Collaborative Care: Comprehensive Healthcare Done Right
by Benjamin F. Miller, Psy.D. and Randall Reitz, Ph.D.

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.

Why Practice-Based Research Networks?

According to the Agency for Healthcare Research and Quality (AHRQ), Practice-Based Research Networks (PBRN) are based in primary care, and involve community-based clinicians and staff in specific activities designed to understand and improve primary care. The AHRQ webpage states: “The best of PBRN efforts link relevant clinical questions with rigorous research methods in community settings to produce scientific information that is externally valid, and, in theory, assimilated more easily into everyday practice.”

AHRQ defines PBRNs as “a group of ambulatory practices devoted principally to the primary care of patients, and affiliated in their mission to investigate questions related to commitment to network activities and an organizational structure that transcends a single research project. PBRNs often link practicing clinicians with investigators experienced in clinical and health services research, while at the same time enhancing the research skills of the network members” (http://www.ahrq.gov/research/pbrn/pbrnfact.htm). See Green and Hickner (2006) for a history of PBRNs.

Building off the idea that a national network is stronger than individual practices in examining research questions, the Collaborative Care Research Network (CCRN), a sub-network of the American Academy of Family Physicians National Research Network, was created to implement a national, practice based research agenda to evaluate the effectiveness of collaboration between psychology, substance abuse interventions, and primary medical care. The CCRN is actively recruiting providers and practices to join its network (www.aafp.org/nrn/ccrn) in order to best answer questions about collaborative care that have yet to be answered.

RISKS AND REWARDS FOR PSYCHOLOGISTS Risks: 1. The physician is in charge in the Medical Home. Depending on the relationship, the psychologist can feel like a valued partner or an under-valued staffer. 2. Collaborative care skill sets vary greatly from traditional psychology, and include screening, outreach, and case management. A doctoral psychologist is not always the most economical option for a small integrated practice. 3. How to reimburse key collaborative activities, such as live introductions, consults, same day visits, and joint appointments has not been solved. Rewards: 1. Primary care practice overcomes psychologist isolation by providing a team approach to care. 2. Psychologists benefit by referrals for a broader array of behavioral services not commonly treated in private practice. 3. When asked, psychologists, physicians, and patients all prefer enhanced collaboration (Gallo et al., 2004).

What Can a Psychologist Do To Engage These Movements?

Attend Training: In many ways, collaborative care requires a different skill set and mentality from traditional psychology practice. One excellent opportunity for training is the Primary Care Behavioral Health Certificate Program offered by the University of Massachusetts Medical School (Blount & Miller, 2009). The certificate program consists of six monthly training sessions that are offered onsite or live via web-conference. The Collaborative Family Healthcare Association (CFHA) is a professional organization that champions collaborative care. They offer an annual conference (October 22-24, 2009 in San Diego, CA) that provides dozens of workshops to orient the beginner and enhance the practice of the seasoned collaborator (www.cfha.net).

Know How to Market Your Skills: At its heart, collaboration is a social interaction. When given an audience with possible physician collaborators, make the most of your face-time to explain how a psychologist can be helpful for numerous behavioral interventions, including advanced diagnostics, brief therapy, lifestyle interventions for chronic medical problems, and addictions treatment; and be able to do this in as little time as possible. Test things out with level one collaboration and if mutually agreeable, move toward closer integration or a partnership.
Make Your Voice Heard: Collaborative care and the medical home are actively being discussed at places like primary care associations and physician groups. These local, state, and national groups are often eager to talk with psychologists. State psychological associations need informed, determined psychologists who understand primary care to lead the way in medical home initiatives and engage other stakeholders in conversations on healthcare.

Through ongoing clinical practice and research, macrosystemic change can occur. Once metrics of collaborative care are empirically validated, specific recommendations on how mental health should be integrated into the medical home will be clearer. For now, it is psychology’s responsibility to advocate for inclusion within a system that has excluded them by separating the mind and the body. Fortunately, collaborative care and medical home movements have opened the primary care door for many psychologists.

Authors

Benjamin Miller, PsyD is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine. Miller is a Board member for the Collaborative Family Healthcare Association and the Administrative Director and co-creator of the Collaborative Care Research Network (CCRN), a national network examining the research to support collaborative care.

Randall Reitz, PhD is the Director of Behavioral Sciences at St. Mary's Family Medicine Residency in Grand Junction, CO. His clinical work and research has focused on group medical treatment in safety net family medicine clinics. He has organized and facilitated treatment groups on diabetes, chronic pain, obesity, depression, anxiety, OCD, lifestyle change, and health promotion.

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