Collaborative Care?

[reca]

I'm doing a collaborative care clinic as a PGY-4 and am confused about how it works. This is a new clinic (I'm the first resident doing it) but it seems....off. We have a dedicated social worker in the primary care office who sees patients but then we make medication recs based on her notes and assessment. Is this how collaborative care typically works? Because the net result is that we're basically just rx'ing SSRI's based on positive GAD-7's and PHQ-9's.

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[tr]

NO. Usually collab care embeds psych in primary care setting, either as consultant to primary care docs or seeing patients on site. SW often involved for coordination of care and/or provision of therapy, but certainly not as stand-in for MD.

What benefit are you providing over primary care alone if you don't do a full psych assessment? Primary care is great at throwing random SSRIs at people on the basis of a PHQ score, they don't need you for that.

 

[reca]

NO. Usually collab care embeds psych in primary care setting, either as consultant to primary care docs or seeing patients on site. SW often involved for coordination of care and/or provision of therapy, but certainly not as stand-in for MD.

I would never prescribe a medication for a patient I hadn't seen. What you describe sounds ripe for a complaint to the medical licensing board.

Sorry, I should clarify. We're technically not rx'ing the medications. We message the PCP to rx the SSRI. My point though, is that we're not seeing the patient. We're making the decision to prescribe based on a SW's assessment and then based solely on that assessment, are making med recs to the PCP (which are always carried out).

 

[Stagg737]

Sorry, I should clarify. We're technically not rx'ing the medications. We message the PCP to rx the SSRI. My point though, is that we're not seeing the patient. We're making the decision to prescribe based on a SW's assessment and then based solely on that assessment, are making med recs to the PCP (which are always carried out).

Seems like a great way to take on liability without providing actual care...

 

[reca]

Seems like a great way to take on liability without providing actual care...

Well, that's my point. It's not actual psychiatric care. It's PHQ-9-->SSRI. I'm confused about what collaborative care should look like because I've often heard it touted as a great way to expand the reach of a single psychiatrist.

 

[hamstergang]

We're technically not rx'ing the medications. We message the PCP to rx the SSRI. My point though, is that we're not seeing the patient. We're making the decision to prescribe

The PCP, not you, is making the decision to prescribe or not. You're there to help guide the decision.

 

[FatherPsychiatry]

This sounds like the CoCM = Collaborative Care Model (notice the capitals). It is a very specific model that the APA is pushing, based a lot on the model done at U Washington AIMS center. There are a lot of models that are collaborative in nature (many discussed above), but they aren't CoCM. See below. In this case, it sounds like the Social Worker is in the role of "BH Care Manager", which is common. To some extent, yes you can argue that it's prescribing SSRIs based on PHQ9/GAD7s. But if you're interested, I'd check out some of the research done on it at U Wash. From what I hear, it will be mandatory as part of ACGME for psych training, for better or for worse.

About Collaborative Care - AIMS Center

Collaborative Care is a specific type of integrated care developed at the University of Washington to treat common mental health conditions in medical settings.

aims.uw.edu

 

[Stagg737]

This sounds like the CoCM = Collaborative Care Model (notice the capitals). It is a very specific model that the APA is pushing, based a lot on the model done at U Washington AIMS center. There are a lot of models that are collaborative in nature (many discussed above), but they aren't CoCM. See below. In this case, it sounds like the Social Worker is in the role of "BH Care Manager", which is common. To some extent, yes you can argue that it's prescribing SSRIs based on PHQ9/GAD7s. But if you're interested, I'd check out some of the research done on it at U Wash. From what I hear, it will be mandatory as part of ACGME for psych training, for better or for worse.

About Collaborative Care - AIMS Center

Collaborative Care is a specific type of integrated care developed at the University of Washington to treat common mental health conditions in medical settings.

aims.uw.edu

View attachment 319044

What is the Registry in this model? Just the EMR/charts?

 

[FatherPsychiatry]

What benefit are you providing over primary care alone if you don't do a full psych assessment? Primary care is great at throwing random SSRIs at people on the basis of a PHQ score, they don't need you for that.

What primary care needs you for is guidance that Lexapro can be prescribed past 10mg, or what to do when a patient complains that Zoloft started giving them nausea when it was increased from 50mg to 100mg a day. Rather than have them wait 3 months to see a psychiatrist, having a model set up for consistent and direct consultation is helpful. The CoCM peddlers do have a lot of evidence this model saves $, improves psych outcomes, results more quickly etc. I'm not for or against, just going with what I learned.

 

[FatherPsychiatry]

What is the Registry in this model? Just the EMR/charts?

Depends on whatever the institutions set up. I suppose everything integrated into an EMR somehow is ideal. But from what I've seen and experienced, its typically a separate database (could even be an Excel spreadsheet) the Care Manager maintains, updates regularly (ie, weekly, or whenever the patient has an encounter), and includes basic stuff like PHQ 9, GAD 7 score etc, and what changes were done on last visit and brief plan going forward. The idea is it should be simple and straight forward for the psychiatrist, SW, and PCP to sit together and go over a large list of people quickly, and make recommendations for the PCP to enact.

 

[wolfvgang22]

Depends on whatever the institutions set up. I suppose everything integrated into an EMR somehow is ideal. But from what I've seen and experienced, its typically a separate database (could even be an Excel spreadsheet) the Care Manager maintains, updates regularly (ie, weekly, or whenever the patient has an encounter), and includes basic stuff like PHQ 9, GAD 7 score etc, and what changes were done on last visit and brief plan going forward. The idea is it should be simple and straight forward for the psychiatrist, SW, and PCP to sit together and go over a large list of people quickly, and make recommendations for the PCP to enact.

Sounds potentially like more paperwork and bureaucracy for what are essentially curbside consults.

 

[Attending1985]

I'm doing a collaborative care clinic as a PGY-4 and am confused about how it works. This is a new clinic (I'm the first resident doing it) but it seems....off. We have a dedicated social worker in the primary care office who sees patients but then we make medication recs based on her notes and assessment. Is this how collaborative care typically works? Because the net result is that we're basically just rx'ing SSRI's based on positive GAD-7's and PHQ-9's.

Wow psychiatry is becoming more and more peripheral and disposable

 

[MisterKitty]

Wow psychiatry is becoming more and more peripheral and disposable

First step before we start having Social Work Practicioners

 

[tr]

Sorry, I should clarify. We're technically not rx'ing the medications. We message the PCP to rx the SSRI. My point though, is that we're not seeing the patient. We're making the decision to prescribe based on a SW's assessment and then based solely on that assessment, are making med recs to the PCP (which are always carried out).

Usually SW assessments are very different from mine. They focus a lot on psychosocial details, don't do a psych ROS to look for other possible diagnoses, and are really weak on medical history. I don't think I could do a good job choosing medication based on a SW assessment.

 

[Mass Effect]

NO. Usually collab care embeds psych in primary care setting, either as consultant to primary care docs or seeing patients on site. SW often involved for coordination of care and/or provision of therapy, but certainly not as stand-in for MD.

What benefit are you providing over primary care alone if you don't do a full psych assessment? Primary care is great at throwing random SSRIs at people on the basis of a PHQ score, they don't need you for that.

I did this as a PGY 4 and no, it isn't that you're an embed. That would be integrated care. Collaborative care is different and there is actual evidence behind it. You make recs to PCPs based on chart review, SW input, and in some cases talking to PCP directly. It is like a glorified curbside as another poster said, but glorified curbsides are becoming more common.

I don't believe it indicates that psych is disposable. It's exactly the opposite. Psych is needed, but the wait times and the capacity to treat all who want/need psychiatric care is limited.

In New York, this model is limited to only the very basic psych needs, like uncomplicated depression, uncomplicated anxiety, ADHD, etc. and sometimes, you're not even recommending a med but rather explaining how to assess for these diagnoses. You're not curbsiding on Zyprexa doses or anyone with significant illness. I think it's in line with how the program was envisioned and implemented at U Wash. Collaborative care isn't part of my practice currently but I'm pushing for it in 2021. Don't knock it until you do it or at the very least read the evidence behind it.

 

[Stagg737]

What primary care needs you for is guidance that Lexapro can be prescribed past 10mg, or what to do when a patient complains that Zoloft started giving them nausea when it was increased from 50mg to 100mg a day. Rather than have them wait 3 months to see a psychiatrist, having a model set up for consistent and direct consultation is helpful. The CoCM peddlers do have a lot of evidence this model saves $, improves psych outcomes, results more quickly etc. I'm not for or against, just going with what I learned.

I expect medicine interns to be able to handle stuff like that after a few months and I find it a bit disturbing that PCPs can’t handle the most basic of psych issues. This sounds more like a way to push for more mid levels in primary care to be able to consult psych without without having to place an actual consult

I did this as a PGY 4 and no, it isn't that you're an embed. That would be integrated care. Collaborative care is different and there is actual evidence behind it. You make recs to PCPs based on chart review, SW input, and in some cases talking to PCP directly. It is like a glorified curbside as another poster said, but glorified curbsides are becoming more common.

I don't believe it indicates that psych is disposable. It's exactly the opposite. Psych is needed, but the wait times and the capacity to treat all who want/need psychiatric care is limited.

In New York, this model is limited to only the very basic psych needs, like uncomplicated depression, uncomplicated anxiety, ADHD, etc. and sometimes, you're not even recommending a med but rather explaining how to assess for these diagnoses. You're not curbsiding on Zyprexa doses or anyone with significant illness. I think it's in line with how the program was envisioned and implemented at U Wash. Collaborative care isn't part of my practice currently but I'm pushing for it in 2021. Don't knock it until you do it or at the very least read the evidence behind it.

Again, it may have evidence behind it, but it sounds like a great way to get a consult completed at a fraction of the reimbursement to the psychiatrist.

 

[Attending1985]

First step before we start having Social Work Practicioners

Or computer algorithms

 

[Mass Effect]

I expect medicine interns to be able to handle stuff like that after a few months and I find it a bit disturbing that PCPs can’t handle the most basic of psych issues. This sounds more like a way to push for more mid levels in primary care to be able to consult psych without without having to place an actual consult

Mid levels are already all over primary care. It isn't a way to get them there. They're there. So the midlevel or PCP (you'd be amazed at some of the PCPs out there who immediately send to psych when someone feels down) asks for clarification or recs. I don't think that's out of line. The alternative is psychiatrists are bogged down with all the people feeling down because their dog died or feeling anxious about COVID or having attentional problems because they're working from home while the people with significant illness sit with their psychosis or mania for 2 months.

Psychiatrists need to go back to being treated like specialists and if PCPs need help with the mundane stuff, I don't see the harm in teaching them through this method.

 

[Attending1985]

I did this as a PGY 4 and no, it isn't that you're an embed. That would be integrated care. Collaborative care is different and there is actual evidence behind it. You make recs to PCPs based on chart review, SW input, and in some cases talking to PCP directly. It is like a glorified curbside as another poster said, but glorified curbsides are becoming more common.

I don't believe it indicates that psych is disposable. It's exactly the opposite. Psych is needed, but the wait times and the capacity to treat all who want/need psychiatric care is limited.

In New York, this model is limited to only the very basic psych needs, like uncomplicated depression, uncomplicated anxiety, ADHD, etc. and sometimes, you're not even recommending a med but rather explaining how to assess for these diagnoses. You're not curbsiding on Zyprexa doses or anyone with significant illness. I think it's in line with how the program was envisioned and implemented at U Wash. Collaborative care isn't part of my practice currently but I'm pushing for it in 2021. Don't knock it until you do it or at the very least read the evidence behind it.

Why are people with mild depression and anxiety taking medications

 

[Mass Effect]

Why are people with mild depression and anxiety taking medications

As I said it isn't always about prescribing meds. It's about giving guidance on the eval, teaching behavioral techniques, OR recommending meds in order for the PCP to handle it in their own clinic. Perfect case was in my clinic as a PGY 4 and we got report of a college kid with previously undiagnosed "ADHD." Our feedback was how to do a proper ADHD eval as well as a substance use eval and the behavioral techniques to try first before meds are even considered for inattention. This kept the patient out of the regular psych clinic and in follow up later in the year, he was doing fine and working with the SW on organizational skills and whatnot.

 

[calvnandhobbs68]

Again, it may have evidence behind it, but it sounds like a great way to get a consult completed at a fraction of the reimbursement to the psychiatrist.

Yeah this will be the sticking point for widescale implementation. How are you getting paid for this? Since reimbursement isn't going to you directly by billing, you'd end up having to justify your salary constantly through metrics and having to prove you're saving the system money in a bundled payment scheme. In a FFS scheme, you're actually shooting yourself in the foot here. It also only even matters for larger systems that run their own insurance plans essentially (so for example, hospitals that have their own insurance plans that basically restrict all their employees to that system...just a managed care system essentially) because that's really the only way you align all of the incentives here.

Wouldn't be surprised if most of these "collaborative care" positions end up getting filled with psych NPs on a widespread scale since they'll be cheaper, most of these are going to be within larger hospital systems and part of cost-cutting/psychiatry "extension" measures within these systems. They'll also easily be able to answer these super basic questions noted above.

 

[Sushirolls]

It would be smarter to require FM docs an IM to do a minimum of 4 months Psych in residency. 1 C/L, 1 IP, 2 OP rotations.

Chart reviews still miss a whole lot, in these curbside model "collaborative care."

A model with greater quality would be pseudo C/L clinic. The doc only does consults, each day, ~70% of the day, every day, and stamps the recommendations into chart after a full consult, with instructions for the PCP, then for ~20-30% of clinic time each day, fields follow up phone calls from the PCPs for down stream guidance of treatment hiccups.

If I were a patient in one of these collaborative models I'd be pissed. I wouldn't recommend it for my own family.

 

[Stagg737]

As I said it isn't always about prescribing meds. It's about giving guidance on the eval, teaching behavioral techniques, OR recommending meds in order for the PCP to handle it in their own clinic. Perfect case was in my clinic as a PGY 4 and we got report of a college kid with previously undiagnosed "ADHD." Our feedback was how to do a proper ADHD eval as well as a substance use eval and the behavioral techniques to try first before meds are even considered for inattention. This kept the patient out of the regular psych clinic and in follow up later in the year, he was doing fine and working with the SW on organizational skills and whatnot.

So instead of just doing the ADHD eval yourselves you told the PCP how to do one as well as a substance eval (which they should probably know how to do) and then they did it. How exactly is this more efficient/better? If it’s the “teach a man to fish” argument, then what happens once you’ve taught them all the basics to no longer need you? If they’re going to need frequent refreshers or reminders, then why not just do it yourselves.

I haven’t seen the data, but am legitimately trying to understand how this model would be superior to the integrated care model where you just have a psychiatrist embedded in a PCP clinic.

 

[hamstergang]

How are you getting paid for this? Since reimbursement isn't going to you directly by billing

I actually thought there were collaborative care CPT codes that were getting paid. At my hospital system, the collaborative care model generated positive cash flow. Also, this isn't a full-time job for the psychiatrist (for us at least), and it serves to generate referrals and develop a close relationship with primary care. The patients treated in this model just weren't getting care before for the most part.

So instead of just doing the ADHD eval yourselves you told the PCP how to do one as well as a substance eval (which they should probably know how to do) and then they did it. How exactly is this more efficient/better? If it’s the “teach a man to fish” argument, then what happens once you’ve taught them all the basics to no longer need you? If they’re going to need frequent refreshers or reminders, then why not just do it yourselves.

You can manage more patients in a shorter period of time through collaboration than direct care on your own. Maybe someday this will be so effective that the primary care doctors don't need us, but that isn't seeming to happen yet.

 

[Mass Effect]

It would be smarter to require FM docs an IM to do a minimum of 4 months Psych in residency. 1 C/L, 1 IP, 2 OP rotations.

Chart reviews still miss a whole lot, in these curbside model "collaborative care."

A model with greater quality would be pseudo C/L clinic. The doc only does consults, each day, ~70% of the day, every day, and stamps the recommendations into chart after a full consult, with instructions for the PCP, then for ~20-30% of clinic time each day, fields follow up phone calls from the PCPs for down stream guidance of treatment hiccups.

This already exists. In NY, collab care and outpatient CL are both things and often happen with the same provider.

If I were a patient in one of these collaborative models I'd be pissed. I wouldn't recommend it for my own family.

It's all done with the patient's permission. I don't really understand the above. Curbsides have always been a thing, but somehow doing it with formal documentation and giving it a name other than curbside makes it a bad thing?

 

[Mass Effect]

So instead of just doing the ADHD eval yourselves you told the PCP how to do one as well as a substance eval (which they should probably know how to do) and then they did it. How exactly is this more efficient/better? If it’s the “teach a man to fish” argument, then what happens once you’ve taught them all the basics to no longer need you? If they’re going to need frequent refreshers or reminders, then why not just do it yourselves.

I haven’t seen the data, but am legitimately trying to understand how this model would be superior to the integrated care model where you just have a psychiatrist embedded in a PCP clinic.

Again, this is why it's important to read the evidence. A lot of these places where you're doing collaborative care are more rural areas where there are not enough/any psychiatrists. So you triage the less complex ones for collaborative care and refer the more complex ones for the few psychiatrists there or the few patients needing to travel to see one.

You don't have to agree with the model, but arguing it's bad without actually taking a look at the evidence is pretty short-sighted.

 

[wolfvgang22]

I'm certain I could do this and be effective. I do similar effective curbside consults like this already a few times per week, with chart review and social work support. I do not get to bill for them. Over the years I'm learning a good psychiatrist can make nearly any model work.

I'm concerned it raises malpractice liability for the psychiatrist. It removes the proven curative and protective factor of rapport I have with patients. That should not be underestimated. I agree with others that I often catch medical and psychiatric problems by actually seeing and examining the patient personally.

It will further increase work load and documentation while reducing my job satisfaction. Like any other organizational innovation dreamed up by administrators (physicians or not), it will be stacked on top of my already busy clinic with no increase in compensation. I know it doesn't have to be that way in a "well run organization." I am a bit jaded.

I think if I could do just these types of consults and nothing else a couple days per week and still get paid the same it could be a cherry job. For me, not necessarily patients. To me this reeks of cost cutting with confetti and pom poms. Yay organization!

 

[Candidate2017]

It takes a while to see a dermatologist, and skin cancer outcomes would likely be better if dermatologists collaborated with PCPs. Think about all the psoriasis-induced depression that would also be alleviated too. The APA and ivory towers could probably pump out studies to show billions in savings and better outcomes by having collaborative derm. But as far as I know, there aren't any derm associations clamoring for collaboration with PCPs.

Sure, there are long waits for psychiatry, but where are all these independent psych NPs who allegedly increase access? Telepsych is also expanding too. Collaboration (or integrated care or whatever) is just another way to demean the specialty. In the real world, collaboration ends up as subjugation.

 

[JKinSC]

Or computer algorithms

First they came for the generalists, and I did not speak out - because I wasn’t a generalist....

 

[Armadillos]

Don’t think this is an inherently bad idea, if I remember correctly the VA has had non-face to face chart review only consult options for numerous specialties and at least at my VA seemed to work pretty well.

Personally I would love to have a half day or two a week of just reviewing charts and making recs, as direct care does get emotionally draining at times.

I could obviously see liability being a concern but presumably if seems to have potential of becoming a more popular model either state medical boards/malpractice laws or insurers will find ways to make it reasonable for the psychiatrists (or else nobody will do it).

 

[tr]

I did this as a PGY 4 and no, it isn't that you're an embed. That would be integrated care. Collaborative care is different and there is actual evidence behind it. You make recs to PCPs based on chart review, SW input, and in some cases talking to PCP directly. It is like a glorified curbside as another poster said, but glorified curbsides are becoming more common.

I don't believe it indicates that psych is disposable. It's exactly the opposite. Psych is needed, but the wait times and the capacity to treat all who want/need psychiatric care is limited.

In New York, this model is limited to only the very basic psych needs, like uncomplicated depression, uncomplicated anxiety, ADHD, etc. and sometimes, you're not even recommending a med but rather explaining how to assess for these diagnoses. You're not curbsiding on Zyprexa doses or anyone with significant illness. I think it's in line with how the program was envisioned and implemented at U Wash. Collaborative care isn't part of my practice currently but I'm pushing for it in 2021. Don't knock it until you do it or at the very least read the evidence behind it.

Interesting, I didn't realize UW had co-opted this terminology for this specific thing. We had things called 'Collaborative Care' in both my previous institution and my current one. Prior institution had an embedded psychiatrist. Current institution has an embedded social worker who provides behavioral and psychotherapeutic support and refers to a dedicated psychiatrist when necessary. Both models involve the psychiatrist doing direct patient care as usual, though also available for curbsiding as needed.

 

[Stagg737]

It's all done with the patient's permission. I don't really understand the above. Curbsides have always been a thing, but somehow doing it with formal documentation and giving it a name other than curbside makes it a bad thing?

I think they were inferring that they'd be pissed the psychiatrist was only peripherally involved instead of doing an actual evaluation. Imo curbsides are for very specific and relatively simple questions (would you pick drug A or drug B for this patient?), not educating other clinicians or essentially making full care plans.

Again, this is why it's important to read the evidence. A lot of these places where you're doing collaborative care are more rural areas where there are not enough/any psychiatrists. So you triage the less complex ones for collaborative care and refer the more complex ones for the few psychiatrists there or the few patients needing to travel to see one.

You don't have to agree with the model, but arguing it's bad without actually taking a look at the evidence is pretty short-sighted.

I'm not arguing it's bad, I'm saying there are some very obvious and very concerning problems with this model and direction it could send the field. Telehealth is extremely prominent thanks to COVID, so the argument of not having people in rural areas is becoming less of a valid excuse. I'm also saying that I really don't understand why those triaged as less complex even need to be seen by psychiatry at all if there is a FM/IM doc in the clinic, as they should know the basics of psychiatry. This is med school level knowledge, if PCPs legitimately can't handle relatively basic cases or problems, then I question if those individuals should be seeing patients at all. If the argument is that this can help expand access by aiding the primary clinicians who aren't physicians/don't have that training to handle the cases, I understand that point more. But then I question the ethics of whether we're providing sub-standard care for their primary health problems.

If you've got links to solid data I'd be interested in reading them, as I'm curious how some of the more obvious problems are addressed within these models.

 

[Mass Effect]

IMPACT: Improving Mood — Promoting Access to Collaborative Treatment - AIMS Center

In the largest treatment trial for depression to date, a team of researchers led by Dr. Jürgen Unützer followed 1,801 depressed, older adults from 18 diverse primary care clinics across the United States for two years.

aims.uw.edu

Evidence Base for Collaborative Care (CoCM) - AIMS Center

A substantial body of evidence for Collaborative Care has emerged since its development at the University of Washington in the 1990s. Beginning with the seminal IMPACT Trial published in 2002, more than 90 randomized controlled trials and several meta-analyses have shown the Collaborative Care...

aims.uw.edu

 

[nexus73]

One problem is it cherry picks the lower acuity patients, potentially leaving psychiatry seeing only the sickest patients. Maybe that's the way it should be, with psychiatrist's time being spent where it's most needed. But reimbursement models don't make this attractive to the psychiatrist as you'll get paid less per minute spent the longer you're with a patient. And you get no pay acting as a case manager for patients with severe social problems, even when this is sometimes the more important part of their treatment. You'll almost certainly be more stressed and make less money seeing extremely complex patients all day.

The other glaring problem is it does nothing for patients with severe diagnoses, schizophrenia/affective, bipolar, severe borderline, autism/ID with severe behavioral disturbance, etc. Our health care organization/corporation has been building up integrated behavioral health the last 3 years. It took about 18 months for admin to realize you aren't going to address severe persistent mental illness with this program. So integrated psych programs are not a panacea to solve limited psych access. You still need community mental health services, which are unavailable in many rural areas.

PCPs get frustrated because they want somewhere to send the patients with severe illness, and integrated care does not solve it. It's a weird situation where the psychiatrist is staffing all the depressed and anxious patients in a primary care office, and the PCP is sort of left hanging with the patients with schizophrenia who can't access community mental health.

 

[Mass Effect]

And you get no pay acting as a case manager for patients with severe social problems, even when this is sometimes the more important part of their treatment

What do you mean by this? What kind of case management work are you doing? I'm not doing any currently.

The other glaring problem is it does nothing for patients with severe diagnoses, schizophrenia/affective, bipolar, severe borderline, autism/ID with severe behavioral disturbance, etc

Of course not. Those patients need to be seen by psychiatry. I don't see that as a problem, but a good thing that it doesn't include the above as that's what psychiatrists are for - to evaluate, diagnose and treat the very things you mentioned.

Our health care organization/corporation has been building up integrated behavioral health the last 3 years. It took about 18 months for admin to realize you aren't going to address severe persistent mental illness with this program. So integrated psych programs are not a panacea to solve limited psych access. You still need community mental health services, which are unavailable in many rural areas.

Integrated care is a different model than collaborative care. They're two different things with two different goals.

PCPs get frustrated because they want somewhere to send the patients with severe illness, and integrated care does not solve it. It's a weird situation where the psychiatrist is staffing all the depressed and anxious patients in a primary care office, and the PCP is sort of left hanging with the patients with schizophrenia who can't access community mental health.

There are multiple reasons that they can't access community mental health (or mental health services in general) and one of those reasons is that psychiatrists around the country are inundated with patients who could be treated in primary care. Get PCPs to treat the ADHD patients, the uncomplicated anxiety patients, the uncomplicated depression patients and make room for those with bipolar disorder, schizophrenia, ASD, and others with serious mental illness. This is how it works in every other specialty -- those with uncomplicated HLD or HTN are being treated by PCP, not cards; those with uncomplicated migraines are in the PCP office getting a triptan, not with neurology. For some reason these very basic things that PCPs should be able to handle are often sent to psych and while I agree that it provides nice, easy cases that act as a break in the day, it's still an important reason that those with the conditions you noted don't always get care.

 

[tr]

IMPACT: Improving Mood — Promoting Access to Collaborative Treatment - AIMS Center

In the largest treatment trial for depression to date, a team of researchers led by Dr. Jürgen Unützer followed 1,801 depressed, older adults from 18 diverse primary care clinics across the United States for two years.

aims.uw.edu

Evidence Base for Collaborative Care (CoCM) - AIMS Center

A substantial body of evidence for Collaborative Care has emerged since its development at the University of Washington in the 1990s. Beginning with the seminal IMPACT Trial published in 2002, more than 90 randomized controlled trials and several meta-analyses have shown the Collaborative Care...

aims.uw.edu

The listed resources suggest that there are a number of different care models that are being called 'collaborative care,' and that differ in their specific implementation of the general concept of bringing psychiatric and care-management elements into the primary care setting.
Doubtless some are more effective than others.
The description provided by the OP doesn't sound like one of the better approaches.

 

[Mass Effect]

The listed resources suggest that there are a number of different care models that are being called 'collaborative care,' and that differ in their specific implementation of the general concept of bringing psychiatric and care-management elements into the primary care setting.

Where are you getting that?

 

[tr]

Where are you getting that?

From reading the abstracts in the 'Evidence Base for Collaborative Care' compilation that you linked.

Also from the 'five core principles' page, which describes broad principles that could be reasonably implemented in many ways that might vary considerably in their details. Of relevance, none of the core principles say that the participating psychiatrists should not evaluate the patients directly, as described by the OP. All of the described principles are perfectly compatible with a model in which the psychiatrist has direct patient contact, which would be vastly preferable IMO.

Principles of Collaborative Care - AIMS Center

Five core principles define the Collaborative Care Model and must be a part of every implementation, as they are necessary to practice the model effectively.

aims.uw.edu

 

[nexus73]

What do you mean by this? What kind of case management work are you doing? I'm not doing any currently.



Of course not. Those patients need to be seen by psychiatry. I don't see that as a problem, but a good thing that it doesn't include the above as that's what psychiatrists are for - to evaluate, diagnose and treat the very things you mentioned.



Integrated care is a different model than collaborative care. They're two different things with two different goals.



There are multiple reasons that they can't access community mental health (or mental health services in general) and one of those reasons is that psychiatrists around the country are inundated with patients who could be treated in primary care. Get PCPs to treat the ADHD patients, the uncomplicated anxiety patients, the uncomplicated depression patients and make room for those with bipolar disorder, schizophrenia, ASD, and others with serious mental illness. This is how it works in every other specialty -- those with uncomplicated HLD or HTN are being treated by PCP, not cards; those with uncomplicated migraines are in the PCP office getting a triptan, not with neurology. For some reason these very basic things that PCPs should be able to handle are often sent to psych and while I agree that it provides nice, easy cases that act as a break in the day, it's still an important reason that those with the conditions you noted don't always get care.

There's a lot here. But integrated care and collaborative care have been used interchangeably from my experience, with many varied approaches under the larger umbrella. I'm a believer in integrated/collaborate care, whether it means a psychiatrist staffing with a care manager once a week, or a psychiatrist inserted into the clinic doing warm handoffs, being a general mental health resource, seeing patients for brief time limited interventions, and being in the primary care office full time.