The Register Report, Spring 2009 Collaborative Care: Comprehensive Healthcare Done Right by: Benjamin F. Miller, Psy.D. and Randall Reitz, Ph.D. Return to Table of Contents

Recent developments in primary healthcare portend exciting opportunity and broad changes in the mental health field. While these movements have their roots outside psychology, our field and practitioners are wise to pay them serious attention, or risk being caught unprepared in a deeply shifted healthcare landscape. This article will provide a primer on collaborative care and its role within the Patient-Centered Medical Home (PCMH). In concert, both these approaches are in their formative stage, and psychologists have an excellent opportunity to influence their role. Psychologists can also lead the practiced-based research that will ultimately inform the model of collaborative care included within the PCMH.

The fact that mental health and primary care are inseparable is well documented (Blount, 1998; deGruy, 1996; Regier et al., 1993). The convergent trajectory of these two areas is an example of how the silo mentality and dualistic approach to health is beginning to change. While there is consensus on the need to overcome the mind-body split, stakeholders are still refining and negotiating a clinical, operational, and financial system to accommodate comprehensive care. What is present in this country is not a system of care, as a system interacts to form a unified whole. Instead, we have fragmented silos. Therefore, we are faced with exploding costs in an attempt to maintain the status quo.

Despite paying more than double for healthcare than other industrialized countries (Anderson, Frogner, Johns, & Reinhardt, 2006), the United States scored only a 69 out of 100 on a National Scorecard on performance in healthcare (Schoen, Davis, How, & Schoenbaum, 2006). While many stakeholders have recommended reform for years (The Institute of Medicine, 2001), these same entrenched healthcare interests seem to have our model in paralysis. Fortunately, the small movements to stimulate medical and mental health services in primary care settings show the best promise of meeting the needs of the American public (Blount, 1998; Blount & Bayona, 1994; Institute of Medicine, 2002).

Collaborative Care

What does a system look like that integrates physical and mental health services in the same setting? Often, this is accomplished when psychologists and other mental health specialists collaborate with primary care physicians. Collaborative teams vary from rudimentary (i.e. developing a preferred referral relationship with a physician group), to complete integration (i.e. requiring an operational, structural, and financial transformation of a clinic). Doherty, McDaniel, and Baird (1996) have offered a five-level continuum describing levels of collaboration that can occur alongside varying degrees of integration. While this continuum does imply a certain hierarchy of values, it is one of the few models proposed which outline the different degrees of integration.

Many psychologists work in settings where collaboration typically falls between level one and level two categories. Psychologists may receive physician referrals through phone, fax, email, or written recommendation. This has often been the approach outpatient mental health services have used. These levels of collaboration have often sufficed in cases that do not involve psychotropic medications, for family therapy, or for specialty care such as court-mandated therapy and inpatient substance abuse treatment. 

Level 1 Minimal Collaboration (Only referrals) Level 2 Collaboration at a distance (Some direct communication) Level 3 Basic on-site Collaboration Level 4 Close Collaboration in a partly integrated system Level 5 Close Collaboration in a fully integrated system

The advantages of levels one and two collaboration are that the treatment strays little from familiar psychologist skill sets and the referral process is often typical. The shortcomings of off-site collaboration include:

• Poor follow through and high no-show rates for external referrals,
• Extra work required by the patient in establishing care with the psychologist,
• Lack of inter-professional familiarity,
• Difficulty scheduling interdisciplinary consults and joint interventions, and
• Disconnect in communication and treatment planning.

Common characteristics of highly integrated clinics (i.e. levels four and five) are on-site full-time mental health staff, combined medical record and billing services, universal screening for depression and substance abuse, enhanced assessment of mental health issues, and focus on treatment approaches that encourage shared patient care.

Psychologists’ graduate school training often prepares for more practical familiarity and facility with basic collaboration. Advance shared patient care requires an advance level of skills that psychologists may or may not have received in graduate school. Success can occur early in an integrated practice by facilitating “warm introductions” between disciplines at the time of a client visit. Other options include “bump in the hall” consults, joint appointments for more complex cases, mental health intakes, on-site psychiatry, group medical appointments, and case conferences.

Collaborative practices that have integrated psychologists excel through their ability to address any health issue, regardless of it being mental or physical (Robinson & Reiter, 2007; Strosahl, 1997; Strosahl & Robinson, 2008). For example, many primary care psychologists partner with physicians to provide population-based care on specific issues such as depression (Katon et al., 1996; Unutzer et al., 2002). This includes universal screening, assertive outreach, and tracking outcomes. Regardless of the type of model recommended, the more important point is that behavioral health is included within primary care vis-à-vis the patient centered medical home (Petterson et al., 2008).

Patient-Centered Medical Home

The medical home has gained more attention recently as policy makers, clinicians, researchers, and most importantly, patients recognize that something has to change within healthcare to create more positive health outcomes. Interestingly, however, the concept of the medical home is not new, as it was first recommended by the American Academy of Pediatrics in 1967 (Sia, Tonniges, Osterhaus, & Taba, 2004). Just as the American Academy of Family Physicians (AAFP) has defined primary care practices as a patient’s first point of entry into the health care system and continual focal point for all needed health care services, so too does the medical home build upon comprehensive care and continuity. It is at the crossroads of all-inclusive care and continuous service that psychology can have the most impact.

The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association have released the Joint Principles of the Patient-Centered Medical Home (AAFP, 2009), which address whole person orientation, coordinated and integrated care, and enhanced access. These principles could be considered appealing to psychologists and conducive to a collaborative care model. The Medical Home concept has received considerable backing from the medical mainstream, Medicaid, Medicare, the Obama administration, recent laws, and popular media. As the movement comes to fruition, primary care will increase its status as the portal to care, the coordinator of care, and the source of specialty referrals. The psychologist with an office in the medical home will be well-situated to affect change.

Support for Collaborative Care

Recent reviews of integrating mental health into primary care outline positive outcomes, but stop short of recommending a particular model or approach for the medical home (Butler et al., 2008). In fact, one area in need of future research is testing specific components of models in an attempt to determine which elements are most necessary for successful outcomes. Further, by deconstructing models and using preliminary metrics to examine what elements of collaborative care more positively affect clinical, operational, and financial outcomes, we will be able to better inform policy makers, administrators, and others if one collaborative care model outweighs another model (Miller, Mendenhall, & Malik, 2009).

One problem that remains is that collaborative care services have grown in regional pockets, and to date there has not been a centralized data set to answer the more complex empirical questions about the effectiveness of collaborative care. If psychology were to take a page from medicine’s book, practice-based research networks would be at the top of the page. continue

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