A Model of Integrated Care

Educational Objectives

The goal of this program is to improve use of the collaborative care model in psychiatry. After hearing and assimilating this program, the clinician will be better able to:

1. Explain the role of the care manager in the collaborative care model.
2. Compare the importance of short-term vs long-term psychiatric treatment in the collaborative care model.
3. Manage movement disorders in patients using the collaborative care model.
4. Differentiate between the roles of psychiatric consultants and therapists in the collaborative care model.
5. Implement training for psychiatric consultants according to the collaborative care model.

Summary

Building a model of collaborative care: speaker’s experience — is dual-boarded in primary care and psychiatry and was first exposed to the model at a conference; used their knowledge to set up the program at their center; is the psychiatrist and acts as the liaison or physician champion, ensuring smooth implementation of the model, helping other primary care providers (PCPs) to troubleshoot issues and working with site leadership to teach them how to implement the model in their clinics; good operational leadership is important; overview of collaborative care model — team members include therapists and medical assistants (MAs); at the center of the model is the patient; the PCP refers the patient into the model and the care manager becomes the main touch point for the patient; the care manager identifies the elements of therapy to be used, reaches out to the PCP to ask questions and advocate for the patient, and gets feedback from a psychiatry consultant; a therapist or nurse manager assists the care manager to understand if patients need a change in intervention; a registry is used to keep track of Patient Health Questionnaire (PHQ) and Generalized Anxiety Disorder (GAD) scores and observe trends; a sorting mechanism is used to find patients who need intervention; the model is mostly used for mental health concerns and some other conditions

Background: the model was designed to address shortages of mental health medicine prescribers; it allows providers to shift more time to taking care of patients with the highest need and illness burden; it allows team members to use their expertise and contribute their knowledge to the understanding of the patient; the model is superior to simply having the team in the same location as it creates a structured mechanism for communication leading to more efficacy of care; it has been studied mainly in depression, anxiety, and trauma spectrum disorders; it has also been looked at in pediatric populations, attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorders; questionnaires vary by age group; the Advancing Integrated Mental Health Solutions (AIMS) Center is a pioneer in advancing this model; the RESPECT-Mil trial focused on posttraumatic stress disorder (PTSD) in the military; other studies include the Depression Improvement Across Minnesota - Offering a New Direction (DIAMOND) trial and a trial from Washington that focused on depression and anxiety; federally qualified health centers excel in team-driven care as they can pick up where primary care is unable to and help identify the issue

Advantages and adaptability: since resources are limited, having a population-focused, measurement-guided approach is important; accountability and actual data guide quality improvement; the patient population is predominantly on Medicaid or does not have insurance and since the model uses a registry, it is easy to keep track of enrolled patients and their progress; team members can be sent to re-engage the patient in treatment if needed; PCPs want patients to regain function and have a higher quality of life faster; being able to get information from a psychiatry consultant quickly elevates the care provided; continuity is often an issue in primary care; the model allows reassessment and ongoing monitoring to see if changes made are effective; it also helps in centers where PCPs have limited time with patients; MAs assist therapists, who are case managers or social workers; for the model to work, therapists have shorter visit time frames and having a system that automatically captures data rather than entering it manually is helpful; workflow adjustments may be needed and the process requires trial and error and communication; meeting with site leadership helps anticipate issues and facilitates problem-solving

Technological features: for medication monitoring, patients should be asked about physical symptoms; if therapists are not comfortable with this, MAs can help them; templates can be created and used to ask about these; PHQ and GAD scores can be tracked in the medical record system and improvement assessed to identify teams that are performing well; this can offer input to troubleshoot areas for improvement; the system can show therapists which patients need case reviews; the episode of care functionality allows providers to ensure continuity easily; therapy managers can see metrics to assess how the team is performing and make changes; the system allows for easy interpretation of data trends; functions can be built in to compare statistics with usual treatment; patients can be reviewed by number of weeks in treatment to identify those who need case reviews

Therapists: mental health therapists, called clinicians, use the registry to track outcomes and prioritize patients for case review depending on the size of the panel; time is protected to review the patient for the therapist and the psychiatrist; they ask patients about adherence and side effects, and can often answer questions the psychiatrist may have since they have rapport with the patient; they focus on short-term psychotherapeutic interventions such as shorter term cognitive behavioral therapy (CBT), problem-solving therapy, and behavioral activation; they create a diagnostic impression and usually determine if the patient stays in the model; if the patient does not improve, they may change the therapeutic approach and clarify what the patient is trying to achieve from treatment; they may review medication recommendations with the psychiatrist; they can do 30- or 60-min appointments; some therapists struggle with short-term psychotherapeutic interventions; the AIMS care solutions team can provide guidance with this; the goal is to empower patients to function well independent of the therapist; if they do not progress adequately, treatment should be adjusted; while the ideal duration of treatment is 6 to 8 mo, ie, 4 to 12 sessions, patients may need longer based on no-show rate; patients can be seen more often if needed or given homework to make progress between sessions

MAs and PCPs: MAs help therapists with scheduling and obtaining scores, help patients fill questionnaires before seeing the therapist, update PCPs about medication recommendations, and help patients fill out side effect questionnaires; they print the case load and highlight patients with high PHQ or GAD scores so the therapist has a better idea of which patients to review; they can also help triage patients; MAs ensure that patients know they can receive medication recommendations without seeing the psychiatrist directly; PCPs should be careful about the diagnosis associated with a referral order; if the patient is referred for depression, anxiety, or trauma spectrum disorders, the MA can get the patient to see the therapist and be assessed for the collaborative care model; if the diagnosis is psychosis, bipolar disorder, or ADHD the patient is scheduled to the psychiatrist even if they want therapy as well; PCPs need to review detailed medication recommendations; since they are the only providers seeing the patient directly, they make the ultimate decision about medication; while they may be uncomfortable with this, the model has been shown to work well in multiple sites; it should be taken into account that they know the patient better and understand the nuances of their treatment; they may have tried medications in the past which are not reflected in the medical record system; it is sometimes difficult to find the referral diagnosis and reasons for referral; MAs help PCPs by reconfirming with patients if they still want therapy or medication

Referral process: PCPs should really understand the model since it is complex and can be confusing, with several subspecialty clinics; they should know how their referral diagnosis affects the order in which patients receive care; patients with a listed diagnosis of bipolar disorder or psychosis deviate from the collaborative care model into the traditional care model; if a patient does not follow up consistently with the therapist, this makes it difficult to collect the information needed to make medication recommendations and for monitoring; if the patient has a high level of need or has problems with activities of daily living, they should be referred to the community mental health center; if they have significant trauma symptoms they are referred to the trauma-specific clinic and are not included in the model; if therapists notice that patients may need assessment for movement disorders or cognitive decline, they should be assessed by the psychiatrist

Problem-solving: AIMS has created a document to help with troubleshooting in the model; patient identification is important; patients selected for the model should be appropriate for the program, and it is important to ensure that they really enter the model via the correct chain of referral; creating a workflow is useful to ensure this; patient engagement means ensuring that patients attend their appointments; patients should be seen in a timely manner to ensure engagement; it is also important to establish a diagnosis; PCPs may not be sure of the diagnosis or may give inaccurate information that changes the time taken for patients to receive appropriate care; it is also key to ensure that treatment to target is being used; therapists who review cases with psychiatric consultants should ensure that patients with the highest scores are being seen; working efficiently and systematically as a team during monitoring and diagnosis is important; scoring should be done consistently to ensure that information can be used; relapse prevention is not a priority at the speaker’s center since the model provides short-term treatment and patients can be transitioned out into long-term therapy if needed; AIMS has a trackable category for patients who need relapse prevention; their progress can be observed to see if they decompensate more quickly than expected, and to assess if they have a relapse prevention plan; metrics like quality of the model and accessibility of care can be assessed; it is possible to try and speed up time to psychiatric recommendations and graduation from the mental health program

Troubleshooting: patients who do not improve need to be reviewed, while those who improve can be assessed at the level of the institution and also within each site and team to look for differences for quality control; ensuring sufficient staffing is key; providers may need to split their time between multiple sites for the model to work; PCPs should be made to feel comfortable in the model and prescribing psychotropic medications; they can be given documents and orientations to help with this; surveys can then be done to assess their effectiveness; these documents and orientations can also be helpful for psychiatric nurse practitioners (NPs); they can be observed directly and be given opportunities to observe the psychiatrist performing case reviews; notes can be reviewed and documents given to guide them through case reviews; the frequency of observation depends on their performance; PCPs may not understand the model; it should be explained to them virtually or over the phone and any concerns addressed; site medical directors usually round on PCPs and become important allies to advocate for the model with PCPs at the site; communication is important in the model; the medical record system helps track performance and to identify patients needing attention; at the macro level, creating workflows helps ensure smooth functioning of the model; meeting with members at the site level and within patient care teams is important as well

Some considerations: psychiatric consultants can be allowed to observe psychiatrists in the model; the American Psychiatric Association (APA) modules on collaborative care can be given; they can be coached when doing their first case review and any questions can be answered; the program manager can give them time to review their caseload and see which patients need outreach and if patients can be removed from the caseload; the transition from psychiatry follow-up to collaborative care is decided on by the psychiatrist and therapist; communicating with the PCP during the transition is important; it is also important to communicate to PCPs when patients have completed their time in the model; psychiatrists in the model have to be good teachers to therapist care managers, MAs, and PCPs; they have to be clear and precise when giving medication recommendations so that PCPs can follow them and feel comfortable with them; the model allows psychiatrists to get more information from patients more quickly than is possible in routine care; other advantages include being able to collaborate with other providers and reassess patients more frequently; cases are presented to the psychiatrist by care managers and if some questions are not answered, the MA can ask the patient for the additional information; if the case is very complicated, the psychiatrist can see the patient directly; care managers perform mental status examinations, but the psychiatrist can see the patient directly; the diagnostic impression is based on input from the therapist and information that is in the chart

Other considerations: the informed consent process is important; medication recommendations should be discussed with the patient first; if they agree, they should be told that the recommendation will be discussed with the PCP and they will begin the medication only if the PCP is comfortable prescribing it; the patient and PCP should be given enough information to give informed consent; as the model enlarges in a site, more diagnoses and age groups can be included, and ways to help with social determinants of health can be identified; the registry can reflect lack of improvement or prolonged treatment, which helps teams identify patients who need help; patients who have not been followed up for a long time show up in the medical record system in yellow or red; each time therapists see the patient the case is reviewed and discussed with the psychiatrist at least monthly; care coordinators may be needed as the model grows; the model forces clinicians to be specific and teach patients about symptoms and side effects clearly

Readings

Carlo AD, Barnett BS, Unützer J. Harnessing Collaborative Care to Meet Mental Health Demands in the Era of COVID-19. JAMA Psychiatry. 2021 Apr 1;78(4):355-356. doi: 10.1001/jamapsychiatry.2020.3216. PMID: 33084852; PMCID: PMC10829844; Engel CC, Oxman T, Yamamoto C, et al. RESPECT-Mil: feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care. Mil Med. 2008;173(10):935-940. doi:10.7205/milmed.173.10.935; Goodrich DE, Kilbourne AM, Nord KM, et al. Mental health collaborative care and its role in primary care settings. Curr Psychiatry Rep. 2013;15(8):383. doi:10.1007/s11920-013-0383-2; Huang H, Forstein M, Joseph R. Developing a Collaborative Care Training Program in a Psychiatry Residency. Psychosomatics. 2017;58(3):245-249. doi:10.1016/j.psym.2016.12.006; Kilbourne AM, Goodrich DE, Nord KM, et al. Long-Term Clinical Outcomes from a Randomized Controlled Trial of Two Implementation Strategies to Promote Collaborative Care Attendance in Community Practices. Adm Policy Ment Health. 2015;42(5):642-653. doi:10.1007/s10488-014-0598-5; Meredith LS, Eisenman DP, Han B, et al. Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial. J Gen Intern Med. 2016 May;31(5):509-17. doi: 10.1007/s11606-016-3588-3. Epub 2016 Feb 5. PMID: 26850413; PMCID: PMC4835392; Price-Haywood EG, Dunn-Lombard D, Harden-Barrios J, et al. Collaborative Depression Care in a Safety Net Medical Home: Facilitators and Barriers to Quality Improvement. Popul Health Manag. 2016;19(1):46-55. doi:10.1089/pop.2015.0016; Reist C, Petiwala I, Latimer J, et al. Collaborative mental health care: A narrative review. Medicine (Baltimore). 2022 Dec 30;101(52):e32554. doi: 10.1097/MD.0000000000032554. PMID: 36595989; PMCID: PMC9803502; Rossom RC, Solberg LI, Parker ED, et al. A Statewide Effort to Implement Collaborative Care for Depression: Reach and Impact for All Patients With Depression. Med Care. 2016;54(11):992-997. doi:10.1097/MLR.0000000000000602; Smith JD, Fu E, Rado J, et al. Collaborative care for depression management in primary care: A randomized roll-out trial using a type 2 hybrid effectiveness-implementation design. Contemp Clin Trials Commun. 2021;23:100823. Published 2021 Jul 26. doi:10.1016/j.conctc.2021.100823; Unützer J, Carlo AD, Collins PY. Leveraging collaborative care to improve access to mental health care on a global scale. World Psychiatry. 2020 Feb;19(1):36-37. doi: 10.1002/wps.20696. PMID: 31922696; PMCID: PMC6953542; Whitebird RR, Solberg LI, Jaeckels NA, et al. Effective Implementation of collaborative care for depression: what is needed?. Am J Manag Care. 2014;20(9):699-707.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Bryant was recorded at the Regional Integrated Mental Health Conference, held in West Baden Springs, IN, October 4-6, 2024, and presented by the Indiana Psychiatric Society. For information about upcoming CME activities from this presenter, please visit Indianapsychiatricsociety.org. Audio Digest thanks the speakers and the Indiana Psychiatric Society for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.75 CE contact hours.

Lecture ID:

PS540701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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