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Key points
- The COVID-19 pandemic has created a mental healthcare crisis with the dire need for improved collaborative care.
- Primary care physicians (PCPs) prescribe the bulk of psychiatric medications, but often provide inadequate treatment.
- Collaborative care can provide comprehensive integrative care with significant cost savings and decreased provider burnout.
- Obstacles such as stigma and logistical barriers will need to be overcome in order to provide collaborative care.
COVID-19 has left in its wake a devastating rise in mental illness and an urgent need to meet the growing demands for treatment. Studies show that due to stigma and the shortage of mental health providers in many parts of the U.S., the majority of patients receive treatment from their primary care physician, or PCP (this category includes internists, family physicians or nurse practitioners, OB/GYNs, and pediatricians). Because most of this care is found to be inadequate, effective collaborative care between PCPs and mental health is needed more than ever to address this national crisis.
In the 1990s, one of the founders of the collaborative care model, the University of Washington's William Katon, M.D., demonstrated in multiple studies the effectiveness of his IMPACT model (Improving Mood-Promoting Access to Collaborative Treatment) for a variety of conditions. Corroborated in at least 80 studies, this model integrates behavioral health and general medical services, leading to better outcomes for both.
Examples of other leading collaborative care programs include the Lifestyle and Weight Management Center at Duke University, Kaiser Permanente’s participation in the COMPASS (Care of Mental, Physical and Substance Use Syndrome) program, Montefiore Medical Center/Einstein Medical School’s Pioneer Accountable Care Organization, The Benson-Henry Institute for Mind-Body Medicine at Harvard/Massachusetts General Hospital, and the Mindfulness Center at the University of Massachusetts, started by Jon Kabat-Zinn.
Since the 1980s, these programs and others have consistently demonstrated cost savings associated with decreased length of hospital stays, improved pain management, and decreased unnecessary ER visits for anxiety-related disorders. They've also demonstrated excellent results with diabetes control/weight management and the treatment of depression and many other chronic medical conditions.
The Obama administration recognized these enormous benefits and wove “value-based treatment” programs such as the Accountable Care Organization (ACO) into the Affordable Care Act (ACA). With ACOs, large primary care clinics are offered economic incentives to provide quality integrative care.
What Does Collaborative Care Look Like?
The core elements of the collaborative care model include:
- Providing care using an interdisciplinary team either onsite or co-located nearby with regular team meetings.
- Having a case manager to set up a registry, which tracks high-risk patients using standardized rating instruments such as the PHQ9, GAD7, and AUDIT C.
- Using curbside and formal consultations with psychiatric providers arranged by the case manager.
- Use of new billing practices such as G codes (CMS) and ACOs, to increase funding streams.
Because ACOs have demonstrated both effectiveness and cost savings, the private health insurance industry has already begun to follow suit by setting up its own value-based programs. In addition, Medicare and Medicaid have started reimbursing at higher rates for collaborative care using these “G codes.”
Current Solutions To The Current Mental Health Crisis
What can mental health professionals do to better integrate services within primary care?
- More mental health professionals need to reach out to local PCPs to form linkages that lay the groundwork for collaborative care.
- Offer curbside consults and/or split treatment with evidence-based cognitive behavioral therapy (CBT) when the PCP is providing medication management. This improves the overall quality of care, especially when working to taper off meds.
- Those that have special expertise in treating chronic medical conditions and/or with weight management, smoking cessation, and addiction can offer to set up specialized programs for PCPs.
- Consider offering to work part-time as a consultant onsite within a large medical practice.
- Be an advocate for improved mental health funding at the local and state levels and for the establishment of collaborative care programs.
- Educate and prepare medical students, residents in medicine/psychiatry, and graduate students in social work, nursing, and psychology programs to work in this exciting field.
Obstacles, Future Direction, and Recommendations
There has always been resistance to collaborative care within the medical system due to stigma, the lack of financial incentives due to poor reimbursement for mental health services, and lack of interest and/or time among both mental health and medical providers. While parity laws have addressed some of these issues, there remains a long road ahead.
In my experience, many doctors and hospitals would like to add on these services but encounter logistical barriers, such as the lack of suitable office space and lack of training in setting up new complex billing systems and integrated electronic medical records.
PCPs are doing their best to keep up with the current demands of clinical practice and are especially overwhelmed nowadays trying to manage the COVID-19 pandemic. They need guidance and support from knowledgeable and experienced mental health professionals to help bridge this gap.
Psychiatry, psychology, nursing, and social work departments at major medical centers could get involved in setting up pilot programs for complex and high-risk patients (those with chronic pain, heart failure, anxiety and related medical conditions, depression and diabetes, the frail elderly, those with comorbid substance abuse, severe obesity, COPD and cancer). Good results can be quickly achieved even when only a few core elements of the model are adopted.
Once positive benefits are realized, doctors and administrators are more likely to try and come up with innovative ways to make these programs financially viable. Providers routinely report less burnout and higher satisfaction when delivering care as part of an integrative team. In turn, this naturally leads to better overall patient care.
