Collaborative Care Model Prepares Psychiatrists for Value-Based Care

This is the fifth in a series of articles on value-based payment.

The movement toward “value-based payment” has greatly accelerated in recent years to address the high level of Medicare spending and is furthered by advances in technology—especially the proliferation of electronic health records (EHRs) and payer-incentive programs to encourage more EHR adoption. The goal of this evolution is summed up in the so-called Triple Aim: improved patient care, better population health, and lower per capita cost of health care.

In the fifth article in the series “Changing Practice/Changing Payment,” Psychiatric News focuses on collaborative care, an established care model that seeks to meet the goals of the Triple Aim by integrating general medical and psychiatric care.

Q: Why collaborative care?

A: Mental illnesses such as depression, anxiety, and substance use disorders are responsible for 25 percent of all disabilities worldwide, with these disorders being a major driver of overall health care costs. There is growing acknowledgment by policymakers, payers, and providers that any solution to driving down the cost of health care must include treating mental health/substance use disorders with comorbid physical conditions.

As payers consider ways to curb the cost of health care, the integration of medical and behavioral health care is emerging as an effective solution. According to a study by Milliman, an estimated $10 billion to $15 billion could be saved each year for Medicare and Medicaid and $16 billion to $32 billion for the commercially insured through effective integration of mental health care with other types of medical care.

Psychiatrists are uniquely positioned to improve access to quality mental health care in integrated care settings. For decades, those in consultation/liaison psychiatry (also known as psychosomatic medicine) have been working in a variety of settings—primary care, hospitals, and outpatient specialty clinics such as those for diabetes care or women’s clinics—to help patients with comorbid psychiatric and physical conditions. They may help treat elderly patients with unsuspected alcohol dependency who received coronary artery bypass surgery or coordinate care for someone diagnosed with cancer who is experiencing depression. More psychiatrists are involved with consult psychiatry through the use of the collaborative care model (CoCM), which improves the integration of physical and mental health care by applying the principles of effective chronic disease management to treating patients with mental illness.

CoCM is the most promising model for integrating physical and mental health care. Psychiatrists trained in collaborative care will be better prepared to meet the demands of the changing health care system, which seeks to improve patient satisfaction, improve population health, and lower the cost of health care.

Q: What is collaborative care and how does it work?

A: The CoCM uses a team-based, interdisciplinary approach to deliver evidence-based diagnoses, treatment, and follow-up care. The model differs from other attempts to integrate behavioral health services because of the replicated evidence supporting its outcomes, its steady reliance on consistent principles of chronic care delivery, and attention to accountability and quality improvement.

A collaborative care team is led by a primary care provider (PCP) treating patients with mental health/substance abuse conditions. They are supported by a behavioral health care manager and a psychiatric consultant. The team implements a measurement-guided care plan based on evidence-based practice guidelines and focuses particular attention on patients not meeting their clinical goals.

This model is flexible and can be implemented across varied geographic locations, practice sizes, and patient populations.

Q: What is the role of psychiatrists in the CoCM?

A: The psychiatrist provides population-based advice and individual treatment recommendations to the primary care team, including a clinic-based behavioral health provider. As a result, a scarce resource is leveraged to improve quality of care for an entire population of patients being treated in primary care—which is not feasible if the psychiatrist sees each patient directly, even for a one-time consultation.

Q: What evidence supports the CoCM?

A: More than 80 randomized, controlled trials (RCTs) have shown the CoCM to be more effective than care as usual. Meta-analyses, including a 2012 Cochrane Review, further substantiate these findings. As a result, the CoCM is recognized as an evidence-based best practice by a range of authorities, including the Centers for Medicare and Medicaid Services (CMS), the Substance Abuse and Mental Health Services Administration, the surgeon general, the National Business Group on Health, and the Agency for Healthcare Research and Quality.

Q: How will CoCM prepare psychiatrists for changes in physician reimbursement?

A: As the health care system moves toward more team- and value-based care, psychiatrists trained in collaborative care are better positioned to work with multidisciplinary teams and participate in Alternative Payment Models, such as accountable care organizations, medical homes, and patient-centered health homes.

APA is working with CMS and other physician groups to design reimbursement codes for the model. To date, CoCM services have typically been covered by grants and innovative state Medicaid programs.

Q: How do I learn more about implementing the collaborative care model?

A: Through the CMS Transforming Clinical Practice Initiative (TCPI), APA’s Support and Alignment Network is training 3,500 psychiatrists in collaborative care and connecting them with Practice Transformation Networks across the country. Psychiatrists can sign up for free live or online training and receive CME credit and technical support for practicing in the CoCM.

To access more information about live trainings and links to the online courses, click here. The course “Applying the Integrated Approach: Practical Skills for the Consulting Psychiatrist” will be offered at APA’s IPS: The Mental Health Services Conference on Saturday, October 8. More information can be accessed here.

In addition, APA, in conjunction with the Academy of Psychosomatic Medicine, released the report “Dissemination of Integrated Care Within Adult Primary Care Settings: The Collaborative Care Model.” The report reviews the current evidence base for collaborative care, essential implementation elements with detailed examples, lessons learned by those who have implemented the model, and recommendations for how to advance its use to better meet the whole health needs of people with mental health conditions. ■