Contouring a CoCM Program to Local Needs and Strengths

Effective collaborative care programs share core principles such as patient-centered, measurement-based, and population-based care, and some of the most effective implementations of the model make smart adaptations based on available needs and resources. In this month’s column, Jim Phelps, M.D., writes about how Samaritan Health Services in rural Oregon built an effective primary care psychiatric consultation program based on its unique situation and strengths. —Jürgen Unützer, M.D., M.P.H.

The waiting list to see a psychiatrist at Samaritan Mental Health had been lengthening for years. We used to joke, wryly, “Psychiatry here has two speeds: inpatient or six months.” Our community, especially our primary care colleagues, desperately needed something in the middle. Given its repeated demonstrations of improved access and improved outcomes, the collaborative care model (CoCM) was an obvious solution. Over more than four years, we’ve developed a 20-clinic primary care psychiatric consultation program based on the core principles of CoCM, contoured to meet our local needs and build on local strengths.

Need 1: Access

The strongest need and principal driver of our efforts was the lack of access to psychiatric services, as manifest in our waiting lists. Because access to psychotherapy for patients with Medicare and Medicaid was similarly limited, primary care providers (PCPs) often prescribed multiple medications trying to help their patients with depression and anxiety (an average of eight psychotropics before consult).

Strength 1: Multiple Willing Psychiatrists

Fortunately, one of the strengths we could build upon was a team of psychiatrists with primary care experience and a strong inclination toward a CoCM approach. Though short of psychiatrists for a traditional model of care, for a CoCM approach in a limited number of primary care clinics, we were relatively psychiatrist rich—including child/adolescent specialists.

We capitalized on this by designing in a psychiatrist’s involvement in every referred case, enabling us to pursue differential diagnosis closely, particularly trauma and/or bipolarity.

Need 2: BHC candidates

We had difficulty finding strong candidates for the behavioral health consultant (BHC) role, especially in our more rural areas (Oregon coast and Cascade foothills). So we shifted to using bachelor’s-level candidates, sometimes with little clinical experience, who then receive two months of on-the-job training: extensive “role induction” instruction, then shadowing an experienced provider, then weeks of observed interviewing and documentation. They are then based in one or two primary care clinics where they receive warm handoffs and conduct a structured interview for our diagnostic database. These mental health consultants (MHCs), as we call them, do not receive the psychotherapy instruction that is part of the training of UW’s behavioral health care managers and do not offer therapy per se. But they are part of the patient-centered team in their clinics, they maintain our registry, and their follow-up patient interviews facilitate treatment to target.

We have a relatively ample supply of candidates for this position (having a local university helps). They are willing to work in our rural communities. But attrition is high: most last about two years in this role, often obtaining additional clinical training and degrees (we expect some to return!). A steady recruitment and training program is necessary. Fortunately, we have a superb director for this process, which is critical.

Strength 2: A Common Electronic Health Record System

EPIC is used for electronic health records throughout our system, which enables extensive direct communication between our MHCs, consulting psychiatrists, and PCPs. MHCs write up their initial interview and send it to the psychiatrist. Based on that write-up, the scanned questionnaire, and further examination of the chart as needed (recent PCP visits, other medical problems, prior medications, labs, and so on), the psychiatrist adds an impression and one to four recommendations. Further details are placed in appendices. PCPs appreciate the detailed guidance and its inclusion in the chart for review at the next appointment.

With this means of focused communication with our PCP colleagues, we’ve found another joy in this CoCM process (besides being able to shrink that wait list by 50%): Every case is an opportunity to teach, offering just a little concept and a little insight in each consult, specific to the PCP’s level of understanding. Routine recommendations can be stored as “dot phrases” and entered as appendices with a few keystrokes. With this guidance, our PCP colleagues’ reluctance has shifted to a solid team approach.

EPIC now includes our registries, both adult and child/adolescent. Our relationship with local psychotherapists (some are in-clinic) is an area for further development, with the hope of broadening access there. There is much more work to do, but we’ve gotten great gains so far, which have been almost universally appreciated in our clinics! We are extremely grateful to the UW team for leading the way. ■