Integrated Care: What Does It Mean for You?

"Integrated care" is everywhere—in theory, at least, and increasingly in practice. The concept is a feature of the delivery-system improvements in the new health care reform law, and policymakers and many clinicians have converged on the idea that general medical and behavioral health services should be brought together in a patient-centered manner. Today, a small but dedicated and growing cadre of psychiatrists is advancing the cause of integrated care and the participation of psychiatrists in collaborative-care models.

APA has established a number of initiatives in this area, headed up by the Work Group on Integrated Care of the Council on Healthcare Systems and Financing, chaired by Lori Raney, M.D., medical director of Axis Health System in Durango, Colo.; and the Board of Trustees Health Care Reform Strategic Action Work Group, chaired by Howard Goldman, M.D., director of the Network on Mental Health Policy Research (funded by the MacArthur Foundation) and editor of the APA journal Psychiatric Services. Work group members include Jürgen Unützer, M.D., who is director of the Center for Advancing Integrated Mental Health Solutions (AIMS) at the University of Washington and one of the pioneers of integration. Along with Wayne Katon, M.D., Unützer began developing models in the 1990s for integrating mental health and primary care and testing them in diverse primary care clinics around the country. Previously working on these issues was the APA Board of Trustees Work Group on Psychiatry and Healthcare Reform, chaired by Paul Summergrad, M.D., APA president-elect and chair of psychiatry at Tufts University.

Practicing in an integrated care system is a new opportunity for psychiatrists—another option on the menu of ways they can use their license to care for people—but it is not a requirement, and it may not be for everyone. Moreover, psychiatrists can work part time in an integrated care setting, while still maintaining whatever kind of traditional inpatient or outpatient practice they currently have (see question 6). There are degrees of integrated care ranging from the original model of consultation-liaison psychiatry practiced in the hospital setting; to co-located care, in which primary care and mental health services are offered in the same location; to a model—developed by Unützer and colleagues—that involves a psychiatrist working in consultation with primary care and other specialists to manage the behavioral health of a defined population of patients. The latter is sometimes referred to as “collaborative care,” and the two terms—integrated care and collaborative care—are often used interchangeably. However, for the purposes of this newsletter, the term “integrated care” will be used.

If you have a question about integrated care that you would like answered in a future newsletter, please send it to Cathy Brown, executive editor of Psychiatric News, at [email protected].

>>Collaborative Care Well Suited to New Medicaid Health Home OptionImplementation of collaborative care for the 20 percent of Medicaid beneficiaries with depression could save the program approximately $15 billion a year.

>>Pioneer in Team-Based Care Explains How Psychiatrists Can Get InvolvedFor psychiatrists who can remember having considered going into primary care medicine, newly evolving models of integrated and collaborative care can be a way to scratch that itch. Wayne Katon, M.D.’s, career illustrates an evolution from consultative to integrated to truly “collaborative care” and that psychiatrists may find multiple ways to participate.

>>Psychiatrist Involved in Collaborative Care Before Concept ExistedCollaborative care can be “a part of what you do, or it can be all of what you do,” says Lori Raney, M.D., chair of APA’s Work Group on Integrated Care. “For most of us, it is part of what we do.” Many years ago, while working on a Navajo Indian reservation in Kayenta, Ariz., as a staff psychiatrist for the Indian Health Service (IHS), Raney discovered a knack for working as a team member with primary care physicians.

>>HIV/AIDS Care Ahead of Curve in Integrating TreatmentThe urgency of the HIV epidemic as a public-health threat helped to spur the integration of services in HIV/AIDS care in a way that has served as a prototype for the new model of care.

>>Who Better to Deliver Collaborative Care?Using telemedicine technologies, off-site mental health specialists collaborating with on-site primary care physicians yielded better depression outcomes than practice-based care with staff available on-site.

>>Collaborative Chronic Care Models for Mental Health Conditions Across Health Care SettingsAnalyses from 57 trials showed that chronic care models, relative to comparison models, provide a robust clinical and policy framework for care integration across populations, settings, and outcome domains, achieving effects at little or no net increase in treatment costs.

>>Suicidal Behavior and Severe Neuropsychiatric Disorders Following Glucocorticoid Therapy in Primary CarePatients treated with glucocorticoids have a higher risk of suicidal behavior and developing depression, mania, or delirium/confusion/disorientation compared with those with the same underlying illness unexposed to glucocorticoids, warranting early monitoring by primary care physicians for neuropsychiatric adverse events among those taking these drugs.