Although most major organizations recognize the importance of collaboration, the challenge for psychiatry is how to best integrate different aspects of psychiatric and primary care. The Patient Protection and Affordable Care Act (ACA) of 2010 provided for the creation of “health homes” that allow improved coordination of complex care needs and payment. The ACA has created several mandates for these medical homes, including comprehensive care management and transitional care, care coordination and health promotion, individual and family support, community and social support referrals, and the use of health information technology to link services.1 These underlying concepts highlight many of the goals of collaborative care regardless of the treatment model. A key aspect of looking at collaborative models of care is the recognition that one needs to start looking at health care beyond the individual and see how it applies to an entire population.2
The need for improved collaboration
Mental health disorders are the strongest predictor of disability.3 In the US, only about 40% of those with mental health concerns receive treatment in any given year.4 Two of the many reasons for this are stigma and limited access to mental health care. A collaborative care approach has been recognized as best practice by various organizations, including the Surgeon General’s Report on Mental Health,5 and many patients prefer an integrated approach to their health care.6
Collaborative care models
Creating improved collaboration between specialties is not as simple as agreeing to work more closely together. The various roles of the participants need to be recognized and defined. The roles change depending on expectations and the level of collaboration. To be successful, it is essential that an appropriate model is used to address the targeted patient population.
Various models have been devised to delineate different levels of integration. The Four Quadrant model was created to highlight the different categories of physical and mental health disorders and the levels of services necessary to adequately treat them.7 Doherty8 explored levels of collaboration from a systems standpoint. He divided the continuum of collaboration into 5 categories. Collins and colleagues9 further subdivided this spectrum into 8 categories.
The SAMHSA-HRSA Center for Integrated Health Solutions also modified Doherty’s model (Table 1).10 This model uses 3 main categories of collaboration that reflect increasing levels of involvement: coordinated care, co-located care, and integrated care. Coordinated care is the most basic level of collaboration, in which primary care and mental health professionals have separate locations; specific treatment issues drive the relationship. One example from New York State is the Child and Adolescent Psychiatry for Primary Care program that allows for real-time phone consultation for primary care physicians (PCPs) with a child and adolescent psychiatrist and assistance for linkage to community mental health resources.11
The next category of collaboration is co-located care. In these settings, a mental health professional and a PCP are part of the same facility, but they may or may not share the same space. Typically, patients are referred to the mental health professional (a combination of social workers, psychologists, and psychiatrists) who provides diagnostic and treatment assistance. The goal is shorter-term treatment with referral back to the PCP. Should the patient have more complex mental health needs, he or she is referred to a community mental health center that has additional supports. An example of this model is the Washtenaw Community Health Organization, in which a psychiatrist provides consultation within a local public health clinic.9
Integrated care is the most intensive level of collaboration. At this level, behavioral health professionals and PCPs work as a team. There is usually a shared record system and treatment plans. The focus of the clinic may be either primary care with integrated mental health care or the reverse. An example of improving primary care in a behavioral health setting is Horizon Health Services, in which primary care clinics are located within the same facility as behavioral health for those without a PCP.9
Dr Martin is Clinical Assistant Professor of Psychiatry at the University at Buffalo. He reports no conflicts of interest concerning the subject matter of this article.
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