One Psychiatrist’s Journey to Integrated Care

This month’s column features Lori Raney, M.D., and her journey to integrated care. Lori discovered integrated care in the middle of a busy career as a community psychiatrist and has become a passionate advocate for this new way of making the work of psychiatrists relevant to the rest of the health care system. Based at a rural community mental health center in Colorado, Lori has worked tirelessly to put integrated care on the map of psychiatry. With her creative, pioneering, can-do spirit and her infectious energy, she has challenged those of us in academia to start “translating” our research into changes in real-world practice and has challenged her colleagues to pay attention to such important concepts as population-based practice and treatment to target. —Jürgen Unützer, M.D., M.P.H.

The road to integrated care was an interesting one for me. It started with some stirring in the community mental health center in which I work after several of our staff attended a National Council meeting in 2006 and came back concerned about the National Association of State Mental Health Program Directors’ report about the newly recognized 25-year mortality gap between patients with serious mental illnesses and the general population. Folks were talking about “integrated care” being one solution to this problem. At the time, I was busy seeing patients and involved in my own medical staff initiatives (telepsychiatry, implementing an electronic health record) and did not pay much attention to the conversations.

In 2007, several staff went to the National Council meeting in Las Vegas, and I asked to go too to learn more about this “integrated care” stuff. Since I thought the mortality-gap issue was why I, as a psychiatrist, was there, I went to the talk on cardiovascular risk and other causes of early mortality presented by Ben Druss, Joe Parks, John Newcomer, and others.

When I got home, the other staff who attended the meeting asked where I was and why I did not attend the IMPACT training with them. (IMPACT stands for Improving Mood: Providing Access to Collaborative Treatment, an evidence-based model of care developed under Jürgen Unützer.) I did not really comprehend the relevance of this training at the time and thought the mortality gap was the main issue for which we needed to find solutions. So I went back to my job at the community mental health center and implemented a data-collection strategy to track metabolic measures for our patients on second-generation antipsychotics. We called this our “pink sheet,” and off we went making sure patients had the proper metabolic screening according to the APA/ADA guidelines.

In 2009, our organization partnered with a Federally Qualified Health Center in a remote town on the border of Utah and Colorado that had money for true collaborative care, an integrated care model in which psychiatrists and other mental health specialists support primary care providers. Four hours of psychiatric consultant time was included in the budget, but I didn’t have a clue what I was supposed to do except answer phone calls from primary care providers (PCPs). There were no books, no information I could find in a Google search, nothing on this topic on APA’s website or at the annual meeting that year, and no one I could find to help me figure this out. I talked to psychologists and social workers and learned what I could, but no one seemed to know what I was supposed to do, since the predominant model being promoted at the time was adding a behavioral health provider (BHP) to a primary care clinic. By some stroke of luck, I remembered the IMPACT trial and did a search. On the University of Washington IMPACT website (now the AIMS Center website), I found a job description for a psychiatric consultant and figured out this was probably what I was supposed to be doing. Armed with this information, off I went to the FQHC on the first leg of an adventure that has led me to places I never imagined I would go in my career as a community psychiatrist.

Still wanting information, I travelled to APA’s 2010 annual meeting in New Orleans for the one and only presentation I could find in the program on the topic of integrated care. I remember the last slide of session chair Ruth Shim that said “Where are the psychiatrists?” Integrated care was not on the radar of psychiatrists or APA at that time, although there was a clear need for us to get involved as some form of the model was proliferating across the country with only two legs of the three-legged integrated care stool—a PCP working with a BHP but no psychiatric consultants involved. As I figured out what I was supposed to be doing through a system of trial and error, I became interested in trying to help other psychiatrists figure out how to do this work; I wanted more of us, and our professional organization, to get involved. I began to meet other psychiatrists, and we started to talk and hold “discussion groups” and worked our way up from that one presentation in New Orleans to a robust Integrated Care Track of 20-plus presentations at APA meetings now.

When APA held a press conference in April to announce the findings of the Milliman report (can be accessed here) and advocated for more collaborative care, I had tingles down my spine and a smile on my face. In four years we went from a spark to a full embrace of the collaborative care model as a profession that understands how important it is for psychiatrists to lend their expertise in new ways. ■