MENTAL HEALTH
THE INTEGRATION OF BEHAVIORAL
HEALTH into Medical Care
Mary Helen Davis MD, DLFAPA
P
rimary care physicians may be
thought of as the foot soldiers of
mental health. It has been estimated
that over 40 percent of their patient
population has either a primary or
comorbid behavioral health condition. Fur-
thermore, they prescribe nearly 75 percent of
all psychotropic medications. This behavioral
health “army” has been under-resourced, and
often clinicians have had limited training in dealing with both the
pharmacological and therapeutic needs of this patient population.
In the emergency room setting, one in eight patients is thought to
have a psychiatric disorder, and this number increases significantly
if you add substance use disorders to the mix.
The financial burden of not caring for these patients is staggering,
resulting in poor medical outcomes and escalating costs. Patients
with chronic medical conditions frequently have comorbid depres-
sion and anxiety; 25 percent of patients with diabetes, 35 percent of
patients with heart failure, and 30 percent of patients with cancer,
even more in those with metastatic or advanced disease. Numerous
studies have demonstrated that patients with behavioral health
comorbidity dramatically increase the cost of care. There have
been over 80 controlled studies illustrating improved outcome and
reduced cost with the integration of behavioral health into primary
care settings. Medical specialists frequently become frustrated over
access to care issues when trying to make a psychiatric referral.
One possible solution is to change or modify the behavioral health
care delivery system. If the bulk of behavioral health patients exist
in the primary care arena, then perhaps we should be looking at
bringing the services to the patient rather than referring them out.
Many areas of the county have begun to adopt the Integrated or
Collaborative Care Model.
WHAT IS INTEGRATED CARE?
Integrated or collaborative care is team-based management of
behavioral health patients in the primary care setting. This involves
the co-location of behavioral health and primary medical provid-
ers in the management of chronic medical and behavioral health
conditions in one location. See Figure 1.
A psychiatrist may spend four to eight hours a week in a pri-
mary care practice managing a patient population with the bulk of
their time spent in indirect care. Direct patient care is reserved for
the outliers or nonresponding patients. This is a population health
model in which a care manager is assigned the responsibility of
screening patients using instruments such as the PHQ-9 (Physi-
Figure 1
cians Health Questionnaire: a nine item screen for depression),
following a treatment algorithm for the pharmacological treatment
of depression, recording the results in a patient registry, utilizing
treat to target concepts and being proficient in skills training and
behavioral activation strategies.
The psychiatrist reviews the PHQ9 scores of all patients seen in
the clinic as tracked in the patient registry. Patients are started on
treatment per protocol by the primary care MD. Response scores
are recorded and reviewed by the psychiatrist, and alterations in
treatment plan are made accordingly. Patients are seen by the psy-
chiatrist only if they fail to respond or their condition worsens.
The psychiatrists are generally available to the case managers or
primary care physicians as needed when they are not in the clinic.
Collaborative care principles are population-based care, mea-
surement-based care, “treat to target,” patient centered collaborative
care, evidenced based and accountable. This approach involves a
shared medical record and communication with all members of the
team. CMS has recently released CPT codes for this level of care
and reimbursement for this model has slowly been gaining traction.
Training in this model is available from the American Psychiatric
Association through the Transforming Clinical Practice Initiative.
To date the APA has trained over 2,500 psychiatrists and primary
care physicians in the use of this model. The Kentucky Psychiat-
ric Medical Association invites those interested to join the next
training in Lexington, Ky., on Saturday March 23, 2019. For more
information and registration, go to: www.eventbrite.com/e/collab-
orative-care-model-training-tickets-51668949218.
Dr. Davis is a practicing psychiatrist with Integrated Psychiatry PLLC.
DECEMBER 2018
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