Severe Mental Illness in integrated behavioral health (collaborate care)

[nexus73]

Looking at the primary care integration programs at Mayo Clinic and University of Washington, the focus is clearly treating Depression and Anxiety disorders, including Bipolar 2 Depression. These programs basically center around a care manager (MSW or RN) who does face-to-face with the patient with a mix of case management and brief therapy in the PCP office. A psychiatrist consults with the care manager and reviews PCP notes to get patient updates. The patient's PHQ-9 and GAD-7 scores are tracked in a registry so the psychiatrist can see who is improving and who is not. The psychiatrist then makes recommendations for ongoing care (med change recommendations typically) which is passed on to the PCP for implementation. The psychiatrist rarely if ever sees the patient face-to-face. Mayo and UW have a lot of research on this treatment model being both effective for symptom improvement and cost effective. The goal is to get people enrolled in the integrated program, get them treated effectively, then get them to graduate back to PCP alone once symptoms are stable (or refer them off to a psychiatrist if symptoms are not improving in a reasonable amount of time).

I'm curious if anyone has experience with a similar treatment model for following patients in primary care with schizophrenia, schizoaffective, and Bipolar I d/o? Or if you've found any research validating integrated behavioral health as an effective treatment for these conditions. The major concern I'd have is the patients with severe mental illness will rarely graduate back to the PCP alone, but will need long term care and case management, so why not just refer them to a community mental health center to begin with (assuming you have one)? And if you don't have one, is having a psychiatrist review notes and get verbal updates from an MSW going to be above the standard of care compared to no psychiatric input at all?

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[splik]

collaborative care was developed for patients with lower level mental health problems (e.g. depression, anxiety disorders, substance abuse, ADHD). Patients with psychotic disorders, bipolar I disorder, severe depression with suicidality should be referred to a community mental health clinic. Sometimes patients with psychotic disorders are treated in a collaborative care model (e.g. patient with depression who then flips into mania, patient with nebulous symptoms that are the harbinger of a psychotic illness) but the consulting psychiatrist will recommend referral for treatment.

 

[deleted343839]

I'm curious if anyone has experience with a similar treatment model for following patients in primary care with schizophrenia, schizoaffective, and Bipolar I d/o? Or if you've found any research validating integrated behavioral health as an effective treatment for these conditions. The major concern I'd have is the patients with severe mental illness will rarely graduate back to the PCP alone, but will need long term care and case management, so why not just refer them to a community mental health center to begin with (assuming you have one)?

The alternative is the "reverse integration" model. Implementation has not been widespread and it seems as though most programs are still in early/pilot phases. More info here: Psychiatry Online

 

[clausewitz2]

The alternative is the "reverse integration" model. Implementation has not been widespread and it seems as though most programs are still in early/pilot phases. More info here: Psychiatry Online

We tried to operate a full on primary care service embedded in our large SMI clinic but they just could not make a go of it financially, I am told.

 

[nexus73]

collaborative care was developed for patients with lower level mental health problems (e.g. depression, anxiety disorders, substance abuse, ADHD). Patients with psychotic disorders, bipolar I disorder, severe depression with suicidality should be referred to a community mental health clinic. Sometimes patients with psychotic disorders are treated in a collaborative care model (e.g. patient with depression who then flips into mania, patient with nebulous symptoms that are the harbinger of a psychotic illness) but the consulting psychiatrist will recommend referral for treatment.

Thanks for the input. Where would you stand from a medicolegal standpoint in the case where referral is not an option...like being a doctor in the middle of nowhere Wyoming, and getting psychotic patients to a psychiatrist is a pipe dream? Would an on site or telepsych doc, working within a similar integrated frame work be looked at negatively or favorably (as at least providing some access to psychiatric care, even if it's not face-to-face)?

 

[deleted343839]

We tried to operate a full on primary care service embedded in our large SMI clinic but they just could not make a go of it financially, I am told.

That's too bad. The reverse integration model makes a lot of sense, at least clinically.

To echo @splik's comment, PCMH was explicitly designed for the low-intensity kinds of emotional/behavioral problems that would likely be untreated or undertreated in conventional settings. When I worked in this kind of setting most of my patients had never been evaluated previously by a mental health professional, which is typical. But part of any good PCMH implementation is having reliable screening and referral mechanisms for higher acuity patients who need specialty referral (or at least consultation). Even some of the big boosters of this model acknowledge that SMI populations need to be followed in a specialty mental health setting: Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care