Expanding Roles for Psychiatry in Population Health

This month, we hear from Neil Korsen, M.D., M.S., an experienced family physician and one of the pioneers of integrated behavioral health care in the United States. Dr. Korsen advocates for psychiatrists taking on the role of teacher, coach, and consultant during this era of accountable care and population health. —Jürgen Unützer, M.D., M.P.H.

Population health is receiving increasing attention as the health care system moves from rewarding volume to rewarding value. The National Academy of Medicine adopted the following definition of population health in 2013: “The health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Accountable care demands that we pay attention to all people who have health care needs, not just those who seek our care. This means that we have to focus on understanding the needs of all groups of people for whom we are accountable and use our resources most effectively to meet those needs to the extent possible.

As we take a population health approach, it is clear that having a mental health condition has a substantial negative impact on health outcomes, especially those related to common chronic conditions such as diabetes, heart disease, and chronic lung disease. A 2014 study commissioned by APA, titled “Economic Impact of Integrated Medical-Behavioral Healthcare Implications for Psychiatry,” showed that even modest improvements in the outcomes of care for people with comorbid mental health and chronic physical health conditions would lead to savings in the tens of billions of dollars.

The population with serious mental illness and comorbid chronic physical health problems has received particular attention. A 2006 study by the National Association of State Mental Health Program Directors Council, titled “Morbidity and Mortality in People with Serious Mental Illness,” showed that this population had a life expectancy that is 25 years shorter than that of a matched population without serious mental illness. It is primarily the effects of chronic medical illnesses that leads to the shorter life expectancy. In both of the above examples, better integration of physical and behavioral health care has been shown to achieve better outcomes for these populations.

Psychiatry has explored how best to extend the reach of specialty expertise in research and practice for many years. The Collaborative Care Model (CoCM), which involves psychiatrists who support mental health care by primary care clinicians, has been demonstrated to be effective for treatment of depression, anxiety, and other common conditions in multiple randomized trials and several meta-analyses. This strength of evidence has finally, this year, led to a Medicare payment for delivery of this model to patients (Psychiatric News, December 2, 2016). This model has been shown to improve outcomes, especially for people with behavioral health problems of mild to moderate severity. Primary care patients, however, have a wide range of levels of need for behavioral health care. Thus, the CoCM offers one approach to better integrating behavioral health expertise for people with physical and mental health problems. But the role of the psychiatric consultant reviewing and providing input to the care of a large number of primary care patients, working through a care manager, is only one possible role for psychiatry in the era of accountable care and population health. Other roles include the following:

• Teacher: Psychiatrists can provide didactic and case-based training to primary care clinicians through a variety of approaches. The Child Psychiatry Access Program (CPAP) in Maine included regular lunch and learns designed to incrementally increase the behavioral health skills of pediatricians. Project ECHO lends itself well to dissemination of best practices for behavioral health care.

• Coach: MaineHealth uses psychiatrists to support licensed clinical social workers in rural primary care practices and the primary care clinicians from those practices. Primary care clinicians can use the messaging system within the electronic medical record to ask their consulting psychiatrists, with whom they develop an ongoing relationship, to review a patient record and provide suggestions. As in the CPAP program, the level of competence and sophistication of the primary care questions increases over time.

• Consultant: An integrated system supports the use of brief consultation by psychiatry with the goal of offering a management plan that can be carried out in the primary care office. The psychiatrist can see the patient for a diagnostic assessment and/or for recommendations on treatment. A series of steps can be suggested for the primary care team to implement. The psychiatrist can be consulted again if the patient continues to be symptomatic.

Psychiatry has been working for years to better connect behavioral with other types of medical care. The rest of the health care system is starting to catch up. There are great opportunities ahead to help our patients achieve better health. ■