Forging a Bond: Collaborative Care in the Outpatient Setting

John Onate, MD

Assistant Clinical Professor of Health Sciences, Department of Psychiatry and Behavioral Sciences, University of California Davis Medical Center

Introduction

Mental illness is commonly diagnosed in the primary care setting, and treatment responsibility is increasingly being given to primary care physicians (PCPs). However, there are situations in which psychiatric consultation is needed. An integrated approach to psychiatric consultation in a primary care clinic, and combined resident training in internal and family medicine with psychiatry, are innovative means of addressing mental illness in primary care.

Epidemiology and Indications for Collaboration

The rates of mental illness are very high in primary care clinics. In the Veterans Health Study, 40% of patients had met criteria for depression, posttraumatic stress disorder, or alcohol-related disorder. Data from the National Comorbidity Survey Replication (NCS-R) demonstrated that between 2001 and 2003, 30% (P=.52) of respondents met criteria for a DSM-IV disorder, and showed a stable prevalence from the initial NCS 10 years earlier. Kessler and colleagues found that the majority of patients with serious mental illness in this study did not receive treatment. However, in those who received treatment, general medical services had an increased responsibility for the treatment of these patients compared to psychiatric services. In an analysis of NCS and NCS-R data, 29.2% of patients seeking outpatient care for mental illness went to general medical clinics (Figure).

Open communication and ongoing coordination of care between the PCP and psychiatrist is important in managing and improving function in patients with mental illness.

Redefining Consultation and Alternatives

In primary clinics that have patient populations with high prevalence of mental illness, an integrated approach to psychiatric consultation may be an innovative option.

Collaborative Care

Collaborative care is coordinated mental health interventions in the primary care setting in which providers and members of the healthcare team are trained and supervised to monitor a patient’s response to treatment. Working closely with mental health specialists and psychiatrists, adjustments in treatment are made by the primary care team to provide the appropriate intervention along with formal psychiatric consultation.

Dually-Trained Clinicians

The American Board of Psychiatry and Neurology, the American Board of Internal Medicine, and the American Board of Family Medicine have approved combined residencies that provide training for a physician to combine the knowledge and skills of each discipline in order to provide comprehensive care to both medical and psychiatric patients. A complete listing of programs can be located at http://www.aamc.org/audienceeras.htm.

Communication and Coordination of Care Between Primary Care Physicians and Psychiatrists

Tanielian and colleagues examined the mode of communication between PCPs and psychiatrists by surveying 413 psychiatrists. They found that 35.8% of new psychiatric patients were referred directly by non-psychiatric physicians. Of those, 82% were PCPs. Once consultation was initiated, most psychiatrists sent diagnostic and treatment information back to the PCP via a letter. However, a study by Yaffe and colleagues also found that the majority of psychiatrists did not receive information from the PCP about the patient. Additional problems with communication come up when expectations of care between psychiatrist and PCP differ. A majority of psychiatrist felt their role was assessment only, while the PCPs expected long-term care.

Suggested Guidelines

The following are suggested guidelines for psychiatric consultation in the outpatient setting that may reduce errors in communication and improve coordination of care between physicians.

First, the PCP should be aware of what mental health resources are available, based on the level of access to care. Additionally, having contact information and networking with case management, social workers, county or state mental health centers, and not-for-profit counseling and mental health support organizations will provide more options and support for patients.

Second, the PCP should explain and educate the patient on the indication and reasoning for consultation. The PCP should take time to assess the patient’s understanding of mental illness and mental health professionals. The patient should be assured that there will be communication between PCP and psychiatrist. The patient’s approval for communication should be documented.

Third, the PCP should communicate in writing to the psychiatrist the reasons for referral, urgency of referral, medical history, treatment history, medication allergies, current medications, and changes in medications, along with pertinent imaging and laboratory studies. The patient should sign a release of information between the two parties.

Fourth, the PCP should clarify problems to be addressed in consultation as well as expectations of continued care.

Fifth, the psychiatrist should respond in writing to the consult question. The psychiatrist should provide a clear and concise explanation of the evaluation results, provide treatment recommendations, and note whether continued psychiatric care is needed.

Last, if there is to be ongoing management of chronic medical and mental illness, then periodically conferencing between PCP and psychiatrist about the management will greatly improve coordination of care and prevent errors in miscommunication.

Improving a patient’s understanding of mental illness and coordination of care is stymied when there is limited access to mental health specialists. Whether due to limited numbers of psychiatrist or limitations set by third party payers, alternatives to off-site referrals should be addressed.

Conclusion

A variety of referrals and collaborative care models to improve outcomes in mental health care in the outpatient primary care setting can greatly aid providers and improve quality and outcomes in patient care. It is important for PCPs to be aware of the high prevalence of mental illness in the primary care setting and the high percentage of untreated or undertreated patients. PCPs will continue to provide the care for the majority suffering from mental illness. It is equally important that psychiatrists and PCPs maintain open lines of communication and work together to meet the needs of patients with psychiatric disorders.

Disclosure: Dr. Onate reports no affiliation with or financial interest in any organization that may pose a conflict of interest.