Peter S. Martin, MD, MPH

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.

 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.

Mental health disorders are the strongest predictor of disability.

 In the US, only about 40% of those with mental health concerns receive treatment in any given year.

 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,

 and many patients prefer an integrated approach to their health care.

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.

 explored levels of collaboration from a systems standpoint. He divided the continuum of collaboration into 5 categories. Collins and colleagues

 further subdivided this spectrum into 8 categories.

The SAMHSA-HRSA Center for Integrated Health Solutions also modified Doherty’s model (

 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.

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.

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.

Simply agreeing to collaborate more effectively and being in the same location has not been shown to improve outcomes.

 One of the greatest challenges is deciding how an organization or community wants to improve the coordination of care. Potential barriers include limited opportunities to exchange information as well as concerns about patient confidentiality.

Sharing information is essential to the success of a collaborative partnership. The benefit of “curbside consults” and the knowledge that can come from these interactions should not be ignored. These interactions can greatly contribute to the comfort level that PCPs have in taking over patient care. However, there are challenges even in the formal exchange of information. For example, federal and state laws make the sharing of substance abuse information difficult, if not impossible (particularly because of federal regulation 42 CFR).

 Electronic health records may not have adequate protection for sharing of psychotherapy notes; therefore, a different mechanism to maintain these types of records may be necessary.

Whenever there are changes, there is also resistance. Even if it is recognized that a change will improve health outcomes, administrative and clinical staff will be anxious about the effects the changes will have on their workflow. Collaboration between different systems quickly becomes complicated, involving multiple levels of staff (eg, clerical, nurses, physicians, care coordinators, and administrators).

Ideally, collaborative care should decrease overall system costs. However, depending on how involved the providers are in different levels of care, they may not see these savings and, if anything, providing collaborative care may increase their costs (ie, needing to invest in a more robust electronic health record). A patient may generate lower systematic costs (eg, fewer visits to the emergency department or inpatient hospitalizations) because of collaborative care efforts, yet the clinic that is doing the collaborating may not directly receive any monetary benefits. Billing issues frequently come up as a source of frustration, especially if there are limitations on payment for same-day visits to different providers. Despite these concerns, multiple different payment models have been effectively used in collaborative settings, ranging from global capitation to pay-for-performance. Most models that show cost savings and sustainability do so by incorporating multiple systems of care (eg, Kaiser Permanente, Intermountain Healthcare).

Regardless of the collaborative approach, there are certain principles that can be used to help ensure success (

). For a program to be successful, it needs to have a defined purpose and population. For example, if a behavioral health center wants to improve the treatment of patients with chronic mental illness who have limited access to health care, an on-site full-time nurse practitioner to assist with general medical treatment, such as the management of hypertension and diabetes, could be on staff.

In addition, strong leadership is required to start and continue any collaborative process: a leader with the ability to work with a team, who can provide active support during development and implementation of the collaborative process-a strong leader who knows when to delegate.

Once a collaborative setup is developed, it needs to be continuously monitored to ensure that it is working smoothly. This monitoring is both informal (ie, “checking-in” with different workers) and formal (ie, creating specific benchmarks to determine whether the collaboration is leading to more effective care). If the collaborative approach is more involved or more complicated, the use of care coordinators becomes essential to allow for appropriate delegation of responsibilities and to decrease provider burnout.

Collaboration takes time. Rather than making a radical change in every aspect of a system, step-wise implementations will allow for a smoother transition. Procedures should be devised to maintain a level of structure. This process can appear tedious, but planning strategies for how to deal with various problems will lead to decreased confusion and frustration.

The effective exchange of information is essential for a successful collaborative approach. Building in time to allow for this exchange, whether it is a formal discussion on a weekly basis or a spontaneous conversation, is necessary to create trust and to improve one’s knowledge base. A shared medical chart greatly facilitates this process and is ideal for allowing a central location for notes and patient data.

Payment options cannot be ignored and are frequently a limiting factor in the success and sustainability of collaborative projects. Health care professionals need to be not only patient advocates but also systems advocates in order for changes in payment structure to take place. Fortunately, momentum is building for these changes as more evidence of their effectiveness becomes available.

Ultimately, the focus on improving the health care and well-being of patients is the primary focus for increasing collaboration. Despite the many challenges that come from improving collaborative care, improved patient outcomes should always be a top priority.

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

 New York State Department of Health. NYS health home provider qualification standards for chronic medical and behavioral health patient populations. http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/provider_ qualification_standards.htm. Accessed April 1, 2014.

 Dundon M, Dollar K, Schohn M, Lantinga LJ. Primary care-mental health integration co-located, collaborative care: an operations manual. March 2011. http://www.mentalhealth.va.gov/coe/cih- visn2/Documents/Clinical/Operations_Policies_ Procedures/MH-IPC_CCC_Operations_Manual_ Version_2_1.pdf. Accessed April 1, 2014.

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 US Department of Health and Human Services. Mental health: a report of the Surgeon General. 1999. http://profiles.nlm.nih.gov/ps/access/ NNBBHS.pdf. Accessed April 3, 2014.

 UnÃ¼tzer J, Harbin H, Schoenbaum M, Druss B. The collaborative care model: an approach for integrating physical and mental health care in the Medicaid health homes. May 2013. http://medicaid.gov/ State-Resource-Center/Medicaid-State-Technical- Assistance/Health-Homes-Technical-Assistance/Downloads/HH-IRC-Collaborative-5-13.pdf. Accessed April 1, 2014.

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 Uebelacker LA, Smith M, Lewis AW, et al. Treatment of depression in a low-income primary care setting with colocated mental health care. 

 Reiss-Brennan B, Briot PC, Savitz LA, et al. Cost and quality impact of Intermountain’s mental health integration program. 

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