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Integrated care for the private practice psychiatrist
With the advent of health reform in the United States, the concept of “integrated care,” where behavioral and medical conditions are treated in a coordinated and organized way, has been widely discussed. This strategy is based on the higher rate of psychiatric illness in patients with chronic medical illness, the higher rate of chronic medical illness among patients, with psychiatric illness, and the resulting increased morbidity, mortality and cost when these conditions are treated in separate systems. 1-6 This integrated approach may address multiple issues including:
- Mental health and substance abuse conditions;
- Health behaviors and their contribution to chronic medical illnesses;
- Life stressors and crises;
- Stress-related physical symptoms; and
- Ineffective patterns of healthcare utilization.
This concept of integrating medical and psychiatric care grew out of two decades of careful systematic research testing the collaborative care model for delivering care to primary care patients with depression, the most common psychiatric diagnosis seen by primary care practitioners2-6. The collaborative care model was initially develop to address the fact that the majority of U.S. patients with depression and other psychiatric conditions, unable to be seen by the inadequate number of mental health specialists in the United States, rarely received adequate treatment for their condition, despite its wide availability and knowledge about its effectiveness.
The initial focus was on medication, because adequate pharmacotherapy was easier to quantify and standardize. This research firmly established that use of a care manager, and a system to measure clinical status and track outcomes, along with availability of a consulting psychiatrist, could be employed in concert with the primary care provider to facilitate patient self-management of their condition, and optimize medication management.
Multiple iterations grew out of this model, addressing other common problems (substance abuse, anxiety7,8, chronic pain, bipolar disorder9), other populations (children and adolescents10) and employing other modalities (CBT, and other brief psychotherapies such as behavioral activation7,11) besides medication management. It should be emphasized that this model was developed to provide psychiatric care to those patients not currently accessing specialty mental healthcare.
Hence, it was not intended as a replacement to specialty mental healthcare, but as a way to expand care to the many patients unable to access specialists., due to the very high rate of psychiatric illness and the very small number of mental health specialists available to treat them. While this situation is aggravated further in disadvantaged populations with inadequate resources, it is a significant problem for well insured middle class patients.
More recently a collaborative care model, Primary Care Access Referral and Evaluation or PCARE, reversed the context in which integrated care is delivered by re-engineering the mental healthcare system rather than the primary care system. It focused on 407 chronic mentally ill patients being served in public sector specialty mental health settings, a population whose substantial medical morbidity was poorly addressed, due to difficulties they had keeping in regular contact with a different medical care setting (i.e. the primary care clinic) to obtain needed care12. PCARE employed a medical nurse care manager working within the specialty mental health setting, to increase coordination of medical care to these vulnerable patients. These care managers worked with patients, providing health education, and medical providers, coordinating diagnosis and treatment, to improve patient’s medical care.
In this landmark PCARE study by Druss and colleagues, at a 12-month follow-up evaluation, chronic mentally ill patients receiving the PCARE intervention received an average of 58.7% of recommended preventive services, compared with a rate of 21.8% in the usual-care group. They also received a significantly higher proportion of evidence-based services for cardio-metabolic conditions and were more likely to have a primary care provider. This improvement in the process of care would hopefully improve longer-term medical outcomes in a population already known to have a much higher mortality rate from medical illness than the general population.
Implementation challenges
Despite an impressive body of work over at least a decade in the 1990s, this collaborative care system was difficult to implement in the primary care system due in large part to lack of a reimbursement mechanism, as well as a paucity of studies to show it was feasible on a broader scale outside of the research setting13. The seminal IMPACT study, published in the early 2000s, was crucial in demonstrating that the collaborative care model could be implemented across a broad array of non-research based primary care systems, was more effective than usual care (including in some systems a care model where there was an available mental health professional working in the clinics), and seemed to be cost-effective in this geriatric population with more medical problems whose outcomes might be adversely affected by untreated psychiatric illness driving up costs14. After IMPACT, more studies of this model were published, and pilot programs of implementation across the US gained more traction15.
The current reorganization of healthcare is likely to address the major implementation challenge for this model, namely reimbursement models to cover the costs of both care management and expert psychiatric consultation (the cost of implementing measurement based care is less of a barrier as the growth of electronic medical records will facilitate this in a likely cost neutral way). However, numerous other implementation challenges remain including the continued separation of mental and medical health systems, as well as philosophies, of care: the separation of mental health and substance abuse systems of care; and a lack of organizational “readiness to change”. Unutzer, architect of the seminal IMPACT program and a key leader in integrated care, recently outlined, in a column in the APA’s Psychiatric News, the vital importance of key clinical and administrative leaders, in helping to maintain a successfully implemented collaborative care program over the long term16.
Role of the private practice psychiatrist
Psychiatrists in private practice have been curious about how they might become involved in this new model. Most suggestions have emphasized a model where they can continue their private practice while carving out a small amount of time to work in the primary care setting and participate in this model. It is not yet clear that many psychiatrists are clamoring to do this, given the difficulties of a split practice and uncertainties about whether their reimbursement for this time will be equivalent to what they would earn just devoting the hours to their practice.
Moreover, if they reduce their specialty practice time, it is unclear who will see the patients they are currently service in the specialty sector. It is too soon to tell what might happen in terms of psychiatric practice patterns in ambulatory psychiatric care. In the meantime, we must ask: is moving to the primary care setting the only way to facilitate integrated behavioral and medical care of patients? Is there anything that the private practitioner might do, even while working in a separate setting, to promote integrated care?
In addition to promoting better patient self-management (something that would automatically be done with good specialty psychiatric care) and having a care manager to help coordinate the patient’s care with the primary care physician (it seems a psychiatrist in specialty practice could achieve this goal without having an additional care manager), there are two major pillars that form the core aspect of integrated care, even within the collaborative care model.
These are: use of measurement-based care to carefully track outcomes and adjust treatments17; and adopting a reliable system to communicate patients’ clinical and treatment status to their medical providers18.
It can safely be said that extremely few psychiatrists in outpatient private practice do either of these things, probably because they add time and cost to these clinicians’ busy day. Moreover, there is no external pressure i.e. regulatory requirement, for them to do so. However, having some kind of electronic medical record appears to be an increasing requirement, and this might facilitate use of measurement in psychiatric care, as well as promote better communication between psychiatrist and medical provider. Let’s briefly look at these two domains.
It is by no means a unique assertion that measurement based care is required to optimize the rapid identification of key psychiatric problem areas at intake, and to then allow systematic tracking of change over time in response to treatment and ultimately, adjustment of treatment (changes, additions, deletions) over time in response to how the patient is doing. This is known in the collaborative care literature as “treat to target”. However, use of measurement is not just useful for optimizing the treating clinician’s care process. It is also vital for communicating this care process to other clinicians that share care of the patient, in an easy-to-understand and quantifiable way.
A simple example is useful here. If a psychiatrist wanted to begin or continue lithium treatment in a patient whose creatinine appeared somewhat elevated, and he sent the patient to a nephrologist, he would want to know much more than that the patient was being evaluated and treated by a nephrologist. He would want to know the nature and quantifiable extent of the problem, what treatment might be offered, and whether that treatment is producing measurable change in this condition. Similarly, the internist or nephrologist who is managing this patient would want to have a sense of the nature and severity of this patient’s mood disorder, and how it had responded to other interventions, in order to share in a risk-benefit analysis of whether or not use of lithium would be prudent. One can imagine many other scenarios involving not just use of medications, but also use of psychotherapy. For example, a patient may have maladaptive health behaviors or non-adherence that interferes with medical treatment, and ongoing psychotherapy might be addressing issues that impact on this. Is there a way to simply communicate to the medical provider what is being done in psychotherapy and what the goals are?
After assuring adequate measurement of patients outcomes, rapid communication with patients’ other medical providers (and also psychotherapists if psychotherapy is not being provided by the psychiatrist) is the second crucial element required to promote more integrated care of the patient. Medical providers rarely receive notes or records from psychiatrists unless they are expressly requested. I have experienced this first hand because I routinely send intake notes and intermittent progress notes to my patients’ primary care physicians and they are usually quite surprised and often say “I never get notes from a psychiatrist.” I will usually send notes when I make a key change in someone’s treatment, or when a series of changes has finally resulted in an important change in clinical status.
I have also routinely kept in my HPI section a running account of each visit (several sentences only) so that I need only send a single note (the most recent one) that can be easily and quickly read and gives a nice summary of the patient’s clinical course up to that point. Conversely, I have been perplexed and exasperated when I manage to get records from other mental health providers, often practicing in institutional settings, and find that I am sent pages and pages of extraneous material, and I have to hunt for the key clinical details which are embedded in separate notes with little linking them together.
This kind of “communication” does not foster integrated care and is often a characteristic of some broadly utilized EMRs that are set up to promote billing and regulatory compliance rather than to improve clinical care. Such EMRs (and I am thinking of summaries of inpatient stays here) often contain multiple documents summarizing disparate parts of a treatment stay, often without any unifying document.
Conclusion
In sum, “integrating” patient psychiatric and medical care does not necessarily require giving up your private practice and moving into a salaried position in a primary care clinic. Private practice psychiatrists can promote integrated care while remaining in their offices in two broad ways: by the careful and systematic use of outcomes measurement at both intake and longitudinally over time, and by communicating with other providers using accurate, succinct and hopefully condensed clinical notes. These notes will include summaries of carefully measured outcomes, perhaps in a graphic form along with treatments provided over time, but will also include the mainstay of current psychiatric clinical acumen, a narrative story of the patient’s life difficulties over time, a story that will complement the quantitative measurements that are used.
Peter Roy-Byrne is Professor Emeritus in the Department of Psychiatry at the University of Washington School of Medicine and Co-Founder of the Psychiatric Medicine Associates in Seattle. Dr. Roy-Byrne is a paid advisor to Valant.
1.APA. Integrated Care Web site.
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