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During my first year of residency at St. Vincent’s Hospital-Manhattan, I rotated on inpatient medicine as part of my training. I made wonderful connections during those months, which continued into my second year during my consultation-liaison rotation on the inpatient medical floors. We exchanged information to the benefit of patients and everyone’s professional development. However, by my third year of training, I was located in an outpatient psychiatric clinic, a silo that hindered collaboration with both primary care providers and other specialists. The rich collaboration that I had enjoyed with my colleagues was less frequent, often limited to a psychiatry consult in the middle of the night during a call shift. Our ability to communicate effectively was hindered by the traditional clinic models in place in our primary care and specialty clinics.
In contrast to the silos encouraged by traditional clinic models, integrated care seeks to combine the services of mental health providers and primary care providers. There are several different models of integrated care. Some models increase access to primary care providers in behavioral health clinics, while others seek to place mental health services within primary care settings. Providing mental health services within a primary care setting reduces a number of barriers to receiving mental health treatment, most notably the stigma surrounding mental health treatment.
The Collaborative Care Model, which was first championed by Wayne Katon, MD, and colleagues at the University of Washington, is one example of a model that seeks to blend mental health services within primary care settings.
There are many different models of collaborative care, but all share four common elements:
- Team-Driven
- Population-Focused
- Measurement-Guided
- Evidenced-Based
The team is led by the primary care provider, who is supported by a care manager. The care manager meets with patients in person and also speaks with them by phone, making sure they are engaged in treatment. A consulting psychiatrist provides treatment recommendations for those not meeting expected clinical goals. These patient discussions primarily occur indirectly during regular meetings between the care manager and the consulting psychiatrist. Registries are used to monitor patient engagement and treatment response; treatment response is monitored through measurable outcomes. Evidence-based treatments are provided in order to achieve these outcomes, and a proactive, patient-centered team promotes engagement and treatment adherence.
We have two integrated models currently in place within our SBH Ambulatory Care Center. The Brief Care Clinic, a satellite clinic of SBH Behavioral Health, has been followed for several years and provides short-term (six months) treatment to patients with bereavement, anxiety, and depression using a combination of psychotherapy and medication management.
Recognizing the opportunity for additional growth as part of the New York State Delivery System Reform Incentive Payment (DSRIP) Program, the Depression Care Management Program at the Ambulatory Care Center was launched in January 2017 as our first collaborative care model program. The Depression Care Management Program is focused on treating depression with a combination of problem-solving therapy, behavioral activation, and medication management. Problem-solving therapy is an approach intended to help patients more effectively manage their emotions by developing action plans directed at reducing emotional distress and enhancing well-being. Behavioral activation’s aim is to work with depressed patients to increase their engagement in activities and decrease their overall level of avoidance, which can exacerbate depressive symptoms. The team is led by Guido Macchiavello, MD, and Mercedes Ruiz, LMSW, is the depression care manager. I am currently the consulting psychiatrist in both programs, and we look forward to serving the Ambulatory Care Center and SBH community.
Matthew Grover