APA Training Helps Collaborative Care Go Live at University of Alabama

The collaborative care model has gone “live,” with the help of training provided by APA, at the University of Alabama College of Community Health Sciences (UA-CCHS).

The departments of Family Practice, Psychiatry, and Social Work at the University Medical Center (which is operated by UA-CCHS) have teamed up to provide mental health services to Medicare patients receiving primary care at UA-CCHS using the collaborative care model (CoCM). The latter was developed by Jürgen Unützer, M.D., M.P.H., and others at the AIMS (Achieving Integrated Mental Health Services) Center at the University of Washington.

The program at UA-CCHS marks an important maturation of the movement toward integrated care because it is a large academic medical center with the third-largest family medicine residency training program in the country.

APA has offered training in collaborative care to some 1,800 psychiatrists and primary care physicians, funded by the federal government’s Transforming Clinical Practice Initiative (TCPI), since it was designated as one of just 10 Support and Alignment Networks in the TCPI. The model at UA-CCHS represents the first time the training has been fully applied in a health system using all of the components of the CoCM.

“The work being done at the University of Alabama is a realization of what APA had hoped to accomplish through the Transforming Clinical Practice Initiative grant from CMS,” said APA Director of Education Tristan Gorrindo, M.D. “We’ve supported the building of awareness for collaborative care, trained psychiatrists and primary care physicians, and now we are seeing the fruits of those efforts at the level of patient care.”

Implementation of the model at UA-CCHS was facilitated by the engagement of the Alabama Physician Alliance (managed by Brookwood Baptist Health) as one of 29 Practice Transformation Networks designated under the TCPI to help practices transform to team-based care. As a Practice Transformation Network, the Alabama Physician Alliance helped UA-CCHS make some of the systemic adjustments, including changes to the system’s electronic health records, necessary for tracking patients over time.

According to the Centers for Medicare and Medicaid Services (CMS), the 29 Practice Transformation Networks are peer-based learning networks designed to coach, mentor, and assist clinicians in developing core competencies specific to practice transformation. This approach allows clinician practices to become actively engaged in the transformation and ensures collaboration among a broad community of practices that creates, promotes, and sustains learning and improvement across the health care system.

The program at UA-CCHS was also made feasible because of new Medicare payment codes that went into effect earlier this year for “psychiatric collaborative care management services.” The codes ensure that the consultative services provided by psychiatrists to Medicare patients will be reimbursed by CMS.

Thomas Weida, M.D., chief medical officer and associate dean for clinical affairs at UA-CCHS, said that while the model is initially confined to Medicare patients, he hopes in time that other insurers will see the value of the CoCM. “What would be really great is if Medicaid picked up on this,” he told Psychiatric News. “That’s really where the need is.”

In the meantime, Weida said the implementation of CoCM for the Medicare population receiving primary care at the university will give the three departments time to iron out bugs and perfect the system before expanding it.

“The Collaborative Care Model fits in perfectly with the principles of the patient-centered medical home,” Weida said. “This is a win for our patients, and it’s a win all the way around for the physician care community here. Patients with mental illness are some of the most challenging patients our primary care doctors see.”

Weida said there are approximately 40,000 family medicine outpatient visits a year. One-third, or approximately 13,000, of these are made by Medicare patients. Weida estimated that perhaps 20 percent of these visits involve mental health problems, translating into roughly 2,600 episodes of care.

Thaddeus Ulzen, M.D., chair of the Department of Psychiatry and Behavioral Medicine at UA-CCHS, said the model will extend psychiatric expertise in a timely manner to primary care patients who might otherwise go months before receiving care.

“With this model, patients in primary care with mental illnesses will be seen immediately by one of the trained social work students to help assess patients’ symptoms and develop a case list of patients who can benefit from collaborative care,” Ulzen told Psychiatric News. “This will be followed by a consultation with one of our psychiatrists to develop a treatment plan that can be carried out by the primary care physician. The primary care physician will be central but will work with psychiatry and social work so that patients get treatment as part of their total care management.”

Robert McKinney, L.C.S.W., agreed. He is the director of the Department of Social Services and an assistant professor of psychiatry and behavioral medicine at UA-CCHS.

“We don’t claim that our social work students will be functioning as psychiatrists, but they will work with primary care and psychiatry to coordinate care,” he said. “In theory, I try to keep one of my students embedded in the family medicine clinic at all times. The way we envision this is that when the patient is seen in primary care, the family medicine resident will make a determination if the patient might be an appropriate candidate for collaborative care management, using the PHQ-9 questionnaire.

“The primary care physician will talk to the patient and describe the program,” McKinney continued. “If together they decide it is appropriate, the social work student embedded in the clinic will meet immediately with the patient to do an intake.”

The patient will be added to a registry and, in consultation with psychiatry, will be tracked over time for improvement on symptoms, McKinney said.

Importantly, the Alabama Physician Alliance, as a Practice Transformation Network, has received grant money to fund a “Practice Improvement Specialist” to be embedded in the primary care clinic to help coordinate collaborative care and assist the primary care physicians in ensuring that new patients are considered for the model.

Weida, Ulzen, and McKinney believe that collaborative care can transform the management of mental health problems in primary care. They said they were especially impressed by data from the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) study by the AIMS Center showing that patients with depression treated in a collaborative care model achieved remission within 90 days, compared with as much as two years among patients treated in usual care.

“IMPACT showed that if psychiatry was used in a specific model, patients in primary care with psychiatric needs did much better than those in usual care,” Ulzen said. “The model allows for more patients to be served per psychiatrist, generating good outcomes with improved access and patient satisfaction, since a lot of patients with psychiatric problems prefer to be seen in primary care.”

He added, “This is a model that is sorely needed. It’s something we would recommend to primary care practices anywhere that want to provide better, timely mental health care to their patients.” ■

Information about the TCPI and the training provided by APA can be accessed here. CMS information on TCPI and the Practice Transformation Networks is available here. The IMPACT study is posted here.