I remember, almost to the day, when my psychiatric practice changed for the better by moving towards a psychiatric consultation model of care. Prior to this day, I was working as a medical director at a community mental health center where almost all my patients each were assigned to face-to-face services with a case manager and a psychiatric medication provider, with additional services provided as needed. We constantly dealt with the limits to how many patients we could serve using this model of care, and always felt we needed more psychiatrists and other mental health care clinicians in order to meet our client’s needs. Each day the staff at our center worked diligently to address the barriers to achieving better outcomes with our patients. However, we didn’t systematically track outcomes, and thus lost track of patients who may be dropping out of care or simply not improving as we had hoped. We had limited abilities to coordinate our care with one another as well as with the primary care providers who were also treating our patients. And finally, our care often wasn’t standardized from clinician to clinician. Our result, too often, was fragmented, uneven access to quality care, and with uncertain and likely reduced clinical outcomes.
Marc Avery, MD
So, I jumped at the opportunity about 15 years ago to participate in an early example of the Collaborative Care Model (CoCM) by participating in the Mental Health Integration Project, or MHIP, sponsored in part by the AIMS center at the University of Washington School of Medicine. Though the MHIP program was initially just a pilot project, I quickly came to realize that our whole mental health center would benefit from incorporating many of the principles that were core to the CoCM model.
My experience with the CoCM model taught me that psychiatrists can play a key role in improving clinical outcomes via the use of psychiatric consultation models of care. A psychiatrists’ training and experience affords the opportunity to provide leadership around the core principles of the CoCM model; namely, promoting integrated team-based care, using population health approaches, and incorporating measurement-based care practices. Though each of these components can be discussed separately, in my experience each one fits together with the other in a kind of jigsaw puzzle – with each potentiating the other. Of course, other models of consultation exist, many with similar features to the CoCM model. However, the CoCM model remains one of the most researched and validated models for primary care integration.
Implementing team-based care has been promoted as one of the potential solutions to addressing our country’s shortage of psychiatrists and other behavioral health providers. We simply can’t “fix” the shortage by working longer hours or waiting for more psychiatrists to graduate (though this would certainly help!). No, we need to take another approach – one where we partner with primary care teams to create a team-based approach to care. By working in our separate environments, we are working ineffectively and inefficiently. But, by joining together as a team, we can share tasks more efficiently by reducing gaps, clarifying roles, and eliminating redundancies. By working as part of a CoCM team, I quickly noted that I was overseeing many times the number of patients in my CoCM work as compared to my usual clinical work, but in the same amount of time. It was obvious from the start that the CoCM model allowed me the possibility to extend my reach as a psychiatric provider to help many more patients.
And, by working together as a team we could add more providers to the team itself, such as care coordinators, community health workers, nurses, or others – with each person working with a clear blueprint for their role and each person practicing at top of scope and skill level. The psychiatrist serves as a consultant on these teams, providing guidance around evidence-based treatments and care pathways and in identifying which patients might need more attention or a change in treatment.
The second central principle of the CoCM model is a switch to incorporate population-health practices. For me this was revitalizing to take on broader accountability for all the patients in my practice – not just those that were showing up for services or those that were improving as expected. For so many of us, we have to deal with busy clinical schedules moving from patient to patient, answering calls between appointments, and scrambling to keep up with documentation. It’s tough and heroic work, to be sure. But it also was too easy to focus our attention only on those patients who are coming into the clinic each day, and to lose track of those patients who do not. As I learned more about the CoCM model, I began to be more comfortable with regularly asking myself a series of population-health style questions:
- Who are all the patients my team is responsible for serving?
- Have we worked to engage each of them into care?
- Who isn’t coming in for services?
- How do we know if people are getting better?
- Who isn’t getting better as we all expected?
To address these questions, we used a shared electronic list of all of our team’s patients that tracked last appointment dates and clinical outcomes scores. A CoCM team periodically reviews all patients on the caseload in a meeting using just such a roster of patients. In many ways these meetings feel like virtual clinical rounds. A key feature of these discussions includes highlighting patients that need a change in care strategy. These changes are often quite simple – perhaps a different approach to engaging the client, a change in medication, or even just making a telephone call. But if it weren’t for these virtual clinical rounds, this opportunity was too often missed. These meetings also disciplined us all to adopt a more population-health approach that focused on outcomes rather than on appointments or processes.
A third principle of the CoCM model that transformed my work was the shift toward use of measurement-based practices, for example by using the PHQ-9 screener tool. Each member of the CoCM team learns how to administer and interpret this tool. No rating scale is perfect, and there is not a single tool that applies to every patient – but I found that the PHQ-9 and other rating scales gave me several new abilities in my consultation work. First, they gave me and my patients a means to quantify clinical improvement. This, in turn, allows me to track improvement over time. They also gave me the ability to communicate more effectively with one another on the CoCM team. For instance, nearly all of our CoCM patients struggle to a certain degree with some amount of depression even if it is not their primary diagnosis. The PHQ-9 and other rating scales serves as a shorthand and structured means of discussing these patients efficiently.
Over the years I have heard countless testimonials from psychiatrists, primary care providers, patients, and other behavioral clinicians about how integrated psychiatric consultation models like the CoCM can improve care experience and outcomes. These psychiatric consultation models do not replace specialty mental health care for those patients who really need those higher levels of care. However, it wasn’t long before I was incorporating many of the principles of the CoCM model into my specialty mental health work with as well. Many patients were able to be treated just as effectively, or better, with an integrated model of care – and with more convenience and improved access for the patient. In addition, consulting practices allow me to extend my reach and thus my impact as a clinical psychiatrist to improve the overall health of more patients.
Dr. Avery is a psychiatrist and Principal for Health Management Associates in Seattle Washington. He can be reached at mavery@healthmanagement.com or (360) 688-7503. Please visit the HMA behavioral health page to learn more.
References
Integrated care: Working at the interface of primary care and behavioral health. Raney, L. E. (Ed.). American Psychiatric Publishing, Inc. (2015).
Core principles and values of effective team-based health care. IOM: Mitchell, et. Al., (2012) http://www.iom.edu/tbc
A Tipping Point for Measurement-Based Care. John C. Fortney, Ph.D., Jürgen Unützer, M.D., M.P.H., Glenda Wrenn, M.D., M.S.H.P., Jeffrey M. Pyne, M.D., G. Richard Smith, M.D., Michael Schoenbaum, Ph.D., Henry T. Harbin, M.D. Published Online https://doi.org/10.1176/appi.ps.201500439 (Sept 2016)
