Psychiatrists Happy Practicing Integrated Care

Megan Brooks

January 07, 2016

Psychiatrists working in integrated care teams report high satisfaction with their work, noting that a collaborative care model allows them to leverage their expertise to reach a large number of patients in a variety of practice settings, results of a survey indicate.

"Overall, the results tell us that psychiatrists are practicing integrated care in several outpatient settings in the community and that they enjoy their work," first author Kathyrn R. Norfleet, MD, of the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, told Medscape Medical News.

"Collaborative care is important to the field because it provides effective care to more people in need of behavioral healthcare and extends the expertise of the psychiatric workforce to assist in providing this care," added coauthor Lori E. Raney, MD, from Health Management Associates, Denver, Colorado, and chair, American Psychiatric Association (APA) Workgroup on Integrated Care.

The survey, published online December 15, 2015, in Psychiatric Services, asked 52 psychiatrists working in diverse integrated care settings across the United States about their experiences and opinions. Their mean age was 51.9 years, and 64% were men.

Views "Overwhelmingly" Positive

Most survey respondents worked part-time in integrated care in a variety of settings, most commonly, federally qualified health centers or community health centers (42%), academic medical center–affiliated primary care clinics (35%), community mental health centers with a primary care clinic on site (33%), and other primary care settings (25%). Only 11 psychiatrists (21%) reported working full-time in a single setting.

They worked in a variety of integrated care models. Forty-one (79%) worked in a collaboration team (consultation to a primary care clinic and regular interaction with primary care physicians [PCPs] or behavior healthcare professionals); 39 (75%) worked in administration; 38 (73%), in traditional referral or consultation (direct patient care consultations in psychiatric practice); 28 (54%), in colocated services (direct patient care consultations in a primary care clinic); 24 (46%), in caseload-based collaboration (regular reviews and consultations for a defined caseload of patients in a primary care setting and regular interaction with PCPs or behavior healthcare professionals); 12 (23%), in reverse integration (collaboration with a primary care service or provider located in a mental health specialty setting); and 12 (23%), in other integrated care models.

About two thirds of psychiatrists said their compensation was provided by salary (67%); 21%, by fee for service; and 29%, by other sources. Salaries were supported by a range of sources, including contracts to healthcare plans (44%), grant funding (36%), and other sources (42%).

Nearly all psychiatrists surveyed said they provided consultation on medication recommendations (98%) and diagnostic clarification (96%). Most reported requests for consultation on behavioral interventions (85%) and for education on a specific topic (85%). Anxiety, depression, and substance use disorders were the most common diagnoses leading to a consultation request.

"Psychiatrists' opinions and experiences working in integrated care were overwhelmingly positive," the researchers say, with most reporting that they particularly enjoyed working in a patient- centered care model, working with a team, the psychiatrist's role as educator, and opportunities for growth and innovation.

"The ability to reach more people in need of behavioral health treatment through the psychiatrist-supported approach in the collaborative care model was viewed as a very rewarding experience," Dr Raney said in a statement.

"This model for providing psychiatric care is held in high regard because it has the potential to improve both access to and quality of psychiatric care in the community," Dr Norfleet told Medscape Medical News. "As part of a behavioral health team in primary care, psychiatrists are able to care for a larger number of patients than they would be able to otherwise. This care is provided in a setting that patients prefer ― their primary care office ―- which helps to reduce stigma around psychiatric care. These unique aspects of integrated care are important because there is a tremendous shortage of psychiatrists, and this model allows us to care for patients who might not otherwise access psychiatric care."

Dr Raney said, "Continued efforts to engage more psychiatrists in this work are needed, and this study provides the first report of the core tasks and satisfaction experienced working in this exciting new area of psychiatric practice.

"The biggest hurdles," she noted, "are finding psychiatrists to do this work and providing the training they need to feel competent in this work."

"We anticipate that providing psychiatric services in integrated care settings will be a growing area of psychiatric practice. One challenge we now face is training psychiatrists and behavioral health professionals in how to most effectively provide care in this model," Dr Norfleet said.

The APA has received a $2.9 million dollar grant from the Centers for Medicare and Medicaid Services to train 3500 psychiatrists in the clinical and leadership skills needed to support primary care practices that are implementing integrated behavioral healthcare programs.

Rewarding Model of Care

Reached for comment, David W. Oslin, MD, professor of psychiatry, University of Pennsylvania Perelman School of Medicine, in Philadelphia, noted that the survey was a "select sample," but he is not surprised with the high satisfaction levels of psychiatrists in integrated care.

He noted that patients who receive integrated care patients are a "bit different than what you see in specialty care programs. These are patients that typically don't want to go to specialty care, and often because their symptoms are not as severe, a lot of these patients actually do very well with modest intervention, so you see a lot of patients getting better, which is rewarding. Integrated care providers work with many different disciplines, which is also professionally rewarding," Dr Oslin explained. As the authors of the survey note, the integrated care model gives providers the opportunity help many more patients, "so you have a bigger impact, and that is also rewarding."

There are also some data to suggest that this model is relatively cost-neutral to cost-effective, he noted. "The data are a little mixed. It's clear that it's at least cost-neutral, but with better outcomes for patients. Those data on outcomes are robust in multiple studies," Dr Oslin said.

In his view, the biggest challenge is figuring out a financial model for integrated care that works.

Dr Raney receives royalties from American Psychiatric Publishing. Two coauthors receive support in the form of a contract for implementation support for the Community Health Plan of Washington and from a contract for educational content from the APA. Dr Norfleet and Dr Oslin have disclosed no relevant financial relationships.

Psychiatr Serv. Published online December 15, 2015. Abstract


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