Psychiatrists Add Value to Integrated-Care Models

Including psychiatrists in integrated care teams can make for dollars and cents—but psychiatrists who join those teams may be in for some change.

Psychiatrists can improve outcomes and lower total costs of care for large populations of primary care patients by consulting with general medical physicians about the best way to treat individuals with chronic and complex medical conditions that are likely to be accompanied by mental disorders. But it’s a practice style that will be a departure from traditional psychiatric office practice and from typical consultation-liaison psychiatry.

In an interview with Psychiatric News, Roger Kathol, M.D., said there is certainly a “business case” for including psychiatrists in integrated care teams, but emphasized that the way they will add value to the emerging model of integrated care is by adopting a form of psychiatric practice different from what most clinicians are used to.

“We have an opportunity to build a business case for inclusion of psychiatrists in integrated care, but in order to do that, we have to show how psychiatrists can bring value to the treatment of patients in primary care settings who have chronic medical conditions and comorbid mental health conditions, because these are the patients who are costing the health care system money,” Kathol told Psychiatric News.

“Those with chronic medical conditions—diabetes or congestive heart failure—will often have twice the total cost of care as patients who do not have chronic medical conditions, and those who also have comorbid mental health conditions may have four times the total costs of care,” he said.

Psychiatrists can help to diminish those costs by inserting themselves in integrated primary care “medical homes” and working in a consultative fashion with other medical professionals as well as other mental health clinicians to help lower the overall treatment costs of these patients with complex and costly medical conditions.

As an example, psychiatrists can be valuable in treating depression that is secondary to congestive heart failure or diabetes, thereby improving compliance with the primary treatment, reducing rehospitalization, and lowering overall costs while improving outcome. In another example, psychiatrists can help improve outpatient management of delirium among elderly patients with urinary tract infections, thereby preventing unnecessary hospitalization.

Kathol is one of a cadre of psychiatrists advancing the cause of integrated care and the participation of psychiatrists in collaborative-care models. He is president of Cartesian Solutions Inc., which works with hospitals, health plans, case-management agencies, and healthcare purchasers to address the needs of high-cost patients with complex medical conditions.

The concept of integrated care is a feature of the delivery-system reforms in the health care reform law, and policymakers and many clinicians have converged on the idea that the full range of medical services should be brought together in one patient-centered location.

APA has established the Work Group on Integrated Care, chaired by Lori Raney, M.D., medical director of the Axis Healthcare System in Durango, Colo., and integrated care was the theme of APA President John Oldham, M.D.’s presidential year; many symposia, lectures, and workshops on the topic were included in APA’s annual meeting earlier this month in Philadelphia. (Coverage of the meeting will appear in a future issue.)

Psychiatric leaders in the integrated-care movement have consistently emphasized that the role of a psychiatrist in a patient-centered medical home is likely to be quite different from that in traditional psychiatric practice. “We need to leverage the limited psychiatric resources in this country to cover the mental health needs of the larger population,” Raney has said (Psychiatric News, October 21, 2011). “Collaborative care has an evidence base that can help us accomplish this, but it is a significant departure from traditional psychiatric care, which focuses primarily on face-to-face evaluations. Moving from traditional office-based practice to consultant specialist who can be effective on a population level will require psychiatrists to develop a new skill set.”

Kathol underscored the point. “The prerequisite for success in integrated care teams is whether the psychiatrist can deliver services that change outcome and lower costs,” he said. “That means engaging them in such a way that they can improve care for those patients with chronic or multiple medical conditions that are out of control.

“That doesn’t mean just walking in and saying, ‘Use me.’ Rather, psychiatrists need to triage general medical patients so that they are seeing the ones to whose care they can bring the greatest value.

“Psychiatrists are the only mental health professionals with the breadth and depth of diagnostic and therapeutic skills to address the needs of complex, high-cost, and treatment-resistant patients, but they must choose to work with high-end sick patients usually with chronic concurrent medical conditions,” Kathol said. “Further, they must create a treatment environment that allows them to target patients with the greatest need, escalate treatment when improvement is not occurring, and measure total health outcomes to document success.”