Approaches to Collaborative Care and Behavioral Health Integration

Overview

Historical trends in psychiatry over the last century mirrored developments in the U.S. healthcare system more broadly that promoted system re-design to provide safer and more personalized, cost-effective, and high-quality health care. Care re-design in the treatment of psychiatric disorders included innovative approaches to providing psychiatric care in the general medical setting, which is commonly the first site of presentation of mental illness, and is often the only resource available for patients. Advances in psychopharmacology greatly facilitated the development of such models, which were designed to address quality, cost-containment, and allocation of limited resources. Initially, psychiatric care provided to medically ill patients was primarily hospital-based, but ever-shorter inpatient stays increasingly drove those services to outpatient settings. This paralleled the trend for shorter inpatient psychiatric hospitalizations (often without the benefit of increased mental health resources in the ambulatory setting), which left primary care providers (PCPs) responsible for treating more acute and complex psychiatric illness in their outpatient practices. Resourceful psychiatrists recognized the need to collaborate with their medical colleagues in developing and implementing pragmatic, cost-effective, outpatient models of high-quality psychiatric care that could be delivered in the primary care setting. One such model, known as collaborative care, is an evidence-based approach for integrating physical and behavioral health services that can be implemented within various primary care settings. Collaborative care includes: (1) care coordination and care management; (2) regular/pro-active monitoring and treatment to target using validated clinical rating scales; and (3) regular, systematic psychiatric caseload reviews and consultation for patients who do not show clinical improvement. This and other models of care integration will be discussed below.

The realization of limited healthcare resources and rapid escalation of healthcare expenditures has forced a change in focus from patient- to population-based care, or from individualized to team-based strategies. This change has, at times, been remarkably challenging for healthcare systems and providers, as it represents a fundamental organizational and philosophical shift in the traditional doctor–patient paradigm. Models of population health have long been applied to patients with chronic medical illness (e.g., diabetes, hypertension, medical complexity). It was not until relatively recently, however, that poor overall health outcomes and significant fiscal burden compelled healthcare systems to apply similar models to patients with psychiatric co-morbidities. Studies have consistently demonstrated that individuals with psychiatric disorders utilize physical health care resources more frequently and experience increased work absenteeism, unemployment, subjective disability, increased morbidity from chronic medical illness and premature mortality. Though more difficult to demonstrate, there is also a cost-offset of appropriate and timely psychiatric treatment.

Furthermore, changes in healthcare reimbursement have resulted in conflicted PCP incentives. On the one hand, pre-paid, provider-risk plans (i.e., capitated programs), such as health maintenance organizations (HMOs), exposed the expensive use of general medical services by patients with untreated or poorly managed psychiatric illness, providing an incentive for the PCP to initiate treatment for the more common psychiatric problems seen in primary care. On the other hand, the PCP gatekeeper system of the 1990s, which evolved to manage the overall cost of care, including specialty care, created a potential incentive not to refer for psychiatric care, even conceivably in the setting of more severe mental illness. Limited formularies, varying by plan, with onerous, time-consuming prior authorization requirements, further complicated and deterred the initiation of appropriate treatment by all providers. Managed care organizations (MCOs) often carved-out substance use and mental health (collectively called behavioral health [BH]) benefits management to managed BH organizations (MBHOs), some with limited referral networks not inclusive of the PCP's psychiatric colleagues. This not only resulted in a major referral disincentive, but also complicated future communication and collaboration between BH and physical health providers. While many MBHOs have spearheaded initiatives to promote primary care treatment of common psychiatric problems, most do not credential or contract with non-psychiatric physicians, so this essentially cost-shifts expense from the MBHO to the (medical) MCO.

Passage of the 2010 healthcare reform legislation (Patient Protection and Affordable Care Act [PPACA]) pushed the envelope to create more inclusive, accessible, coordinated, and integrated care systems, and to achieve the “triple aim” (i.e., improved quality, improved outcomes, reduced total healthcare cost). These initiatives include the patient-centered medical home, accountable care organizations, and integrated programs for the “dual eligible” populations (i.e., those eligible for both Medicare and Medicaid, either the elderly and indigent, or the disabled and poor). To be successful in any of these initiatives, there is an important and recognized role for consultant psychiatrists and an overall more robust strategy for the global management of patients with mental illness.

Epidemiology

Epidemiologic studies over the past several decades have underscored the scope and profound public health impact of psychiatric disorders in the community, as well as their widespread under-detection and under-treatment. The Epidemiologic Catchment Area (ECA) Study, conducted in the early 1980s, attempted to quantify the prevalence of psychiatric problems in community residents of the United States. Within a 6-month span, roughly 7% sought help for a BH problem. More than 60% never saw a BH professional, but sought care in a medical setting (e.g., emergency department, ED PCP's office). Even among those who met full criteria for a diagnosable psychiatric disorder, 75% were seen only in the general medical (rather than the BH) setting. It was inferred, therefore, that psychiatric distress was exceedingly common in the primary care population. About half of general medical outpatients had some psychiatric symptoms. The use of structured diagnostic interviews detected a prevalence of 25% to 35% for diagnosable psychiatric conditions in this patient population. However, roughly 10% of primary care patients had significant psychiatric distress without meeting diagnostic criteria for a psychiatric disorder. The majority of diagnosable disorders were mood disorders (80%), with depression being the most prevalent (60%); anxiety disorders were a distant second (20%). The more severe disorders (e.g., psychotic disorders) were more likely to be treated by BH professionals. The National Comorbidity Survey (NCS), conducted between 1990 and 1992, demonstrated a 50% life-time prevalence of one or more psychiatric disorders in US adults, with a 30% 1-year prevalence of at least one disorder. Alcohol dependence and major depression were the most common disorders. A rigorous replication of the NCS (NCS-R), in 2001 to 2002, also measured severity, clinical significance, overall disability, and role impairment. The NCS-R found the risk of major depression was relatively low until early adolescence, when it begins to rise in a linear fashion. The slope of that line has increased (i.e., becoming steeper) for each successive birth cohort since the Second World War. The life-time prevalence of significant depression was 16.2%; the 12-month prevalence was 6.6%. Two findings, however, were of particular interest. First, 55.1% of depressed community respondents seeking care received that care in the BH sector. The other significant finding, attributable to advances in pharmacotherapy and educational efforts, was that 90% of respondents treated for depression in any medical setting received psychotropic medication. While this suggested improved community depression treatment, it was tempered by the finding that only 21.6% of patients received what recent, evidence-based guidelines (American Psychiatric Association [APA]; Agency for Healthcare Research and Quality [AHRQ]) considered minimally adequate treatment (64.3% treated by BH providers, and 41.3% of those treated by general medical providers), and almost half (42.7%) of patients with depression still received no treatment. Older studies documented PCPs' failure to diagnose over half of the full criteria mental disorders of their patients, but later studies demonstrated that PCPs recognized their more seriously depressed or anxious patients. These studies also demonstrated that higher-functioning, less severely symptomatic primary care patients have relatively good outcomes, even with short courses of relatively low doses of medications. This highlights the diagnostic difficulty for PCPs—primary care patients are different from those who seek specialty care (i.e., the population in whom most psychiatric research is done). Primary care patients may seek treatment earlier in the course of their illness, since they have an established relationship with their PCP that is not dependent on their having a psychiatric disorder. They frequently present with somatic complaints, rather than psychiatric symptoms. Since the soma is often the primary focus of the PCP, this further obscures the diagnosis. Primary care patients often present acute psychiatric symptoms that clear quickly (i.e., before therapeutic medication levels are reached), suggesting they might benefit as much from watchful waiting and the empathic support of their PCP.

There is a high noise-to-signal ratio in psychiatrically distressed primary care patients. That is, as many as one-third of significantly distressed patients have sub-syndromal disorders not meeting criteria for diagnosable mental disorders. This diagnostic ambiguity, coupled with relatively good outcomes after brief trials of sub-therapeutic medication doses, is cause to re-consider the significance of the PCP's “failure” to diagnose. Much primary care patient angst resolves spontaneously, either with resolution of an initiating event, expressed caregiver concern, or the placebo effect of a few days of medication. In such cases, the presenting symptoms may be attributable to an adjustment disorder.

Barriers to Treatment

Symptom recognition is necessary but not sufficient to ensure primary care treatment of psychiatric problems. Even when PCPs are informed of standardized screening results, they may not initiate treatment. PCP, patient, and system factors collude to inhibit the discussion necessary to promote treatment (“don't ask/don't tell”). Physician factors (“don't ask”) include the failure to take a social history or to perform a mental status examination (MSE). This may be attributed to deficits in training of medical students and residents, to time and productivity pressures, and to personal defenses (e.g., identification, denial, isolation of affect). Variation in skills and attitudes are broad across primary care. In general, PCPs tend to be more experienced and comfortable addressing physical complaints. Some PCPs fear their patients will leave the practice if asked about BH issues. Others may even question the benefit of treatment. More significantly, the absence of a ready response or approach, or the lack of a psychiatric referral source are major deterrents to screening and identification of a new problem within the context of a 15-minute primary care visit. Denial or avoidance may prevail when the time-pressured PCP feels unsure of how to treat, whether to refer, or whom to ask.

Stigma, prevalent among patients and providers, is a major patient deterrent to bringing up psychiatric symptoms. Often patients “don't tell” because of shame or embarrassment. Patients may not know they have a diagnosable or treatable BH disorder. They may equate psychiatric problems with personal weakness, and assume their PCP shares that view. For these and other reasons, primary care patients frequently present with physical complaints, increasing diagnostic complexity substantially. This is particularly confounding for physicians because medical disorders may simulate psychiatric disorders, psychiatric disorders may lead to physical symptoms, and psychiatric and medical disorders may co-exist.

System factors include the ever-changing healthcare finance and reimbursement climate (e.g., managed care, “carve-outs,” provider risk, capitation, fee-for-service, coding nuances, differential formularies, prior authorization) that promotes financial imperatives to contain cost and to increase efficiency. This systemic instability, confusion, and administrative time-creep easily dwarfs the impulse to pursue the treatment of a possibly self-limited condition. BH carve-outs have complicated the possibility of reimbursing PCP treatment of BH disorders, while pre-paid plans (e.g., HMOs) decrease incentives to offer anything “extra.” The necessity to increase productivity has excessively shortened the “routine visit,” now often less than 15 minutes, while the excessive burden of required documentation further erodes clinically available time. Although the electronic health record (EHR) has standardized and improved screening, documentation, and follow-up, it is also a source of clinical time depletion. The care-promoting advent of new, safer, more tolerable psychotropic medications has been offset by soaring pharmacy costs and by restrictive (and possibly short-sighted ) formularies. The practice of primary care has reached a crisis point: the pressures are so overwhelming that few PCPs want to sustain full-time clinical practice.

The Goals of Collaboration

Although effective, evidence-based treatments exist, access and quality of care remain significant issues that are best addressed through the collaboration of psychiatry and primary care. The four major goals of collaboration are to improve access, treatment, outcomes, and communication.