Behavioral Care Integrated into Primary Care

September 19, 2016
James Rundell, MD

Collaborative care operationalizes chronic care model principles to improve access to evidence-based treatments.

The terms “integrated care” and “collaborative care” often have been used interchangeably for primary care patient populations who have comorbid medical and behavioral conditions. Collaborative care, a specific type of integrated care based on a model developed by Dr Wayne Katon and colleagues at the University of Washington, has been shown to be more clinically effective than traditional behavioral health consultation models in more than 70 randomized control trials.1-3 Collaborative care operationalizes the principles of the chronic care model to improve access to evidence-based behavioral health treatments for primary care patients.4

In the collaborative care model, the primary care physician has a behavioral health care manager to provide ongoing care management for a caseload of patients who have diagnosed behavioral health or substance use disorders. The collaborative care consulting psychiatrist provides the primary care practice with expert advice and consultation through regular case review and recommendations for treatment and medication adjustments.

 

Core Elements

According to expert consensus, all effective collaborative care models share 4 core elements: (1) team-driven, (2) population-focused, (3) measurement-guided, and (4) evidence-based.5 Collaborative care is team-driven, led by a PCP, with support from a care manager and consultation from a psychiatrist who provides treatment recommendations for patients who are not achieving clinical goals.5 Other mental health professionals also contribute to the collaborative care model. Collaborative care is population-focused, using a registry to monitor treatment engagement and response to care. Collaborative care is measurement-guided, with consistent use of patient-reported outcome measures.  Collaborative care teams use evidence-based approaches to achieve optimal outcomes.

The care manager, the linchpin member of the care team, links the team to the patient and to each other. Accomplishing this involves the use of telephone; measurement-based clinical outcome metrics; and health information/electronic medical record technologies, such as registries, alerts, and reminders. Care managers also work to keep patients engaged in their care, assess treatment adherence, and explore treatment preferences. This information is then communicated to the team by available means (eg, in-person, telephone, practice team meetings).

The collaborative care psychiatrist reviews the care manager’s caseload at routine intervals. Recommendations are formulated (eg, medication and dosing changes, psychotherapy and psychosocial interventions, referral to specialty behavioral health services) for the treatment team, particularly the primary care clinician. Other members of the collaborative care team often include a primary care-based psychologist or social worker for enhancing access to evidence-based psychotherapies and patient assessments, including urgent assessment of a patient’s potential to harm him or her self or others.

A goal of population-based care within the collaborative care model is to raise the capacity of the primary care system to manage behavioral health conditions. A significant portion of psychiatrist time in integrated care settings is indirect, involving curbside consultations with primary care clinicians, teaching nurse care coordinators about mental health issues, and providing suggestions in the patient’s record to the PCP based on the latest evidence-based practice guidelines.5

 

“Stepped Care” an Essential Component

Collaborative care behavioral health specialists identify complex or treatment resistant cases and directly manage those cases or facilitate referral to specialty behavioral health settings as needed. Known as “stepped care,” this is an essential component of population-based care. It ensures that limited specialty resources are applied judiciously to the portions of the population most in need.

A traditional barrier to widespread dissemination of the collaborative care model has been lack of payment models. Traditional reimbursement based on face-to-face productivity has not made the population management strategies described above financially viable in many settings.

Fortunately, Medicare will begin reimbursing care provided by psychiatrists in collaborative care settings in 2017, according to the Centers for Medicare and Medicaid Services (CMS). In the Medicare Physician Fee Schedule Proposed Rule, CMS has included coverage for Psychiatric Collaborative Care Management Services. The recommendation is to pay for psychiatric consultative services to primary care physicians in the collaborative care model.

References:

1. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273:1026-1031.

2. Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53:924-932.

3. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10:CD006525.

4. Wagner EH. Meeting the needs of chronically ill people. BMJ. 2001;323:945-946.

5. Dissemination of Integrated Care Within Adult Primary Care Settings. Joint Task Force (American Psychiatric Association and Academy of Psychosomatic Medicine) Report. 2016.

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