Can someone explain integrated care to me?

[chajjohnson]

I've heard the term "integrated care" in relation to psychiatry clinics thrown out a lot both during my psych rotations and my interviews. No one has actually explained to me what it is, so when the topic is brought up I usually just nod politely. Can someone explain in the most basic sense what an integrate care practice looks like? From context clues I have an image of a PCP and Psychiatrist in the same building, and a patient essentially has back-to-back appointments with their PCP and psychiatrist so each knows what they are doing.

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[OldPsychDoc]

I've heard the term "integrated care" in relation to psychiatry clinics thrown out a lot both during my psych rotations and my interviews. No one has actually explained to me what it is, so when the topic is brought up I usually just nod politely. Can someone explain in the most basic sense what an integrate care practice looks like? From context clues I have an image of a PCP and Psychiatrist in the same building, and a patient essentially has back-to-back appointments with their PCP and psychiatrist so each knows what they are doing.

Might be like that...might be a psychiatrist "embedded" in a PCP office doing flash consults when psych patients come in.

 

[birchswing]

This pretty much sums it up:

 

[boogaaloo]

It's basically an instrument with with we psychiatrists devalue ourselves!

 

[hamstergang]

At my hospital, there's a social worker in the PCP office. All patients get a depression and anxiety screen. If positive, the PCP refers to the social worker who can provide a brief psychotherapy. If psychiatric needs are too great for a specific patient, the social worker helps refer the patient to an actual psychiatric office.

There's also a psychiatrist who provides case-load supervision to the social worker. The psychiatrist serves as a curbside consultant to the PCP for any cases involving medication. The psychiatrist can also briefly see patients in that office as a consultation if needed.

There are other models, however.

 

[Candidate2017]

At my hospital, there's a social worker in the PCP office. All patients get a depression and anxiety screen. If positive, the PCP refers to the social worker who can provide a brief psychotherapy. If psychiatric needs are too great for a specific patient, the social worker helps refer the patient to an actual psychiatric office.

There's also a psychiatrist who provides case-load supervision to the social worker. The psychiatrist serves as a curbside consultant to the PCP for any cases involving medication. The psychiatrist can also briefly see patients in that office as a consultation if needed.

There are other models, however.

That's how it works at my hospital too. It's a bad idea. The SWs at the PCP office believe they are practicing psychiatry and the PCPs don't really heed advice from psychiatry. Xanax, Adderall, Norco for everyone. Like you say, curbside consults and brief consultations are par for the course. However we are not practicing to the standard of care if we are giving curbsides or doing brief consults. We are specialists and PCPs need to do a proper referral to psychiatry so we can do our thing. We are not PCP scut monkeys doing 12 minute evals and justifying why it's OK for the PCP to hand out Prozac to everyone who is tearful.

 

[Liquid8]

Sometimes I think these terms are too vague to be of any use to anyone. I’ve heard integrated practice being referred to as the use in incorporating complimentary/alternative medicine into psychiatric practice or putting psychiatrists in other locations to increase access. From a service delivery perspective, integrative care is a system where psychiatrists manage their patients in both an inpatient and outpatient setting.

When I trained, we would have psychiatrists who would look after public inpatients, and another group in the community who would look after public outpatients. If an outpatient became very unwell, or was non-compliant and needed involuntary care, they would need an admission. The patient goes to hospital and gets looked after by the inpatient team. When they get better they get discharged to the outpatient team. At a different service, they used what they termed to be a more “integrative” model, where the outpatient psychiatrist would be responsible for the care of their patients while in an inpatient setting. The rationale for this was that the outpatient team has known the patients for longer, so should be better placed to manage them, as well as other things like reducing errors made in handover and trying to reduce admissions unless absolutely necessary. My service tried to introduce something similar, where one of the outpatient teams who manages mainly chronic patients would manage their own inpatients. It ended up being too much work for that team which only had a part time psychiatrist (0.5-0.6 FTE) and junior doctor (1.0 FTE). In contrast, our inpatient coverage was around 3 psychiatrists (2.0 FTE) and 4 junior doctors (4.0 FTE) for 25 inpatients, less those managed by the community team.

 

[hamstergang]

That's how it works at my hospital too. It's a bad idea. The SWs at the PCP office believe they are practicing psychiatry and the PCPs don't really heed advice from psychiatry. Xanax, Adderall, Norco for everyone. Like you say, curbside consults and brief consultations are par for the course. However we are not practicing to the standard of care if we are giving curbsides or doing brief consults. We are specialists and PCPs need to do a proper referral to psychiatry so we can do our thing. We are not PCP scut monkeys doing 12 minute evals and justifying why it's OK for the PCP to hand out Prozac to everyone who is tearful.

The standard of care for these patients is to be seen by the PCP unguided while waiting months to see a psychiatrist and therapist, if they ever bother to seek care. In this model, the psychiatrist and social worker are providing population based care, not patient based care, and therefore your criticisms are off the mark.

At my hospital, it hasn't turned into PCPs just handed out narcotics. Maybe doctors in your area just aren't that good.

 

[deleted343839]

What is Integrated Care? - Collaborative Family Healthcare Association

As with any delivery model, the devil is in the details. There are good implementations and terrible implementations.

 

[Ceke2002]

I can give 4 separate examples of integrated care in South Australia - three of them positive, one of them negative.

Scenario 1:

Patient presents to GP with stark symptoms of severe depression, possible psychotic features and self injury. GP immediately refers the patient to an Acute Crisis Intervention Service, at which point the patient is assessed in home by a Psychiatric Nurse and Social Worker. Patient is then referred to Psychiatric Registrar, and eventually taken on as a long term therapy patient by one of the Chief Psychiatrists at the CMHC.

Scenario 2:

Patient presents to GP with mild to moderate symptoms of depression. GP discusses medication options with patient, an agreed to medication is started and gradually titrated up to the therapeutic levels. At the same time a referral is made for a set number of Psychology appointments per calendar month to be subsidised through the medicare better mental health access scheme. Both the GP and the Psychologist then work together to ensure the best possible treatment.

Scenario 3:

Patient presents to GP expressing difficulty in weaning off a long term Benzodiazipene dependency (in this case, Xanax), despite an obvious willingness to do so. Patient is referred to a Psychiatrist who specialises in benzo tapering protocols. The Psychiatrist draws up a long term taper plan to be followed and administered by the GP, the Psychiatrist also sees the Patient for a quarterly review during the tapering process.

Scenario 4:

Patient presents to GP who thinks they have more knowledge about mental health than what they actually do. GP becomes frustrated when patient doesn't get better in a set amount of time, and proceeds to start throwing ever increasing doses of medication at said patient, before suddenly dumping the them without warning. This is not how integrated care is supposed to work

 

[chajjohnson]

So I asked people at my home program about this. They basically said when a psych doc is doing integrated care they basically plop themselves down in a primary care clinic work room and wait for all the PCPs to come to them with flash consults or questions about patients they are seeing that day. Sometimes the psychiatrist will go see a patient for a few minutes, sometimes it's just recs on starting meds. They don't see any pure psych patients of their own.

I gotta say none of this really appeals to me, but I can see how it would be useful. Not sure why psych alone has a practice like this though.

 

[SeniorWrangler]

Some institutions have "integrated pain" or "integrated wound care" or other specialties in primary care, too, for commonly occurring issues in primary care. The problem with all of them is that it isn't cost-effective under fee-for-service reimbursement.

 

[NickNaylor]

So I asked people at my home program about this. They basically said when a psych doc is doing integrated care they basically plop themselves down in a primary care clinic work room and wait for all the PCPs to come to them with flash consults or questions about patients they are seeing that day. Sometimes the psychiatrist will go see a patient for a few minutes, sometimes it's just recs on starting meds. They don't see any pure psych patients of their own.

I gotta say none of this really appeals to me, but I can see how it would be useful. Not sure why psych alone has a practice like this though.

Our local VA has a pretty bustling integrated care service (we can actually do an elective with the service), and this is essentially how it operates.

The other key thing - as implemented in this particular setting - is “measurement-based care,” as the expectation is that any patients enrolled in the integrated care registry will demonstrate improvement over time on whatever instrument is being used (e.g., PHQ-9, GAD7, etc.). This is used heavily as it helps the psychiatric folks figure out who needs to be seen or for whom an intervention might be warranted irrespective of whatever the PCP does (or doesn’t) bring up to the psychiatric team.

As to why it may be appealing, it’s essentially C/L minus all of the actual work with the ability to punt difficult cases to a dedicated psychiatrist. In the implementation above, for example, patients with psychotic disorders or bipolar disorder aren’t eligible to be followed by the integrated care team as they require in-depth assessments and follow-ups which aren’t appropriate for a curbside approach; the result is a lot of “straightforward” cases which aren’t particularly difficult.

I personally don’t find it appealing, but I could understand why some people might enjoy it.