Pioneer in Team-Based Care Explains How Psychiatrists Can Get Involved

For psychiatrists who can remember having considered going into primary care medicine, newly evolving models of integrated and collaborative care can be a way to scratch that itch.

“Like a lot of people who do consultative psychiatry, when I was in medical school, I was torn between primary care and psychiatry,” said Wayne Katon, M.D. “In the end I opted for psychiatry, but my life’s work and career since making that choice has been working with mental health issues in a primary care population.”

Courtesy of Wayne Katon, M.D.

Today, Katon is director of the Division of Health Services and Psychiatric Epidemiology at the University of Washington in Seattle and one of the fathers of the integrated-collaborative care movement.

For 30 years he has worked to develop and test models for integrating mental health treatment into primary care practice; for many of those years it was a practice model far outside the mainstream. Not so today when one of the driving forces of health reform—to improve the quality of outpatient medical care in the primary care setting and prevent unnecessary hospitalization—has dovetailed with what Katon and his colleagues have been showing for more than two decades—that the people who do the worst with physical illness often have comorbid psychiatric illness and that a team-based approach can improve health outcomes while lowering cost.

The result is a rapid acceleration of interest in the collaborative-care model. “We run two dissemination centers at the University of Washington training systems of care in collaborative and team-based care,” Katon told Psychiatric News. “We have had more people contacting us to train their systems of care in these models in the last three years than we have had in the previous 30 years. That’s because health reform is moving us very rapidly in this direction.”

Traditional Practice Can Be Maintained

Katon’s career and the evolution of his own interest in a model of care focused on psychiatric illness in the primary care setting illustrate at least two items of significance: the distinction between “integrated” care and “collaborative” care; and the fact that there is a variety of ways a psychiatrist can fit into this new model of care, while still maintaining a traditional office-based practice.

During his residency in the late 1970s at the University of Washington, Katon did an elective rotation in one of its family medicine clinics. “That’s when I began to recognize that the vast majority of people with depression and anxiety never get to a mental health professional,” Katon said. “And I saw that if we could empower the primary care system to improve the recognition and quality of treatment, we could have a tremendous public-health impact, more so than I could as a psychiatrist seeing individual patients.”

What began as a consultant role gradually evolved into what is called “integrated” care today. “I would work a day or two a week in the clinic, and they would schedule me with patients to see,” Katon recalled.

Some 30 years later Katon still is doing that basic model of integrated care, working one-half to three-quarters of a day once a week at the Swedish Charity Hill Family Medicine Clinic in Seattle. But back in the early 1980s, after finishing his residency, Katon also began doing research with the Group Health Cooperative of Puget Sound, the region’s long-established HMO, experimenting with different health-service models for care of depression and anxiety disorders in primary care.

Out of that work would come a seminal paper in the evolution of collaborative care, published in the April 5, 1995, JAMA, titled, “Collaborative Management to Achieve Treatment Guidelines Impact on Depression in Primary Care.” In that paper, Katon and colleagues showed that a collaborative intervention involving a psychiatrist working in a team with the primary care physician and nurses significantly improved adherence to medication, depressive outcomes, and satisfaction with care.

The model was a more formalized version of the consultative work Katon had been doing. Patients receiving the intervention alternated visits with the primary care physician and psychiatrist over four to six weeks with appointments spaced seven to 10 days apart. The psychiatrist monitored patient symptoms and recommended intensification of treatment when patients had persistent symptoms. Occasionally, patients with side effects or treatment resistance were seen for a third or fourth visit.

Early Work Led to IMPACT

Seven years later, Katon’s work on new health service models would evolve into the IMPACT (Improving Mood: Access to Collaborative Treatment) Program, directed by Jurgen Unutzer, M.D., M.P.H., and a second major publication, in the December 11, 2002, JAMA.

That paper described a fully realized model of what is today known as “collaborative care.” Rather than simply seeing individual patients in a primary care setting, in the collaborative-care model the psychiatrist consults with a “care manager”—usually a nurse or social worker—who coordinates care of psychiatric conditions for a caseload of perhaps 100 or more patients in the primary care setting. “I now spend the first hour in my primary care clinic supervising as many as 50 patients and then see six to eight traditional psychiatric consultations over the next three hours,” said Katon.

Also critical to the collaborative care model is regular use of the PHQ-9 and other validated instruments to measure treatment progress and provide a target for recovery.

And in a December 30, 2010, paper in the New England Journal of Medicine, Katon and colleagues extended the model to care of patients with poorly controlled heart disease and/or diabetes and comorbid depression. That paper showed that the collaborative-care model significantly improved control of both medical disease and depression and reduced medical costs.

So how do psychiatrists get paid? Katon acknowledges that reimbursement for the different components of a collaborative-care model has been the most significant barrier to dissemination. But he says it is an issue that is evolving, with a lot of “natural experiments” cropping up around the country. At the University of Washington, for example, the hospital pays for the psychiatrist and care coordinator and has extended the model to multiple primary care and medical specialty clinics.

At the Diamond Project, a major collaborative-care initiative in Minnesota, participating private insurers have agreed to pay for psychiatric supervision and care manager time.

Katon says he believes Medicare will be moving to “bundled” payments that can include payment for psychiatric supervision of care managers for medical patients and is reforming its payment structure to reward hospitals that have lower rates of rehospitalization. Additionally, one of the quality indicators developed by the National Committee for Quality Assurance for emerging “patient-centered medical homes” is a requirement to demonstrate improvement in at least one mental health condition.

So Katon maintains that as hospitals and health systems respond to new payment incentives, they will realize the value of psychiatry because—as his work has shown repeatedly—it is medical patients with comorbid psychiatric illness that end up costing the most.

“This is really a chance for psychiatry to be part of the dialogue of health reform and become involved in helping hospital systems integrate mental health care in way that’s never happened before,” he said. ■