APA2014
Practical Ideas for Implementing Collaborative Care
The theory behind integrated care models in mental health is easy to grasp: Those who have depression or anxiety often have other problems, such as high blood pressure or unexplained pain, so having a psychiatrist collaborate with a primary care physician (PCP) makes sense.

If it were that simple, collaborative care would have made its way into more medical practices, according to Wayne J. Katon, MD, a faculty member at the University of Washington and a 30-year devotee to integrating mental healthcare with other medical services.

In the Sunday morning interactive session, “Integrated Care Models: The Development of Collaborative Care,” Dr Katon shared practical advice with attendees at the 167th Annual Meeting of the American Psychiatric Association. Those who took part in the informal exchange at the Jacob K. Javits Center in New York City got past the theory and heard how to make integrated care work financially, how to address liability issues, and how to get it off the ground.

Dr Katon’s explanation for why integrated models make sense was perhaps the most pragmatic of all: Most Americans simply won’t go to a psychiatrist, usually due to financial barriers or reasons of stigma. And yet PCPs are under great pressure to address mental health issues with patients, so finding an alternative to “referring out” makes sense.

Dr Katon’s role as the mental health provider among medical residents treating an at-risk population in Washington State has given him insights into what works and what doesn’t, including the fact that the stigma surrounding mental healthcare can extend to PCPs themselves. But if the doubters can be shown the value of collaborating with a psychiatrist on tough-to-treat patients, they can become the model’s greatest advocates, Dr Katon said.

He offered the example of a PCP who was a former athlete and “would not refer a case to me for 2 years.” Then that doctor had a patient with chronic back pain that did not go away with conventional treatment. Dr Katon met with the woman and discovered she had complete upheaval with her 4 children, including a drug-addicted daughter who had become a prostitute. “This woman had difficulty setting limits—her kids were constantly hitting her up for money,” Dr Katon said. Working on the patient’s depression helped alleviate her pain, and today the referring physician is a promoter of integrated care.

Step therapy. Dr Katon said that while more PCPs are prescribing antidepressants, patients often don’t get better because the doctor doesn’t have the expertise to evaluate how well the drugs are working, or to know when to switch drugs or increase a dose. This is where a collaborative model works wonders, because over time, the PCPs learn the finer points of dealing with common ailments like depression and anxiety; they are able to provide better care on their own, and they are more likely to do screenings because they know they have a mental health provider as a back-up.

Support staff and registry. Allied health professionals must be used to track side effects, outcomes, and adherence. Social workers and specially trained nurses can be trained to do better patient intake interviews. Much of the success of collaborative care appears to depend on scheduling and tracking: decisions are made on which patients merit a consultation, and which need on-site sessions with the psychiatrist. All of this will become more important under healthcare reform, when payment is tied to outcomes, Dr Katon said. Psychiatrists in attendance shared ideas, including names of specific electronic health record platforms that allow the PCPs and the mental health professionals to collaborate while remaining compliant with the Health Insurance Portability and Accountability Act.

Referring back to the PCP. Dr Katon warned the group, “Patients don’t want to leave you. The trouble with that is that it clogs up your schedule,” he said. It’s essential to set limits and expectations up front, such as, “I’ll follow you with your doctor until you’re better.” Patients seeing a psychiatrist in a collaborative practice must be made aware of the need to allow new patients to see the psychiatrist.

Paying for collaborative care. Many of the questions were practical ones about how to bill time for a social worker or a case manager. Dr Katon acknowledged that his arrangement works in part because he teaches the medical residents, and part of his salary is covered by the medical school. He was up front about the fact that figuring out the billing can be difficult, and that in the short run, a practice might feel that it’s spending on staff but the insurance company is the one that sees the benefit. But Dr Katon is optimistic that value-based reimbursement on the horizon, including entities such as accountable care organizations, will start to offer greater rewards to practices that develop collaborative approaches.

“Multicondition patients cost the most money, and it’s where you can have the most impact on cost savings,” Dr Katon said. “A diabetic who is depressed costs the system about $12,000 a year.”
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