Integrating primary care and mental health key to improving patient care, lowering costs
Primary care physicians play important role in detecting mental, behavioral health issues
A team approach to care
PCPs play a key role in detecting depression and other mental health disorders.
They should evaluate and diagnose patients, then encourage them to pursue treatment if necessary.
Still, “we need a team approach to be able to [treat patients] in a consistent and reliable way over time,” says Phillips. “To be sure a patient is doing well, we need to be checking in with them.”
At the Harvard-affiliated practices, the team often includes a population manager—possibly a nurse—who reaches out to patients regularly and monitors their symptoms; a social worker, who provides psychotherapy; and a clinical pharmacist, who makes adjustments to medications. A medical assistant screens patients for mental health disorders using tools such as the Patient Health Questionnaire (PHQ-9), which is used to screen for depression. The practices maintain lists of patients who have depression and other mental health disorders. From time to time, the population manager re-administers the PHQ-9, which indicates whether the prescribed medication or therapy has worked.
“If a patient has depression, we want to make sure he or she has a 50% reduction in their PHQ-9 score in 16 weeks,” says Fiona McCaughan, a nurse manager for Somerville Hospital Primary Care, a Harvard-affiliated practice. “If they haven’t, we need to try something else.”
Some practices are adding mental health professionals to their staff. The Harvard practices have hired psychiatric social workers to work in their clinics. “When I see a patient who might have depression, I can introduce him or her to a social worker, initiate treatment and continue to follow him or her over time,” says Phillips. “That way, we know the patient is going to create a relationship. When patients are depressed, it’s very difficult to initiate relationships with providers. So if you leave it up to the patient to do so, it may become a barrier to treatment. There’s also a stigma of going somewhere else for psychiatric care.” Indeed, studies show that more than half of primary care doctors are not successful at referring patients to mental health providers.
“Patients like to have their care delivered by the doctor they trust,” says Joji Suzuki, MD, associate psychiatrist at Brigham and Women’s Hospital in Boston. Another benefit of having a mental health professional on staff: the PCP can do a “hallway consult.” “Because the providers are physically here, they can talk to each other and make minor changes to a patient’s treatment plan without referring a patient to a psychiatrist or taking up an entire visit,” says Mccaughan.
The practices affiliated with Harvard’s Center for Primary Care are working with other mental health professionals—psychiatrists, addiction specialists and psychopharmacologists—via telemedicine and videoconferencing. These specialists are on call for the practice, and PCPs can contact them if they have a difficult case or questions about medications.
One tool that works well at several clinics in Cambridge, Massachusetts, is integrated case review, in which a PCP sends a patient record with a question to the psychiatrist on call. The psychiatrist reviews the record and makes a recommendation to the PCP.
“It simplifies treatment for me, and the patient doesn’t need to see someone else,” says Phillips. “As I do more of these consults over time, they raise my level of expertise at managing mental health problems.” Currently, the practices are conducting regular videoconference sessions, in which teams from the practices discuss patients with their mental health expert. Eventually, the practices may use telemedicine to enable patients to have consultations with psychiatrists.
There are many different models for integrating mental health services into primary care practices. Collaborative care (also known as IMPACT), involves using a care manager and a psychiatric consultant. The care manager—who may be a clinical social worker or psychiatric nurse—coordinates patients’ care and does the counseling. Research has shown that the collaborative care model is twice as effective as usual care in terms of clinical outcomes. Practices can review the evidence behind each model and choose the approach that will work best for them.
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