Several years ago, a patient of mine was suffering from intrusive thoughts and associated rituals stemming from a case of obsessive compulsive disorder (OCD). One day, she took a significant risk and shared her distress with her primary care provider, who realized that she needed a behavioral health clinician (BHC). Fortunately, one was "embedded" at the same health care provider where I work—a concept that is gaining in popularity.
Soon, she eliminated 90 percent of her ritualized behaviors and regained control. If she had not spoken up, and her primary care provider was not equipped to input data and integrate with a BHC, the story might have ended differently.
Every day, patients visit a health care provider or hospital in order to discuss one or more physical symptoms, when in reality what they may really need is to talk about their mental health. In a collaborative care model (also called integrated care or health homes), the opportunity for patients to receive comprehensive care for all of their physical and behavioral health needs is greatly enhanced.
Untreated behavioral health issues can have significant downstream repercussions on physical health, and can occasionally cause an alteration to treatment protocols. Whether it is heart disease or cancer or psoriasis, physical ailments are closely connected to mental health conditions such as depression and anxiety.
When psychological problems lead to or exacerbate physical symptoms in a traditional “compartmentalized care” setting, it is more likely that the patient’s overall health (mind and body) will be impacted by disconnected treatment. Cardiologists are not skilled psychiatrists, and vice versa, but by coming together in a collaborative care model, they can each be more confident in knowing that their patient is receiving holistic treatment.
The collaborative care team may include a primary care physician, a mental health specialist (social workers, psychiatric nurse practitioners, counselors, psychologists, and psychiatrists), and other physical medicine specialists who may be treating the patient. All team members agree to hold each other accountable and to work in sharing their knowledge of the patient with the overall goal of using this information to ensure the best possible outcome.
Each team member is expected to set goals with the patient that are aligned with and supportive of those from other team members. This model implies that team members share ideas, outcomes (positive or otherwise) and recommendations with each other in a respectful and supportive manner. Finally, the team evaluates the outcomes using validated measures and makes adjustments to the collaborative plan accordingly.
Research around collaborative and integrated care models began in the 1970s, so this is not a new idea, but adoption has been tepid. Fortunately, with more than 80 trials completed, there is greater acceptance of this approach as a well-supported model of care. In true collaborative fashion, many of these trials involved multiple specialties, including OB-GYN, pediatrics and pain management, and studied patients with a range of complex needs. As recently as 2016, the American Psychiatric Association and the Academy of Psychosomatic Medicine (since renamed the Academy of Consultation-Liaison Psychiatry) issued a report and a public statement recommending collaborative care.
One case study, tracking the impact of collaborative care in a hospital system, demonstrated a 57 percent reduction in depression among primary care patients. Results like these can nudge other health care systems and leaders to adopt technologies and software that facilitate the collaborative care approach.
The Road Ahead
The benefits of patient-centered collaborative care go beyond better physical and mental health. This approach takes into account the patient’s values, beliefs and preferences while encouraging him or her to actively participate in an individualized treatment plan. Additionally, the economic benefits of collaborative care must not be overlooked. Depression costs employers an estimated $44 billion annually in lost productivity.
Across all disciplines, we need to find ways to integrate our knowledge and skills so that everyone can engage in such a dynamic and effective mode of care. Despite the positive results from collaborative care models, there is still work to be done to successfully adopt these practices across our health care landscape. I recently joined NeuroFlow, a health care technology company whose goal is to bridge the gap between mental and physical health in all care settings. But currently, fewer than 3 percent of psychiatrists and psychiatric nurse practitioners work with primary care physicians in designing and implementing treatment plans for their shared patients. Increasing that percentage would allow many more patients to reap the benefits.