Integrated-Care Movement Rapidly Gaining Momentum

"Integrated care" is everywhere—in theory if not in practice.

The concept is a feature of the delivery-system reforms in the new health care reform law, and policymakers and many clinicians have converged on the idea that the full range of medical services should be brought together in one patient-centered location.

Integrated care is the theme of APA President John Oldham, M.D.'s presidential year. And today, a small but dedicated cadre of psychiatrists is advancing the cause of integrated care and the participation of psychiatrists in collaborative-care models (see Integrated Care: Key Points).

APA has established a Work Group on Integrated Care, chaired by Lori Raney, M.D., medical director of the Axis Healthcare System in Durango, Colo. Work group member Jurgen Unutzer, M.D., director of the Center for Advancing Integrated Mental Health Solutions (AIMS) at the University of Washington, is one of the pioneers of integration; along with Wayne Katon, M.D., Unutzer began developing models in the 1990s for integrating mental health and primary care and testing them in diverse primary care clinics around the country.

In interviews with Psychiatric News, Raney and Unutzer said the concept of integrated care has moved far past the "tipping point" of momentum that ensures its inevitability as an established model of care. A large and growing body of research has demonstrated the cost-effectiveness of collaborative care, and dozens of national and regional programs across the country are implementing the principles of collaborative care (see Integrated-Care Resources).

At this month's Institute on Psychiatric Services in San Francisco, Raney and Unutzer will present the first five modules of a training program for psychiatrists interested in evidence-based collaborative care. This program was developed by the AIMS Center with funding from the Center for Integrated Health Solutions (CIHS), the Substance Abuse and Mental Health Services Administration, and the National Council on Community Behavioral Health (see Principles of Effective Integrated Mental Health Care).

The program is intended to provide a comprehensive preparation in the theoretical and practical aspects of integrated care and education about how psychiatrists can participate in collaborative-care teams.

"Our vision is to take the curriculum and teach it as a course at the institute in October and again at the APA annual meeting in Philadelphia," Unutzer told Psychiatric News. "We will also be presenting it at other professional meetings to cultivate a group of people who have these skills."

Also, Unutzer said the AIMS Center plans to partner with CIHS to put the modules online.

The first part of the module outlines the case for integrated mental health services in primary care, discusses principles of and approaches to integrated mental health care, provides an overview of the research evidence for collaborative care, and describes roles for a primary care consulting psychiatrist in an integrated-care team.

Not Your Father's Office Practice

That role will be different—in some ways radically different—from traditional psychiatric office-based practice. "We need to leverage the limited psychiatric resources in this country to cover the mental health needs of the larger population," Raney told Psychiatric News. "Collaborative care has an evidence base that can help us accomplish this, but it is a significant departure from traditional psychiatric care, which focuses primarily on face-to-face evaluations.

"Moving from traditional office-based practice to ‘consultant specialists’ who can be effective on a population level will require psychiatrists to develop a new skill set," she said. "Preparing for this new role will require training, financing, and leadership to be successful."

For instance, as a member of a collaborative-care team, a psychiatrist would have regular weekly meetings with a care manager and review patients who are not improving and make treatment recommendations. The psychiatrist might still provide direct treatment to a small percentage of the most severely ill patients, but could provide input on as many as 10 to 20 patients in a half day as opposed to three or four patients.

Collaborative Care Differs From C/L Model

Integrated-care models have evolved from the traditional consultative role that consultation-liaison psychiatrists have practiced, to a "co-located" model in which psychiatrists see individual patients in a primary care clinic, to a fully collaborative care model in which a psychiatrist takes responsibility for a caseload of primary care patients and works closely with primary care clinicians and other primary care-based mental health care providers (see Psychiatry and Primary Care: An Evolving Relationship).

Though models may differ, the core principles of collaborative care are constant: patient-centered care teams providing evidence-based treatments to a defined population of patients using a measurement based "treat-to-target" approach. (The latter refers to the use of tested instruments so that symptoms can be measured with numerical targets established for clinical treatment goals.)

Raney emphasized that the move toward a more consultative team-based approach is not for everyone. "We are only talking about psychiatrists who want to do this," she said. "But many of us who do this kind of work get a lot of enjoyment out of it. You are working in a care team, consulting with and educating primary care doctors, which can be very satisfying.

"It also takes the psychiatrists out of the narrow, stifling role of doing 15-minute med checks, which is what a lot of us in community psychiatry find ourselves doing," she noted.

Raney and Unutzer added that there are hurdles for the integration of primary care and mental health care to overcome, especially how to finance psychiatry's role in a collaborative-care model.

In August, Unutzer drafted a proposal for inclusion of psychiatry in integrated-care demonstration projects under the Medicare and Medicaid programs. The proposal, "Collaborative Care for Primary/Co-Morbid Mental Disorders" was submitted to the Center for Medicare and Medicaid Innovation, and last month APA Medical Director James H. Scully Jr., M.D., in a letter to CMS Administrator Donald Berwick, endorsed the proposal (see APA Backs Collaborative-Care Model Being Considered for Medicare).

Unutzer underscored the satisfaction that can be derived from a collaborative and consultative role in which psychiatrists work alongside colleagues in primary care and are valued for the expertise they provide.

"As consultant in a collaborative-care model, even working part time with a primary care clinic, I can make an enormous difference at the level of population health," he stressed. "I think this is a fabulous opportunity for psychiatry as a profession, and I think we should position ourselves to take advantage of it."