Behavioral Integrative Care: Treatments That Work in the Primary Care Setting
I n a typical primary care practice, detecting and managing mental health problems competes with other priorities such as treating acute physical illness, monitoring chronic disease, providing preventive health services, and assessing compliance with standards of care. Efforts to improve the treatment of common mental disorders in primary care have traditionally focused on screening for these disorders, educating primary care providers, developing treatment guidelines, and referring patients to mental health specialty care.
Behavioral health integration BHI in primary care refers to primary care physicians and behavioral health clinicians working in concert with patients to address their primary care and behavioral health needs.
Primary Care Behavioral Health Integration
Numerous overlapping terms have been used to describe BHI, and this has caused some confusion. BHI at the level of coordinated care has almost exclusively been studied and practiced along the lines of the collaborative care model CCM. The most substantial evidence for CCM lies in the management of depression and anxiety.
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Usual care involves the primary care physician and the patient. CCM adds 2 vital roles—a behavioral health care manager and a psychiatric consultant.
Consultations typically take 3—5 minutes personal communication from J. Kern, December , based on unpublished data from 4, consultations and cover a broad range of topics. The most common questions, by diagnostic category, have to do with mood, anxiety, and substance use disorders Often the primary care provider will have the behavioral health provider make the call to the psychiatric consultant, utilizing the behavioral health provider as a conduit for information and mental health expertise in synthesizing the information being relayed.
The psychiatric consultant usually does not document these brief consultations, and the primary care provider and behavioral health provider may or may not do so, depending on their practice preference.
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The psychiatric consultant gathers additional information from the primary care provider and behavioral health provider to help the team confirm a diagnosis or develop a provisional diagnosis and initiate a treatment plan. Because providing consultation for patients who have not been directly evaluated and making recommendations through a series of approximations may cause some uncertainty, more seasoned clinicians with a greater depth of expertise may find this work more suitable than clinicians with less experience.
However, working with residents to hone these skills is important, since much of the excitement around practicing in integrated care settings is coming from the newly minted psychiatric workforce. Consultation requests cover a broad range of age groups and diagnoses, and it is important for the consultant psychiatrist to be prepared to provide recommendations in a variety of areas.
An example of this is a family medicine physician calling a consultant psychiatrist, who is trained in adult psychiatry, with a question regarding treatment recommendations for a child. Rather than declining a consultation because of a lack of formal training in child and adolescent psychiatry, one reasonable course of action for the psychiatrist would be to inform the primary care provider that he or she will research the issue and call back. A desired outcome of this process of indirect consultation is developing the capacity of the primary care provider to recognize patterns of care in treating mental health conditions.
As competency and confidence build, the consultant psychiatrist will begin to notice the primary care providers and behavioral health providers begin to ask more difficult questions as they learn to apply knowledge gained from the process of repeated consultations for similar clinical situations. It is unclear what constitutes a successful consultation experience, but several key factors are highlighted in Table 2.
Failure of the psychiatric consultant to adhere to them can lead to an unpleasant and unhelpful experience for other members of the team This is important to consider, as historically psychiatrists have been perceived by primary care providers as being unavailable 23 and perhaps unwilling 24 to provide consultation. The process of indirect consultation not only builds the capacity of the behavioral health provider and the primary care provider to treat mental health conditions but also promotes the development of trusting relationships between all team members.
This is important, as primary care providers are being asked to step out of their comfort zone and provide care that is typically considered more within the scope of psychiatric practice, and trusting the consultant to be there and guide them through the process is an important feature in the success of the model. TABLE 2. Key Components of Indirect Consultation a.
Psychiatrists often have liability concerns about providing consultation for patients they have not directly evaluated. There are two things to consider in the provision of indirect consultation: 1 establishment of a doctor-patient relationship and 2 the nature of the administrative relationship between the providers. As for the first, historically, in many states, indirect consultation usually does not attain the threshold required in establishing a doctor-patient relationship, a step necessary in determining whether there is a duty to a patient in a malpractice situation.
A supervisory relationship with the behavioral health provider or primary care provider, which is infrequent in these models, has the highest form of liability, since they report to the psychiatrist, who is then responsible for the oversight of the care they deliver. More frequently, the relationship is seen as consultative, with each party practicing independently. This form of split treatment traditionally carries the least liability. It is important to have the primary care provider remain in charge of all patient care, including ordering medications and any additional testing.
Comprehensive guidance on this topic may be found in an APA resource document published in Caseload-focused registry review is another form of indirect consultation and a necessary component of this population-based care model to allow the leveraging of psychiatric expertise to larger populations. Behavioral health providers or other designated staff enter patient information into a database, referred to as a registry, that includes results of screening and tracking tools such as the PHQ and the GAD , medications prescribed, current mental health treatment, follow-up contacts, and other data deemed necessary by the team.
Twenty or more patients may be reviewed in an hour, and recommendations might include medication adjustments, changes in behavioral approaches, scheduling a face-to-face patient visit with the psychiatrist, or referral to a higher level of specialty mental health care. In addition to individual patient recommendations, aggregate data from the registry can be utilized in many ways, including determining whether there are specific areas that need more focus or areas of success that warrant dissemination.
Pooled data is necessary if an organization is being reimbursed for the services rendered based on outcomes or other quality measures. As such, every consultation request should be viewed as an opportunity to teach. The primary care provider and behavioral health provider are looking for information and guidance, and providing a brief explanation of why a specific recommendation was made goes a long way toward this goal and helps them gain confidence in their skills.
More formal education on specific topics is usually welcome and can be provided over a meal or at other specified times.
Sharing journal articles and joint attendance at meetings can also be helpful. Regardless of how the information is obtained, an important aspect of retaining knowledge is the ever-present availability of the consultant psychiatrist to reinforce the didactics through actual patient care experiences. It is important to appreciate that the psychiatrist is also a learner in this process, with much to gain from the knowledge and experience of the other members of the team. Leadership opportunities exist for all members of the team, and psychiatrists are especially suited to fill this role.
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Sharing a background of medical education with the primary care providers and expertise in treating psychiatric disorders with the behavioral health providers, psychiatrists can help mitigate problems that occur as a result of cultural differences between the systems of care. The environments are quite different Table 3 and can lead to differing expectations of team members and approaches to patient care. Anticipating difficulties beforehand can lead to less frustration and should be the norm. Resistance to the model by team members who may initially be reluctant to change their familiar approach to care is a common barrier, but negotiable by the perceptive psychiatrist trained in group dynamics and expertise in behavior change.
An interesting multisite study 26 highlighted the effects that these intangible differences can have. All sites received the same training and postimplementation support, and they had similar patient characteristics, but they demonstrated remarkably different outcomes, presumably as a result of these other influences. While other examples of integrated care exist, it is the inclusion of psychiatric expertise and adherence to the guiding principles of the collaborative care model that can lead to more effective treatment TABLE 3. Edited by Raney LE. Reprinted with permission.
Each team member has a clear role on the collaborative care team, and the psychiatrist needs to be available to provide consultation and guidance in a readily accessible manner. Indirect consultation with primary care providers and behavioral health providers is a crucial part of the system of care, and key elements such as developing mutual respect and trust must be adhered to. Psychiatrists can prepare for working in integrated care environments by establishing collegial relationships with primary care providers and improving their general medical knowledge and the treatment of common mental health presentations in the primary care setting.
Cultural differences between primary care and mental health care need to be well understood, and active monitoring of the team dynamics is an important role psychiatrists can play. Integrating primary care and mental health provides new opportunities and challenges for psychiatrists. Understanding the fundamentals of the process allows a sophisticated application of psychiatric skills, already in short supply, to be leveraged across larger populations of patients. To meet this challenge, psychiatrists will need to be competent in their roles and be prepared to provide leadership as teams navigate these new relationships.
The author wishes to acknowledge the pioneering work of Wayne Katon, M. He died March 1, Psychiatr Serv in press Google Scholar. Forgot Username? Forgot password? Keep me signed in. New User. Sign in via OpenAthens. Change Password. Old Password. New Password. Password Changed Successfully Your password has been changed.
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Returning user. Forget yout Password? If the address matches an existing account you will receive an email with instructions to reset your password Close. Forgot your Username? Enter your email address below and we will send you your username. Back to table of contents. Previous article. Perspectives Full Access. Lori E. Raney Search for more papers by this author. Add to favorites Download Citations Track Citations. Five Core Principles of Effective Collaborative Care a Patient-centered team care The care is patient-centered and provided by prepared, proactive teams using shared care plans that incorporate patient goals.
Teams consist at a minimum of primary care providers, behavioral health providers, and psychiatric consultants who work to engage and treat patients using the collaborative care process. Population-based care Patient populations are defined in advance and then screened, tracked in databases referred to as registries , and carefully followed for adherence and response to treatment.
Caseloads are regularly reviewed for progress toward goals, and patients who are not improving receive further recommendations to enhance outcomes. Measurement-based treatment to target From initial screening to regularly scheduled rescreening, care is measured with standard tools and treatment is adjusted for patients who are not improving until preset goals are met.
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Evidence-based care Treatments with reliable evidence are used in patient care, including evidence-based brief interventions proven to work in the primary care setting, psychopharmacology, and fidelity to the collaborative care model itself. Accountable care Adherence to the above principles allows providers using the collaborative care model to be held accountable to health care systems for costs and quality outcomes. Key Components of Indirect Consultation a Enlarge table.
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