Psychiatrist Involved in Collaborative Care Before Concept Existed

While on a Navajo Indian reservation in Kayenta, Ariz., working as a staff psychiatrist for the Indian Health Service (IHS), Lori Raney, M.D., discovered a love for the American West and a knack for working as a team member with primary care physicians.

“The Indian Health Service is a self-contained system with mental health, primary care, dental care, and vision care working together,” Raney said. “I was the only psychiatrist, and every morning I was expected to meet with the rest of the physicians—we all showed up regardless of discipline.”

That was in the mid-1990s. Raney had completed a residency program known for traditional psychodynamic training at Sheppard Pratt Hospital in Baltimore when a fellow trainee who had taken a position with the IHS called his colleagues in the East with word that there were jobs available in a ruggedly beautiful landscape.

“Several of us went out there together, and I fell in love with the West,” she recalled. After two years as director of the Counseling Services Department at Kayenta, Raney took a position as clinical director for the entire ambulatory care clinic, also on the Navajo reservation—the first psychiatrist to hold that position. “For five years I supervised all the primary care doctors and got a lot of practice in running a primary care clinic,” she said. “It’s the foundation of my interest in merging mental health and primary care.”

Lori Raney, M.D.

Today, Raney is one of the leaders within psychiatry of the movement toward collaborative care and is chair of the APA Work Group on Integrated Care. The names—integrated care, collaborative care—are used interchangeably, but in fact denote different models of care.

A true collaborative-care model is different from simply co-locating a psychiatrist in a primary care clinic, which is what is usually meant by integration. “What makes collaborative care unique is that a team of clinicians from different disciplines, including psychiatry, work together, screening patients, tracking their progress, and making sure they improve over time,” Raney explained. “The psychiatrist works closely with a care manager on a consultative basis for a caseload of patients and is readily and immediately available to primary care physicians in a way psychiatry has never traditionally been.”

Following her experience in the IHS, Raney moved to Durango, Colo., where she started a family and began working for the next 13 years as medical director of a community mental health center for Axis Health System.

It was in 2006, she said, that the leadership of Axis became very interested in the then-nascent integrated-care movement. The catalyst was a widely disseminated finding that individuals with severe mental illness were dying on average 25 years earlier than the general population.

“That was a wake-up call that got the attention of a lot of mental health centers,” Raney said. It demonstrates the shared and mutually reinforcing interests—of both the primary care and mental health sectors—that is driving the integration of the two. Just as psychiatrists have an opportunity to assist in the management of depressive and anxiety disorders among patients in primary care settings (and among those with multiple, chronic medical conditions), so the mental health sector needs to incorporate the skills and expertise of primary care to monitor, manage, and treat metabolic disease and other chronic medical conditions among the population with severe and persistent mental illness.

Going 'Full Bore' Into Collaborative Care

In 2007, Raney said Axis went “full bore” into collaborative care, and she became the consultant psychiatrist for a Federally Qualified Health Center and a School Based Health Center. In 2011, she helped design and open the new Cortez Integrated Health Care Clinic, bringing primary and mental health care under one roof.

“My office is literally in the primary care suite, so I am right there with the primary care doctors seeing my patients with severe mental illness but also providing consultation to primary care and behavioral health providers as questions come up,” she said. “I can walk out of my office and into an exam room with a primary care clinician and help that clinician with a patient if needed. And I do that quite frequently.”

Today, Raney continues an eclectic practice doing plenty of what looks like traditional psychiatry along with varieties of consultative, integrated, and collaborative care. “My current practice is a mix of things,” she said. “I see my patients in the community mental health center, but I also go to a federally qualified primary health care center where I work as a consultant psychiatrist on a collaborative care team. I do a lot of consultation with the behavioral health care and primary care providers, and I do educational meetings on a monthly basis. And I do some consultative work to school-based health clinics.”

Raney also has a small private practice in the community.

She emphasized that the opportunity to fashion a collaborative practice according to a clinician’s own setting, circumstances, and personal interests should be one of the attractions of the integrated-care movement—and a source of comfort to clinicians who may think that traditional one-on-one psychiatry is going to disappear.

It won’t. “This is one of the important things—that collaborative care can be a part of what you do, or all of what you do,” Raney told Psychiatric News. “For most of us, it is part of what we do.”

She urges psychiatrists to make use of a growing number of resources for learning how to do collaborative care; at this year’s APA Institute on Psychiatric Services in Philadelphia in October, there will be some 20 workshops and symposia on the subject. Also, she recommended that psychiatrists look to their own community health centers and hospitals for how they can contribute their expertise. “A hospital psychiatrist can be thinking, 'there’s a handful of patients with congestive heart disease and other chronic medical conditions and comorbid psychiatric illness that are high utilizers of health care resources—how can I help with these patients?’ ”

Psychiatrists Urged to Consider Retraining

She also urged psychiatrists to think about retraining in general medical skills. At APA’s annual meeting in San Francisco in May, Raney organized a symposium titled “Primary Care Skills for Psychiatrists.”

“It was in the afternoon on the last day of the meeting, and we thought no one would show up,” she said. “But it was an overflow crowd of around 250 psychiatrists, and we couldn’t get everyone in a room that accommodated 77.”

For the profession in general, Raney said that the collaborative-care movement is an opportunity to address the perennial problems of training a sufficient workforce. “We will never have enough psychiatrists and will never talk enough young people into entering our field,” Raney said. “So we need to think in new ways about how to use our workforce to meet the needs of the population. I personally find this work to be incredibly rewarding because I am able to utilize and extend my expertise in a way that I never have before.” ■