This is the definition given by the Agency for Healthcare Quality and Research in Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus
“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.”
Integrated or collaborative care is the coordination of care for patients who have psychiatric disorders, which includes substance use disorders, and general medical illness. There is a higher rate of psychiatric illness in patients with chronic medical illness, and a higher rate of chronic medical illness among patients, with psychiatric illness, especially with serious and persistent mental illness. Patients with these conditions have increased morbidity and mortality and are costly, but because of the way our service systems have evolved over time, the prevailing tendency has been to treat medical and psychiatric illness as if they occur in different domains. That simply is not true from the standpoint of patients, and if we are going to have patient-centered care, it needs to encompass all of their needs.
—APA President-elect Paul Summergrad, M.D.
In the primary care setting, the model with the most robust evidence base is IMPACT (Improving Mood—Providing Access to Collaborative Treatment), which was developed by Jürgen Unützer, M.D., Wayne Katon, M.D., and colleagues at the University of Washington. The patient's primary care physician works with a care manager to develop and implement a treatment plan (medications and/or brief, evidence-based psychotherapy). IMPACT care managers use the PHQ-9 to screen for symptoms of depression at the start of a patient's treatment and regularly thereafter. Psychiatrists serve as expert consultants to the patient and care team. Treatment is adjusted based on clinical outcomes and according to an evidence-based algorithm. A number of organizations in the United States and abroad have adapted and implemented the IMPACT program with diverse patient populations. See Psychiatric News for more information.
In the public mental health setting, there are several models being tested to improve health in the SMI population. The PCARE (Primary Care Access, Referral, and Evaluation) model, developed by Benjamin Druss, M.D., and colleagues at Emory University, employs a medical nurse–care manager to provide education and care coordination to help patients with serious and persistent mental illness engage in primary care. In the PCARE study, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care. At a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services, compared with a rate of 21.8% in the usual-care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions and were more likely to have a primary care provider. See the American Journal of Psychiatry for more information.
New York state, among others, has implemented clinical quality improvement efforts that emphasize integrated approaches, including improved standards for screening and monitoring general medical conditions among individuals with serious mental illness; incentives for integration between behavioral and general medical providers; and redesign of state financing, licensing, and regulatory policies. For a description of these efforts, see Psychiatric Services.
The Substance Abuse and Mental Health Services Administration has 93 grantee sites providing services in the Primary and Behavioral Health Care Integration (PBHCI) Program. Through this program, SAMHSA provides support to communities to coordinate and integrate primary care services into publicly funded, community-based behavioral health settings. For descriptions of models around the country funded by the PBHCI program, click here.
A number of states are developing behavioral health homes—a behavioral health agency that serves as a health home for people with mental illness, including substance use disorders—as a Medicaid waiver option under the Affordable Care Act. For more information, click here.
It is important because it speaks to the care and well-being of people for whom we have clinical responsibility. It speaks directly to our ethical and professional responsibilities. Independent of any other consideration, it is the right thing to do to improve the care and quality of life for people we take care of.
There is a growing body of evidence to indicate that people with serious psychiatric and substance abuse illnesses are more medically compromised than people who don't have these disorders and they have a shorter lifespan. Suicide is an important contributor, but so are the ravages of both medical and psychiatric illness. There is also evidence that the total cost of care is greater, and the cost of general medical care is greater, often because it is often unconnected to a comprehensive care system for patients’ total psychiatric and other medical needs. We cannot improve the quality of patient care, improve patients’ experience of care, and reduce the total cost of care—if we ignore psychiatric and substance abuse disorders. It’s not just a matter of integrating systems into one venue, but changing the way we think about mental illness and substance use disorders. Behavioral care is central to the management of all illness. All of this speaks to the unique expertise that psychiatric physicians bring to patient care.
In this audio interview, Dr. Summergrad summarizes the importance of integrated care to psychiatry.
Psychiatrists need to make themselves relevant in the health care reform arena. It is well known that psychiatric comorbidity contributes to poor outcomes and increased cost. It is also a given that we do not have enough psychiatrists to cover current needs, and so we need to leverage the expertise we have in different ways. By implementing population-based care models such as IMPACT (see "Other Resources" at end of newsletter), we can assist primary care in better identification and treatment of mental illness by acting as consultants and performing caseload-based registry reviews, guiding the process primarily from behind the scenes. This conveys a new sense of importance to our profession as it allows us to better meet the needs of the larger population.
Payment for services has been identified as one of the barriers to the implementation of evidence-based collaborative care programs. Large-scale implementations of collaborative care use a number of different payment approaches ranging from fully capitated payment (for example, Kaiser Permanente, VA, Department of Defense) to case-rate payments (for example, in Minnesota’s Diamond Program) that cover the costs of primary-based care managers and consulting psychiatrists. In the Washington Mental Health Integration Program, a health plan provides direct payments for the psychiatric caseload reviews and consultations based on the number of clinics, caseloads, and care managers supported by the psychiatric consultant. Traditional fee-for-service payment arrangements do not yet pay for psychiatric consultation and case reviews that do not involve direct patient contact, but several health care systems pay for such services similarly to the way that they cover liaison psychiatry services. This kind of systematic caseload-focused psychiatric consultation may become increasingly relevant as health care organizations develop patient-centered medical homes and accountable care organizations that are charged with providing comprehensive care for defined populations of patients who often have limited access to or use of traditional mental health services.
The issue of liability in integrated settings can be considered along two lines. The first is whether a doctor-patient relationship is established. Legally, this is usually determined by whether there is direct evaluation of a patient (in person or by televideo) and subsequent documentation of findings. Indirect or “curbside” consultations do not establish a doctor-patient relationship, so involve minimal liability. An additional area of consultation in collaborative settings in primary care is between the consulting psychiatrist and the behavioral health provider. Liability in this situation can depend on the role of the psychiatrist, which can range from consultative to collaborative to supervisory. Liability is increased if you are the supervisor of the behavioral health provider and are ultimately responsible for the care provided.
The primary care provider retains overall responsibility for the patient and may choose to use the consultant psychiatrist's advice or not. The PCPs also write all orders based on the consultations — not the psychiatrist, who is just in the consultation role.
Yes, you can still do psychotherapy and maintain a private practice. Working in integrated settings is often an additional job, and much of the work does not have to be on site in the medical setting. For example, a psychiatrist working full time could choose to work in his or her private practice 24 hours a week and be the consultant psychiatrist for a primary care clinic 16 hours a week. These roles would overlap to the extent the psychiatrist wants to be accessible to the primary care team; he or she would need to adjust his or her schedule to return phone calls in a timely manner, perform caseload review with the behavioral health provider, and potentially conduct on site visits to provide education to the team on various topics.
You do not need your own personal EMR to do this work; however, if the primary care clinic has an EMR system, you may need to enter documentation in that EMR system, many of these systems can be accessed through the Internet. The SAMHSA-HRSA Center for Integrated Health Solutions has an excellent section on HIPAA/privacy in integrated settings and other information-technology issues around integrated care (see "Other Resources" at end of newsletter). EMRs in primary care settings are used to collect aggregate data (in databases called “registries”), and regular review of these data by the consulting psychiatrist is important because they can be used to discover care gaps and adjust treatment. Although spreadsheets can accomplish this, use of the registry feature of an EMR is the data-gathering choice of the near future.
Psychiatrists are responsible for “not making people sicker” and have a responsibility to minimize the risk of medications such as second-generation antipsychotics by choosing those with less cardiovascular disease risk when possible, as this is the major driver of early mortality in the SMI population. There is a responsibility (and current standard of care) to screen all patients for the iatrogenic effects of these medications including monitoring BMI changes, blood pressure, cholesterol, and blood sugar. Psychiatrists are medically trained and have the skills needed to counsel their patients about lifestyle interventions to reduce risk of cardiovascular disease, including smoking cessation. Given the numerous barriers to obtaining primary care, and the continued early mortality despite our efforts, there is a growing movement for psychiatrists to treat some common medical problems such as dyslipidemias, hypertension, and diabetes. This will require appropriate retraining, use of algorithms, and back-up PCP consultation to be effective and address the liability that will come with this change in scope of practice. In some models, primary care providers are now acting in the role of consultant to the psychiatrist, reflecting a kind of flip side of the consultation we provide for them in primary care—a reciprocal relationship. Finally, psychiatrists, by virtue of their training in the full range of medicine, are in a unique position to lead teams in public mental health settings to address this health disparity in the SMI population. From the behavioral homes funded through the Accountable Care Act State Plan amendments and other initiatives, psychiatrists should seek and welcome opportunities to head these initiatives to improve the quality of life and lifespan of the SMI population.
Psychiatrists need to know the models of integrated/collaborative care and the role that psychiatrists play in them. They need to understand the importance of population health and how a collaborative care team might use data to monitor the health status and medical utilization patterns of a defined population of patients.
Psychiatrists who want to work in integrated care settings need to enhance their understanding of common chronic medical conditions. This does not mean that psychiatrists would necessarily be directly treating hypertension or diabetes, but they should be comfortable consulting with primary care and other specialists about these conditions.
Emerging integrated care models also need clinicians with leadership skills. Psychiatrists are in a unique position to lead these teams because they have training in general medical and psychiatric care.
The AIMS Center at the University of Washington offers individual and group-based learning in in-person and online formats. “The Integration of Primary Care and Behavioral Health: Practical Skills for the Consulting Psychiatrist Curriculum,” which has been offered as a course at APA meetings for the past several years, is available online in PowerPoint format. To access it, click here.
Next year American Psychiatric Publishing Inc. will publish The Psychiatrist’s Guide to Integrated Care, edited by Lori Raney, M.D.
Each year at APA’s annual meeting and at the Institute on Psychiatric Services, a special “Integrated Care Track” provides training symposia on a wide range of integrated care topics. For information about the track at this year’s institute, click here. The institute will be held in Philadelphia from October 10 to 13.
There are many psychiatrists across the country who have been working in a variety collaborative care models (both in primary care and public mental health settings) for the past several years. Their experience in this work is a nice alternative from the hamster wheel of 15-minute “med checks.” It is really rewarding to extend psychiatric expertise across a much larger population of patients, knowing you can reach patients who had not been in treatment or were getting ineffective care. They can get effective treatment through a model that allows you to review the care they are receiving and offer timely suggestions to adjust treatment. For those working in bringing primary care to the seriously mentally ill population, the collaboration with primary care is helping to raise psychiatrists' comfort level with general medical skills, and these patients are beginning to show signs that their health status can be improved. Many psychiatrists report these experiences as not only professionally rewarding but also “fun.” If we can show medical students and residents how exciting this work can be, then maybe we can recruit more to join us in this effort.