effects of CBD vary according to products nationally anyway. that can interact with other medications,

20 GOOD PRACTICE FALL 2019 Trends and Opportunities

In the case of CBD products and others he has seen numerous patients who use in a similar arena—Sainr-John’s-wort for or have considered using medical mari- depression or melatonin for sleep prob- juana or CBD after finding little relief from “I consider it my duty lems—her stance is to stay within her conventional treatments. When working realm of expertise. with such clients, he asks questions to help “As a behavioral scientist, I feel my job is them clarify how they think CBD could help to tell clients that to ‘prescribe’ exercise or sleep hygiene— them in terms of better functioning. He to talk to people about ways they can encourages them to research the products behaviorally amend what they’re doing in and return to discuss their findings. there is a paucity of their day-to-day lives to improve their well- “Because self-efficacy can be a signif- ness,” she says. “But for me, it’s touchy icant predictor of success in behavior territory to say to a client, ‘Why don’t you change,” he says, “I want to help clients research around this try this?’ because I’m a professional tell- increase their agency and ability to make ing them that. I’m not their neighbor saying, independent decisions.” ‘Hey, I’ve heard great things about CBD oil!’ Encourage investigation, but make chemical.” Why don’t you go check it out?’” sure to refer. Diane Cohen, PhD, a practi- If a patient asks about CBD—or any tioner in Oakland, California, had firsthand other psychiatric medication or quasi- experience with CBD after injuring her neck SARAH BURGAMY, PsyD medication—Burgamy advises them to in a car accident. While visiting Washington Colorado Practitioner check with their primary-care physician state following the incident, she went to a or to consider a psychiatric consultation. cannabis dispensary, where she purchased Medical professionals are better equipped a topical form of CBD. Cohen says she to gauge the advisability of trying a CBD experienced pain relief and was grateful product for a health condition than nonpre- that she didn’t have to rely on nonsteroidal it’s not advisable to recommend that a scribing psychologists, she says. anti-inflammatories, to which she’s allergic, patient take CBD without suggesting Psychologists can also contact their or on stronger pain medications. further exploration with their medical state licensing board about how the state That experience has led her to encour- provider,” Childress-Beatty says. regulates psychologists’ recommendations age patients who are interested in trying Sarah Burgamy, PsyD, past-president of CBD, Childress-Beatty adds. CBD to discuss it with their primary-care of the Colorado Psychological Association, Keep up with new developments. physicians or psychiatrists, as well as with takes that tack with her patients—educat- The research on CBD is changing rapidly, a dispensary’s “budtender” or on-site ing them on the latest research on CBD, so experts advise staying abreast of the physician. but not recommending it. literature, such as medical and other peer- Although Johns Hopkins researcher “As a professional, I consider it my reviewed journals. Meanwhile, to educate Vandrey errs on the side of caution, he duty to tell clients that there is a paucity its members, the Colorado Psychological believes providers should at least be of research around this chemical,” the Association in 2016 launched an annual open to having these conversations with Denver-based practitioner says. “So, while “Green Symposium,” a half-day workshop their patients. I am a big proponent of patient autonomy, where experts talk about the latest devel- “You need to be open and honest and I caution people to really make sure to opments in cannabis. evaluate the risks and benefits for that partic- consider what they know about the product Encourage independent thinking. ular individual,” he says, “the same as you that they’re planning to put in their body.” Daniel Rockers, PhD, president of the Cali- would for any other treatment or therapy.” ● Consider scope of practice. Burgamy fornia Psychological Association and a also considers scope-of-practice issues. private practitioner in Sacramento, says

Food and Drug Administration Iffland, K., & Grotenhermen, F. (2017). An update For consumer updates on products containing on safety and side effects of cannabidiol: A Resources cannabis or cannabis-derived compounds, review of clinical data and relevant animal studies. including CBD, visit fda.gov/consumers. Cannabis Cannabinoid Research, 2(1), 139–154.

GOOD PRACTICE FALL 2019 21 Practitioner Profiles

TREATING CHRONIC PAIN How three practitioners are working to help patients and providers better understand and treat chronic pain

BY AMY NOVOTNEY

22 GOOD PRACTICE FALL 2019 Practitioner Profiles

bout 20% of U.S. adults have chronic pain, according to the Centers for Disease Control and Prevention. As experts in helping patients better “Pain is a highly understand and manage their thoughts, emotions and behaviors, pain psychologists are an important piece of an interdisciplinary puzzle disabling and costly when it comes to helping patients cope with pain and reduce its inten- phenomenon, so it Asity. Brent Van Dorsten, PhD, for example, helps patients who have experi- remains close to the enced multiple injuries and amputations manage their pain through cognitive pulse of the American behavioral therapy (CBT) and other behavioral techniques. Jennifer Naylor, PhD, approaches pain management from a research and clinical perspec- health-care system.” tive, devoting her career to helping veterans combat chronic pain. And on BRENT VAN DORSTEN, PhD a systemic level, Jennifer L. Murphy, PhD, educates and trains providers on Colorado Center for Behavioral Medicine, Denver, Colorado taking a biopsychosocial approach to chronic pain management. “I think one of the most beautiful things about psychologists being involved in this work is our ability to make an enormous difference in a patient’s quality of life,” Murphy says. “Chronic pain is not just a physical injury, treatments and potential prognosis, and Helping patients gain control focusing on things the patients themselves can phenomenon, but a do and have control over to help improve their BRENT VAN DORSTEN, PhD long-term outcomes, is the most important complex interaction step in all that we do,” he says. “It’s also a step of biology, psychology After graduating from West Virginia University that is far too often cut short or addressed in a with a PhD in clinical psychology with a health cursory way in most medical settings.” and social support.” psychology emphasis, Van Dorsten knew that He also provides mood assessment and JENNIFER NAYLOR, PhD no matter where his career ended up, under- mood management for patients, in addition to Durham VA Health Care System, standing pain assessment and treatment would treatment adherence interventions, relaxation Durham, North Carolina be a much-needed skill. training and sleep hygiene strategies. “Pain is a highly disabling and costly phenom- “When a patient has pain over a long period enon, so it remains close to the pulse of the of time, it is easy to establish poor sleep habits, American health-care system,” says Van Dorsten, just as it is to establish poor dietary and poor who is now president of the Colorado Center for exercise habits,” he says. “Simply helping “Within a matter of a Behavioral Medicine (CCBM) in Denver. patients change the way they prepare for sleep few weeks ... you really Van Dorsten has worked as a pain psychol- and their sleep habits can have very positive ogist for more than 30 years, first at the Univer- outcomes for their quality of life.” see dramatic changes sity of Colorado School of Medicine, and since In a health-care system where physicians 2012 as the director and sole practitioner at and facilities increasingly set goals to write in affect and physical CCBM, a community-based behavioral health fewer opioid prescriptions, Van Dorsten also movement as well as psychology center. works closely with patients who have been on He provides cognitive-behavioral assess- opioid medications for long term. The inevitable a restoration of hope ments and treatments for patients with a vari- question that follows a decision to taper these that is often lost in this ety of chronic pain conditions, though primarily meds is “What are we going to do for these spine pain conditions. He also educates his patients instead?” he says. CBT for chronic pain population.” patients about their chronic pain and assesses and other nonpharmacological interventions JENNIFER L. MURPHY, PhD factors that may undermine their recovery. are increasingly becoming more respected and James A. Haley Veterans’ Hospital, “After doing this for what feels like a life- sought after by physicians and patients. Tampa, Florida time, I truly believe that the provision of accu- Van Dorsten urges psychology graduate rate information and education about one’s students and early career psychologists to get

GOOD PRACTICE FALL 2019 23 Practitioner Profiles

training in pain psychology to help ensure “Individuals with chronic pain patients are getting more evidence-based behavioral treatments. ... often have a reputation as “There is a dearth of practitioners nationwide who are well trained in pain manage- being challenging to work ment, and the magnitude of the problem is only going to continue to grow,” he says. with, which is unfair. Most As a result, Van Dorsten and Jenni- fer L. Murphy, PhD (also profiled here), of them just want their are working with Stanford University pain psychologist Beth Darnall, PhD, to suffering to lessen and boost awareness of the breadth and depth of behavioral interventions for don’t know how to make pain. The Effective Management of Pain and Opioid-Free Ways to Enhance that happen, which is a Relief (EMPOWER) study is designed to compare the effectiveness of two frustrating experience.” evidence-based behavioral pain treatments (cognitive-behavioral treatment for pain, designed by Murphy, and chronic JENNIFER L. MURPHY, PhD pain self-management) in reducing pain and the use of opioids among patients with chronic pain. The study, which runs through 2023, is active in 10 primary-care and pain clin- Trained as both an experimental and stress disorder, depression and anxiety ics in Colorado, Arizona, Utah and Califor- clinical psychologist, Naylor continues to as well as chronic physical diseases, all of nia and will include findings from a 1,365 maintain an active research career examin- which are contributing to and impacted by patients tapering off opioids long term, ing how neurosteroids—steroid hormones chronic pain. The team works together with Van Dorsten says. found naturally in the body—may play a primary-care physicians to develop tailored role in reducing chronic pain intensity. In a recommendations, which may include addi- double blind, randomized controlled trial tional physical measures, such as physical of almost 100 Iraq/Afghanistan-era veter- or occupational therapies, and psychologi- Embracing a ans, Naylor found that participants treated cal measures, including referrals to mental with a pharmaceutical-grade tablet formu- health, pain school classes offered by the biopsychosocial approach lation of the neurosteroid pregnenolone Department of Veterans Affairs (VA; see showed “significant and meaningful reduc- more below). The team may also suggest JENNIFER NAYLOR, PhD tions” in low back pain intensity ratings at engagement strategies for providers to six weeks compared with their peers who use with their patients, such as motiva- As a health psychologist, Naylor is fasci- received a matching placebo. The findings tional interviewing or cognitive-behavioral nated by the mix of biology, psychology were presented at the American Pain Soci- techniques, and when indicated, they will and social issues behind chronic pain— ety Scientific Meeting in April. provide recommendations for a variety of and the many different ways health-care Naylor is also part of an interdisciplin- medical interventions such as surgery or providers can treat it. ary team of pain specialists made up of injections, as well as medication manage- “Chronic pain is not just a physical anesthesiologists, psychologists, psychi- ment for both pain and mental health symp- phenomenon, but a complex interaction atrists, primary-care physicians, pharma- toms or conditions. of biology, psychology and social support, cists, physiatrists and nurses. Much of her “Primary-care providers are not getting a and it impacts so many different areas of work includes advising the providers on lot of pain care training, so transitioning from people’s lives,” says Naylor, who provides non-opioid and behaviorally based pain a biomedical to a biopsychosocial approach services at the Interdisciplinary Pain Clinic, management treatment plans for veteran is new for many of them,” she says. Durham VA Health Care System in Durham, patients, who often experience mental To help address this knowledge gap, North Carolina. health disorders such as post-traumatic about a year ago Naylor helped to develop

24 GOOD PRACTICE FALL 2019 and implement a series of pain courses for tertiary pain center, she supervises a sectors on the behavioral management of patients and providers at the Durham VA number of services there, including the pain, emphasizing that treatment should Health Care System, thanks to funding from inpatient Chronic Pain Rehabilitation focus on increasing individuals’ self-effi- the Mid-Atlantic Mental Illness, Research, Program. Patients often present after being cacy around chronic pain by better under- Education and Clinical Center. The patient in pain for 15 or more years. They may be standing its complex nature and the many courses, provided on-site and through tele- physically dependent on opioids but not active strategies that can reduce its nega- health, run for three weeks every month. particularly benefiting from them func- tive impacts. They not only educate patients about tionally anymore and feel isolated. “Within Murphy encourages any early career managing chronic pain but also promote a matter of a few weeks in the program, psychologist with an interest in this area to patients’ active engagement in self-care, being cared for by a nurturing team and gain training experience with the veteran Naylor says. receiving education about how to approach population to see if they might be a good fit. “The more empowered individuals are in pain differently, you really see dramatic She notes that those with chronic pain are their ability to improve their own function, the changes in affect and physical movement desperately in need of providers who are less dependent they are on more passive as well as a restoration of hope that is often validating and collaborative. modalities such as medication,” she says. lost in this population,” she says. “Individuals with chronic pain—particu- Murphy no longer sees many patients larly those who may have opioid-related herself as she is focused on system-level issues—often have a reputation in the initiatives to increase nonpharmacolog- health-care system as being challenging Educating clinicians ical options for pain management. She to work with, which is unfair. Most of them has led VA efforts to increase the avail- just want their suffering to lessen and don’t about pain care ability of interdisciplinary pain rehabilita- know how to make that happen, which is tion programs such as the ones in Tampa a frustrating experience,” she says. “They JENNIFER L. MURPHY, PhD so that those with complex chronic pain are so appreciative of clinicians who listen, can receive the comprehensive care they believe them and then take the time to Murphy has seen firsthand how psychol- need. In addition, Murphy is the VA’s master build rapport—after that they can begin ogists’ biopsychosocial approach to pain trainer for cognitive-behavioral therapy for learning tools to take back control of their helps patients. As the pain psychology chronic pain (CBT-CP) and the lead author of pain and their lives.” ● program manager at the James A. Haley the VA’s CBT-CP manual. She trains health- Veterans’ Hospital in Tampa, Florida, a care professionals in the public and private

Best practices for treatment of pain

In May, the federal Pain Management pain treatment: medications, interven- tests and clinician time with patients to Best Practices Inter-Agency Task Force tional procedures, restorative therapies, establish a therapeutic alliance and to released its report on acute and chronic behavioral health and complementary set clear goals for improved functional- pain management best practices, which and integrative health approaches. ity, quality of life and daily activities. The calls for a balanced, individualized, “There is no one-size-fits-all approach report also highlights the disparities and patient-centered approach. when treating and managing patients challenges faced by special populations, Launched in 2017, the task force was with painful conditions,” says Vanila M. including veterans, active military, women, convened by the Department of Health Singh, MD, task force chair and chief youth, older adults, American Indians and and Human Services (HHS) in conjunc- medical officer of the HHS Office of the Alaska Natives, and cancer patients and tion with the Department of Defense and Assistant Secretary for Health. “Individ- those in palliative care. the Department of Veterans Affairs with uals who live with pain are suffering and “This report is a road map that is the Office of National Drug Control Policy need compassionate, individualized and desperately needed to treat our nation’s to ensure best practices in the treatment effective approaches to improving pain pain crisis,” Singh says. of pain. The report underscores the need and clinical outcomes.” to address stigma and ensure patients The authors emphasize safe opioid Read the full report at www.hhs.gov/ash/ receive access to care and education. It stewardship by recommending more time advisory-committees/pain/reports/index.html. also highlights five broad categories for for history-taking, screening tools, lab

GOOD PRACTICE FALL 2019 25 Legal and Regulatory Issues

THINKING OF ransitioning from practice into retirement or other pursuits is often an exciting endeavor for psychologists. But without the right planning and preparation, it can also be daunt- RETIREMENT? ing.T To help guide psychologists who are considering retirement or a career change, here are answers to some of the most Key points to consider before common questions APA’s Office of Legal and Regulatory Affairs receives on how to you close your practice step away from psychology practice.

BY CONNIE GALIETTI, JD I’ve set a retirement date. When should I start notifying my existing patients? The time frame depends on where and for whom you work. To best answer that question: »» Review your contracts or employee handbook. If you’re employed by or contracted with a facility or health-care practice, check to see if your workplace policy documents or your employment contract spell out notice requirements. Then work with the company to ensure a smooth transition. »» Use your clinical judgment. If you are self-employed, or your workplace documents offer no guidance, how

26 GOOD PRACTICE FALL 2019 Legal and Regulatory Issues

You will need to securely store any retained records and be prepared to respond to requests for access, which may be difficult if you have a lot of paper records.

much notice you give may depend on several one or more of the following ways to publicize factors: each patient’s diagnosis, length of the your retirement: therapeutic relationship and continuing treatment needs. For example, you may want to »» Publish an ad in the local paper. tell patients with severe conditions who need »» Send a letter to all former patients within the continued therapy as soon as possible to help retention window. them transition to a new psychologist. »» Keep your website active with instructions »» Review APA Ethics Code, particularly stan- for requesting records. dards 10.09 and 10.10, offers guidance on how to »» Update your voicemail message to include protect your patients when terminating therapy. instructions. Before making referrals, you should obtain a written authorization from patients that will You might consider announcing the closure of allow you to provide copies of their records to your practice four to six weeks in advance to their new therapists. give you time to respond to records requests.

Do I have to notify former patients? How long should patient records be kept? How do I do that? How do I store them? Some states require you to give notice in a State and federal regulations dictate how prescribed manner, while others don’t, so long you must keep patient records. The contact your state psychological association or Centers for Medicare and Medicaid Services, licensing board to find out. for example, may require you to retain But either way, patients have the right to Medicare patient files for 10 years after last access the protected health information in their date of service. For psychologists not bound health records for a period of time, so it’s import- by Medicare or state law requirements, or ant to tell them how to get that information. contractual obligations, the APA Record If your state has no requirements about Keeping Guidelines (on.apa.org/practice- how to notify former patients, you can use guidelines-record-keeping) recommend that

GOOD PRACTICE FALL 2019 27 Legal and Regulatory Issues

you retain adult records for seven years and or electronic). Take great care to keep them juvenile records for three years after a patient secure if you store records in your home. reaches the age of 18. Be sure to follow your statutory and contractual obligations around I’ve become close to some of my patients record-keeping. over the years. Is it OK to meet for coffee If you are leaving a facility or group practice, or pursue friendships after I retire? contractual arrangements or employer poli- The relationship between a psychologist and cies may determine whether you or the facility/ a patient is not built on equal footing, and the practice will retain control over your patients’ confidential and sensitive nature of your discus- records for the duration of the required period. sions in a professional setting does not equal If you will be retaining the records after retire- friendship. You risk harming a former patient by ment, you will need to store them securely and developing a new relationship that can easily be prepared to respond to requests for access, slip back into a therapeutic one. Consider why which may be difficult if you have a large case- you want to form a friendship and how this load and a lot of paper records. would benefit you and the patient. Review APA If you are unable, or unwilling, to store the Ethics Code Section 3 for guidance. records at home or respond in a timely manner to requests for access, make arrangements What should I do about my license? with a colleague or a Health Insurance Porta- Keep your license active if you think you’ll want bility and Accountability Act (HIPAA)-compli- to see patients again or do volunteer work. If you ant storage company to manage this task for don’t foresee practicing in any capacity, you can you. You will need a HIPAA business associ- switch to inactive or, if your state offers it, retired ate agreement (BAA) to do this, and there will status. Contact your state’s regulatory board to likely be costs associated with these options. research the options, requirements and costs. To make document storage more cost effective and efficient, consider using a standard docu- I’m starting to have second thoughts ment destruction protocol while you’re still about retiring. What if I’m not sure? practicing, which will save you from having to Retirement is your decision. It’s also not sort through everything right before you retire. permanent, so you can change your mind. If If you decide to store records in your home, you aren’t sure, consider a trial run by keep- you could make them more secure by: ing your license active for another year (or two) and reassessing. You will have to meet »» placing them in fire-resistant file cabinets; your state’s CE requirements and pay the »» transferring paper records to electronic files fees, but this will give you the time to decide for easier storage; if retirement is right for you. ● »» encrypting your electronic records and using password protection to make sure The words “patient” and “client” are often used inter- they are not easily accessed by others. changeably. This article uses “patient.”

Under HIPAA, if you store files electron- ically, you must perform a risk analysis to determine and document any threats and vulnerabilities to the files and document the security measures you’re using to address A checklist of tasks for closing those risks. Also, under both HIPAA and your practice can be downloaded at state laws, you are subject to breach noti- apaservices.org/practice/business/ management/tips/closing.pdf. fication requirements if someone were to gain unauthorized access to the files (paper

Disclaimer: Legal issues are complex and highly fact-specific and state-specific. They require legal expertise that cannot be provided in this article. Moreover, APA and APA Services, Inc. attorneys do not, and cannot, provide legal advice to our membership or state associations. The information in this article does not constitute and should not be relied upon as legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions.

28 GOOD PRACTICE FALL 2019 on.apa.org/books

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