Collaborative Care Leaders Seek to Bring Model to Residency Training

The Collaborative Care Model (CoCM) may be an opportunity for psychiatry training programs to leverage stressed manpower resources to support primary care clinics served by the department, while teaching young psychiatrists the skills necessary for the health system of the future.

At last month’s meeting of the American Association of Directors of Psychiatric Residency Training (AADPRT) in San Francisco, Anna Ratzliff, M.D., director of the University of Washington Integrated Care Training Program, and Hsiang Huang, M.D., M.P.H, program director of the Psychosomatic Medicine Fellowship at Cambridge Health Alliance, introduced residency directors to the tools necessary for training young psychiatrists in the CoCM.

Tristan Gorrindo, M.D., director of APA’s Division of Education, also spoke at the workshop. “While we have over a decade of evidence testifying to the efficacy of the collaborative care model, most psychiatrists, including training directors, are just learning the nuts and bolts of the model,” Gorrindo told Psychiatric News. “We used this workshop as an opportunity to empower training directors with knowledge they could then use to fold into their training programs and support residents who are looking to work in this model after graduation.”

In an interview with Psychiatric News, Ratzliff said the model can be a way for psychiatry departments to begin to fundamentally rethink how they use stressed resources to meet the demand for patient care.

“There is an opportunity for psychiatric academic programs to be on the leading edge in developing collaborative care rotations to help their departments leverage available psychiatric resources for the support of their broader primary care programs,” she told Psychiatric News. “It may be that psychiatry residency programs can be the champions for collaborative care, helping general practice settings to be more creative in developing in-depth learning for trainees from all disciplines.”

The AADPRT session on CoCM was an extension of the training that APA is providing to psychiatrists and primary care physicians as part of the Transforming Clinical Practice Initiative (TCPI). APA, which was one of just 39 organizations chosen to participate in the initiative, was given a $2.9 million, four-year federal grant from the Centers for Medicare and Medicaid Services to offer online and in-person training on CoCM. The model was developed by the late Wayne Katon, M.D., Jürgen Unützer, M.D., M.P.H., and others at the AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington.

Training Builds on Existing Skills

The AADRT program mirrored the APA training, providing an overview of the rationale for collaborative care and the CoCM structure, with special attention to how training directors can adapt the training to teach residents and develop faculty who can pass on CoCM skills.

Ratzliff especially emphasized that training programs do not have to “reinvent the wheel” but can mold what they are already teaching their residents—such as consultation-liaison skills and use of measurement tools, such as PHQ-9—to their application in collaborative care. Central to the role of the psychiatrist in CoCM, for instance, are the “curbside consultation” skills that residents are commonly taught—listening, reflecting on the information provided in a case consult, and making clinical judgments based on that information. “It’s a matter of training directors being able to leverage what is already happening in their programs to prepare their trainees for work in a collaborative care model,” she said.

Huang said he believes exposure to integrated care early in training is crucial. “I think it is important to have a required integrated care rotation so that all residents graduate with skills in population-based mental health care,” he said. “Teaching residents how to use measurement based care, such as using the PHQ-9 for depression management, is a key skill to learn on integrated care rotations, even if a collaborative care experience is not yet in place.”

Some training programs have pioneered the introduction of integrated care into their programs, but overall it would appear that as a regular element of residency education, collaborative care is still in its infancy. A February 2105 paper in Academic Psychiatry reported the results of a survey of training directors at 52 general psychiatry and 36 child and adolescent programs. The researchers found that many offered integrated care experiences, but few offered these rotations as a regular part of training.

A comprehensive report by APA’s Council on Medical Education and Lifelong Learning also was published online in Academic Psychiatry in February 2015. It offered specific recommendations for undergraduate, graduate, and continuing medical education and perspectives on future directions for interprofessional and interspecialty training. The report noted that new Accreditation Council for Graduate Medical Education “milestones” for psychiatry provide benchmarks that residents are expected to meet by the time they graduate and include those that are uniquely suited for accomplishment in integrated care settings. For example, under the domain of “systems-based practice,” the milestones state that “residents should be able to provide integrated care for psychiatric patients through collaboration with other physicians” (Psychiatric News, March 6, 2015).

Case Study Shows How to Leverage Resources

In a report in press in Psychosomatics, Huang, Marshall Forstein, M.D., and Robert Joseph, M.D., M.S., described the development of an integrated care rotation at the Cambridge Health Alliance (CHA), an accountable care organization located in Massachusetts that comprises three community hospitals and 12 primary clinics. The program had its origin in the late 1980s as a response to the HIV/AIDS epidemic when CHA developed a model in which primary care providers, nurses, social workers, and psychiatrists shared clinical space and worked as a team. CHA was also unique in providing co-located psychiatric consultants at primary care clinics since the 1990s.

In 2013, the program transformed CHA’s outpatient C-L component to a formal “integrated care rotation” to offer PGY-3 psychiatry residents a more longitudinal experience of consulting exclusively in primary care clinics. The rotation consists of six months of weekly half-day sessions. In 2014 behavioral care managers were hired, allowing residents to have a case review experience (using a mental health registry) once weekly. In 2015, an integrated care chief resident position for a PGY-4 resident was created.

“Systematic depression screening using the PHQ-9 is part of the workflow across all primary care clinics at CHA,” Huang, Forstein, and Joseph wrote. “[P]sychiatry residents have the opportunity to use baseline and longitudinal depression scores to help guide the depression treatment of their patients. Residents who have rotated in primary care often tell us that they bring the practice of measurement-based care to their outpatient psychiatric clinics (where the use of instruments is not routinely done).”

Ratzliff urged department chairs and residency program directors to take advantage of resources available through APA’s TCPI grant training and the AIMS Center at the University of Washington.

“We hope educators will see collaborative care as an opportunity and that the AADPRT program is a start to providing training directors creative ways for teaching the psychiatric skills of the future,” she said. ■