25 Years of Integrating Care at Safety-Net Health Care System

This month’s column features Dr. Robert Joseph, who has spent 25 years perfecting the role of a consultation-liaison psychiatrist at Cambridge Health Alliance (CHA), one of our nation’s premier safety-net health care systems. Even in Cambridge, Massachusetts, an urban area that has one of the highest concentrations of psychiatrists in the nation, it can be exceedingly difficult to get mental health care, and Robert’s work to integrate behavioral health services into primary care has made a big difference in improving access to care. His journey toward a fully integrated behavioral health care system at CHA is an inspiration to many of us. —Jürgen Unützer, M.D., M.P.H.

Late in medical school, I found myself torn between doing a residency in internal medicine or psychiatry. I loved medicine but found myself frustrated during an ambulatory medical clerkship by the sense that I was trying to practice psychiatry with my hands tied behind my back. Many of the patients I met seemed anxious, depressed, or overwhelmed, and many of those without overt emotional symptoms were engaged in self-destructive behavior or poor self-care. I felt at a loss to understand their behavior or how to help them.

This experience was among the factors that led me to pursue a career in psychiatry, where I was drawn to the opportunity to better understand the nature of patients’ distress and behavior. Following residency, an interest in medical education led me to the practice of consultation-liaison psychiatry at Cambridge Health Alliance, an academic medical center affiliated with Harvard and Tufts Medical School.

Cambridge Health Alliance is a safety-net primary care network with two community hospitals and a strong history of commitment to community medicine and psychiatry. Initially, I worked within a fairly traditional model of consultation psychiatry, providing psychiatric opinions upon request to my medical and surgical colleagues within a general hospital while supervising adult psychiatry residents and eventually fellows in psychosomatic medicine.

As a consult psychiatrist, I quickly became aware of the burden of mental illness in medical settings and how little conventional psychiatry seemed to offer many of these patients (despite the fact that Cambridge has one of the highest per capita rates of psychiatrists in the country). This was in part due to the limited resources and less-than-friendly access policies available to safety-net patients, but also due to the fact that most patients did not tend to define their symptoms or maladaptive behavior in terms of emotional distress and therefore would rarely seek or accept a referral for psychiatric care.

Concurrently, I observed how much psychological distress (as well as overt mental illness) was seen exclusively by my medical colleagues despite the minimal training they received in this area. Mental illness was, of course, sometimes overlooked and sometimes poorly managed, but I was equally struck by the persistent efforts of many of my primary care colleagues to address these problems in the context of difficult-to-access specialty care.

These observations gradually led me to develop an ambulatory integrated care practice beginning in 1990. The service began by providing consultations at one internal medicine training site while precepting medical residents. Over the subsequent decade, the clinical service gradually grew to include all 15 affiliated primary care sites.

As a consult service, our mission from the outset was to help the primary care providers manage the mental health needs of their patients. We provided formal and informal consultations and brief treatment and triaged those patients who needed (or wanted) ongoing or intensive care to a general psychiatry clinic.

Over time and influenced by the work of Ed Wagner, Wayne Katon, and Jürgen Unützer (among others), the service has gradually adopted a population-based, proactive style of integration utilizing screening and a collaborative care model with consulting psychiatrists, embedded therapists, and care managers.

As the service grew, training of residents and workforce development followed. It soon became apparent that the pace of the work (high volumes of new patients and quicker turnover compared with general psychiatry) was a challenge for staff and trainees. Beyond the labor involved with the sheer number of discrete patients seen, some staff missed the satisfaction of longer-term relationships with patients. This was most difficult for staff who transitioned from a traditional delivery model. Conversely, traditionally trained consult psychiatrists sometimes struggled with the ongoing responsibilities for patients inherent in ambulatory work and with the fact that some patients seen in primary care have no comorbid medical illness.

Despite these challenges, there seems little doubt about the value of integrated care in a safety-net population, including communities relatively well endowed with mental health providers. Even in Cambridge, the mismatch between the prevalence of psychiatric morbidity and access to conventional psychiatric care is acute. Our integrated program has dramatically improved access, and our providers feel well supported by the initiative. One primary care colleague recently commented that the integration service has elevated the quality of psychiatric care he is able to provide and went on to speculate about how this could be a valuable model for other specialists as well.

Finally, as noted in previous articles in this column, promoting workforce development and the training of psychiatrists along with emphasizing the rewarding nature of the consultant’s work is crucial to sustaining this transformational effort. In addition to providing direct patient care, the psychiatric consultant is essential to the functioning of the treatment team. To be effective, the consultant must develop close working relationships with the members of a multifaceted treatment team while providing essential clinical expertise.

Most importantly, the consultant, in conjunction with the treatment team, can take satisfaction in helping many patients who otherwise would receive no care. ■