Integrated Care: Working at the Interface of Primary and Behavioral Health

How does psychiatry in the United States plan to ensure that each person or family who needs mental health care receives it? How do we address the fact that most psychiatric care in this country occurs in the primary care setting? With health insurance reform, a focus on population health, and an attempt to address the global care of those we serve, integrated care is the direction in which virtually all health systems and insurance plans are heading. Dr. Raney is the medical director of Axis Health System and owner of Collaborative Care Consulting in Dolores, Colorado. She practices in an integrated care setting in a location with very limited psychiatric resources and has become a national champion for educating psychiatrists and others to embrace this model of care. She has compiled a comprehensive text, with distinct chapters written by a variety of leaders in the field. Each chapter can stand on its own and includes a review of the critical importance of the topic, plus very practical “how to” instructions, case vignettes, and extensive references. As the project director for integrated care at a community mental health center (CMHC), I wish I had had a text like this when we started many years ago!

The book is divided into two major sections. The first covers the integration of behavioral health into the primary care setting. The topic of collaborative care for adults is extensively outlined by Jürgen Unützer, M.D., and Anna Ratzliff, M.D., from the University of Washington. This model uses a behavioral health clinician embedded in primary care and a psychiatric consultant to assess a large number of primary care patients. Standardized measures for common mental health conditions and registries are used to follow and improve outcomes for much larger numbers of individuals. They also cover the critical area of workforce training and development, for which they have a robust online and publicly available curriculum through the Advancing Integrated Mental Health Solutions Center Web site (aims.uw.edu). Dr. Raney herself describes the day-to-day work of being part of a team in a typical primary care setting, with particular focus on the role of the psychiatrist.

Barry Sarvet, M.D., from Baystate in Massachusetts and Robert Hilt, M.D., of the Seattle Children’s Hospital provide an excellent review of integration for child and adolescent psychiatry. They review options ranging from the traditional direct consultation for the pediatrician or comanagement, to colocated and integrated services in a specific clinic, to statewide consultation projects connecting child psychiatrists and pediatricians.

Risk management issues are reviewed, with the focus primarily on the collaborating psychiatrist. Discussion is also directed at scope of practice and when physicians may reasonably expand the care they provide with additional education and support. The chapter is neither excessively reassuring nor dire about malpractice pitfalls, but it raises important liability questions that are often sticking points for moving forward with integrated care.

The second section of Integrated Care covers the less formally researched yet clinically very active area of bringing primary care into the mental health setting. Martha Ward, M.D., and Ben Druss, M.D., of Emory University lay out the public health crisis and why this is so critical for persons with serious and persistent mental illness. John Kern, M.D., describes in detail how to set up and sustain integrated care in a large CMHC. Joe Parks, M.D., provides guidance regarding setting up a network of behavioral health homes throughout a large geographic region, including metrics, payment, and outcomes to manage. Finally, Erik Vanderlip, M.D., and Lydia Chwastiak, M.D., from the University of Washington push all of us in psychiatry to integrate nutrition, physical activity, smoking cessation, and screening and basic treatment as components of treating metabolic syndrome.

Despite its comprehensive scope, there is little direct discussion about substance abuse and how organizations that deal primarily with addiction are moving forward. There is also no discussion of racial, ethnic, and linguistic issues that may be significant barriers to care for some people. Payment for services is addressed in some of the chapters, but the issue is so state specific that it is difficult to address in a single volume.

This book will be of huge value to psychiatrists, primary care physicians, and clinical staff of all disciplines; administrators; and state government officials. Most of all, it will benefit those who need our care so desperately and do not have adequate access.