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Integrated care for the private practice psychiatrist

November 20, 2014
by Peter Roy-Byrne, MD
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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

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