The Yale Roadmap for Health Psychology and Integrated Cardiovascular Care.

Abstract

Objective: Cardiovascular disease remains the leading cause of morbidity and mortality in industrialized nations. Many patients living with chronic cardiovascular disease suffer from complex multimorbidities requiring high-intensity care and behavioral risk factor management, and about a third copresent with a mental health disorder. These comanifestations are extremely taxing for patients and our health care system, complicate treatment, and increase the risk of adverse health outcomes. Health psychology emerged in response to a need for specialists who could design, deliver, and test evidence-based approaches to manage behavioral risk factors and the mental health burden of chronic diseases. We aimed to conduct a state-of-the-art review as to how health psychology emerged as a key specialty in delivering integrated care for cardiovascular populations, and to review challenges and opportunities that lie ahead of further integration of the specialty for integrated cardiovascular care. Method: As our health care system embraces more patient-centered care and big data science to detect at-risk patients and predict outcomes, health psychologists should be at the forefront to apply their expertise and demonstrate their value in designing and applying intervention models to improve outcomes. We first review challenges, then illustrate this framework using the Wagner chronic care model, present business case considerations, and conclude with an action agenda to promote the integration of health psychology as a cotreating specialty into cardiovascular care. Results: To provide direction for this undertaking, we present a roadmap for the field of health psychology to sustainably extend existing holistic, integrated approaches in cardiovascular care. Conclusions: To lessen the burden and improve outcomes in cardiovascular disease, care must shift away from siloed delivery models that are focused on traditional atherosclerotic risk factors to holistic, integrated approaches that address biological, psychological, social, and behavioral factors relevant to cardiovascular disease. Using the presented roadmap, health psychology can play a major role to address these needs of integrated cardiovascular care.

If not us, who? If not now, when? Paths forward in science, patient care, and training to maximize the impact of cardiovascular behavioral medicine.

“…Vela and Feingold describe the iterative process by which this program was developed and modified and by which it is continually evaluated. Similarly, the aspirational paper in this issue by Gaffey et al (2022) describes the rationale and evidence to support the establishment of integrated care programs, while also highlighting two high-cost, poor-outcome areas in which our impact could be greatest. In one of those areas (heart failure), professional organizations have already called for the integration of psychological and traditional medical care.…”

“…To this end, we need our own professional organizations contributing to this effort by lobbying federal and state governments, health care systems that now can cross state lines, and insurance providers. As noted by Gaffey et al (2022), movement away from fee-for-service to value-based care may help to support us, yet it will still be essential for our professional organizations and for us as individual professionals to speak strongly, consistently, and persistently for parity in clinical care and payment, here too following the lead of our medical colleagues. We must point to what are increasingly recognized as patient needs, using the evidence of these needs and the impact of our treatments when applied properly to improvements in what we will call the pathogen of health-risk behavior and to quality of life, at the very least.…”

“…Among the papers in this issue, the one by Sall et al (2022) describing the training program at Eastern Carolina University (ECU) comes closest to this training model. The papers by Vela and Feingold (2022) and Sears et al (2022) describe the integrated cardiovascular care that would offer a context for this training, and the paper by Gaffey et al (2022) speaks in detail to how such a model might be applied for the care of patients with peripheral vascular disease or heart failure. What we find particularly noteworthy is the placement of a ‘psychologist attending’, a member of the clinical (health) psychology training faculty, within a cardiology clinic.…”

“…For many faculty members in clinical health psychology training programs, this will be fraught with obstacles and will require some uncomfortable changes. We point to the papers by Sall et al (2022), Vela and Feingold (2022), Sears et al (2022), and Gaffey et al (2022) for roadmaps to undertaking this revamping of our clinical training.…”

“…Concerning the second question, we believe that the time for change is now. Our field has generated sufficient evidence to move full steam ahead with a research agenda emphasizing clinical trials and implementation science (Stoney et al, 2022), and we have strong exemplars in integrated cardiovascular care (Gaffey et al, 2022; Sears et al, 2022; Vela & Feingold, 2022) and training (Sall et al, 2022) that can be replicated elsewhere. But where to start?…”