Collaborative Care Leaders Seek to Bring Model to Residency Training

The AADRT program mirrored the APA training, providing an overview of the rationale for collaborative care and the CoCM structure, with special attention to how training directors can adapt the training to teach residents and develop faculty who can pass on CoCM skills.

Ratzliff especially emphasized that training programs do not have to “reinvent the wheel” but can mold what they are already teaching their residents—such as consultation-liaison skills and use of measurement tools, such as PHQ-9—to their application in collaborative care. Central to the role of the psychiatrist in CoCM, for instance, are the “curbside consultation” skills that residents are commonly taught—listening, reflecting on the information provided in a case consult, and making clinical judgments based on that information. “It’s a matter of training directors being able to leverage what is already happening in their programs to prepare their trainees for work in a collaborative care model,” she said.

Huang said he believes exposure to integrated care early in training is crucial. “I think it is important to have a required integrated care rotation so that all residents graduate with skills in population-based mental health care,” he said. “Teaching residents how to use measurement based care, such as using the PHQ-9 for depression management, is a key skill to learn on integrated care rotations, even if a collaborative care experience is not yet in place.”

Some training programs have pioneered the introduction of integrated care into their programs, but overall it would appear that as a regular element of residency education, collaborative care is still in its infancy. A February 2105 paper in Academic Psychiatry reported the results of a survey of training directors at 52 general psychiatry and 36 child and adolescent programs. The researchers found that many offered integrated care experiences, but few offered these rotations as a regular part of training.

A comprehensive report by APA’s Council on Medical Education and Lifelong Learning also was published online in Academic Psychiatry in February 2015. It offered specific recommendations for undergraduate, graduate, and continuing medical education and perspectives on future directions for interprofessional and interspecialty training. The report noted that new Accreditation Council for Graduate Medical Education “milestones” for psychiatry provide benchmarks that residents are expected to meet by the time they graduate and include those that are uniquely suited for accomplishment in integrated care settings. For example, under the domain of “systems-based practice,” the milestones state that “residents should be able to provide integrated care for psychiatric patients through collaboration with other physicians” (Psychiatric News, March 6, 2015).

In a report in press in Psychosomatics, Huang, Marshall Forstein, M.D., and Robert Joseph, M.D., M.S., described the development of an integrated care rotation at the Cambridge Health Alliance (CHA), an accountable care organization located in Massachusetts that comprises three community hospitals and 12 primary clinics. The program had its origin in the late 1980s as a response to the HIV/AIDS epidemic when CHA developed a model in which primary care providers, nurses, social workers, and psychiatrists shared clinical space and worked as a team. CHA was also unique in providing co-located psychiatric consultants at primary care clinics since the 1990s.

In 2013, the program transformed CHA’s outpatient C-L component to a formal “integrated care rotation” to offer PGY-3 psychiatry residents a more longitudinal experience of consulting exclusively in primary care clinics. The rotation consists of six months of weekly half-day sessions. In 2014 behavioral care managers were hired, allowing residents to have a case review experience (using a mental health registry) once weekly. In 2015, an integrated care chief resident position for a PGY-4 resident was created.

“Systematic depression screening using the PHQ-9 is part of the workflow across all primary care clinics at CHA,” Huang, Forstein, and Joseph wrote. “[P]sychiatry residents have the opportunity to use baseline and longitudinal depression scores to help guide the depression treatment of their patients. Residents who have rotated in primary care often tell us that they bring the practice of measurement-based care to their outpatient psychiatric clinics (where the use of instruments is not routinely done).”

Ratzliff urged department chairs and residency program directors to take advantage of resources available through APA’s TCPI grant training and the AIMS Center at the University of Washington.

“We hope educators will see collaborative care as an opportunity and that the AADPRT program is a start to providing training directors creative ways for teaching the psychiatric skills of the future,” she said. ■