Collaborative-Care Model Built on 'Medical Home' Foundation

Caring for patients with depression takes work—often too much work for primary care doctors to handle alone, although they may shoulder that burden because there are too few mental health clinicians around to help.

Beginning a couple of decades ago, physicians and health service researchers began looking for ways to make depression care in the primary setting more effective, especially given the overwhelming need and the insufficient resources available to cope with it. One choice was co-location, having psychiatrists set up shop in the same clinics as primary care doctors. A referral could be handled by walking down the hall—if the psychiatrist were not already overbooked. Co-location alone was not the answer, many now believe.

Another model, which grew into programs like IMPACT or RESPECT, was developed based on a closer interaction of primary care clinics with mental health providers. In IMPACT, the psychiatrist stays in the background, serving mainly as a consultant or reference source, backing up a care manager and the primary physician who handle diagnosis and care.

IMPACT has produced many offspring, but not all are identical twins. As with evolution, variation arises depending on local conditions and interests, driven as much by necessity as by choice.

The Dartmouth-Hitchcock Medical Center in New Hampshire is putting together its version now, one that combines the psychiatrist's presence in the primary clinic with an extended role as a consultant to the primary team, along with some limited clinical activity.

The system is expected to be in operation by late summer, although educational programs for the doctors and other staff at the family practice group have already begun.

“We began as part of a year-long, strategic planning process for the whole medical center, looking not at just caring for the individual patient but for the population in the region,” said William Torrey, M.D., an associate professor of psychiatry at Dartmouth Medical School.

The Department of Psychiatry at Dartmouth-Hitchcock worked closely with its primary care community in designing a collaborative-care program adapted from IMPACT. They sought to build care around a medical-home model by linking a psychiatrist directly with teams in pediatrics, family practice, and general internal medicine in outlying towns as well as at the main medical center.

“Our aim is to build a system based on what had been shown to work,” including IMPACT, he said.

The medical center agreed to hire a full-time psychiatrist who devotes one day a week to leading the collaborative process for the whole system. Christine Finn, M.D., directorof the Crises and Consultation Service, moved from Massachusetts General Hospital to Dartmouth in January to organize and manage the program. She has extensive consultative experience in emergency psychiatry.

“Our first goal is to provide more specific support to primary care physicians by being present in person at least once a week at general internal medicine or family practice sites,” said Finn in an interview.“ That personal connection, knowing that they're there, may be the most important thing.”

Plans currently cover the main medical center and sites in three other towns within driving distance of the main campus. Different psychiatrists will be attached to each clinic, adding up to the one new full-time equivalent position.

Along with the primary care provider and the psychiatrist, the depression care manager will serve as the team's third member.

The care managers will serve as the pivots for the system. They will meet in the office with the patient, offer education on depression, follow up by phone, monitor medication adherence and side effects, troubleshoot any problems, and coordinate care with the primary physician. Care managers will use the PHQ-9 for both diagnosis and for measuring patient progress. All three team members will consult on referrals for additional therapy when needed.

Care managers may be licensed clinicians and may offer some therapy, but Torrey is wary of filling their time with therapy if it would crowd out their care managerial duties.

At Dartmouth, the psychiatrist may also provide some short-term care in some circumstances, but will not take on many patients for long-term treatment.

“The psychiatrists will see patients and be available for short-term management but will also attend team meetings and be available for informal consults,” she said. These embedded psychiatrists will also provide easier access to expertise for the primary physicians and for the care managers, helping them choose the right therapy and the right therapist for a patient.

The psychiatrists also will offer formal didactic talks on topics of interest, like suicidality, or informal conferences over lunch at which the primary clinicians present cases for discussion.

“Care for patients with conditions other than depression will remain the shared responsibility of the primary care physician and psychiatric resources now available at the medical center or in the community,” said Finn. “The new program will ... be best able to determine the type of psychiatric care that would be of benefit if they are being referred out.”

These varying roles can provide the primary practice with a better understanding of depression, its management, and its measurement to improve clinical decision making, say its advocates.

Funding the program still presents problems, said Torrey. Insurance will pay for some direct evaluations but not the system's consultative functions. They will be covered by the medical center for the moment.

“Insurance doesn't pay adequately for behavioral health care, so you can't do it unless you subsidize it,” said Torrey in an interview.“ It's hard to grow if you're going to lose more money by growing. At the same time, there is great demand relative to supply.”

Linking psychiatry closer with general medical care may be good for both patients and psychiatrists, commented Thomas Wise, M.D., chair of the Department of Psychiatry at Inova Fairfax Hospital in Falls Church, Va.

“Psychiatry has something to offer primary care, so we have to develop a model where we're included on the inside of the medical home,” said Wise. ▪