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January – February 2021
Guest column from Dr. Jonathan Henry, board-certified psychiatrist
A provider’s perspective on the Coordinated Care Model
 The advent of the Coordinated Care Model, or CoCM, is a blessing to patients and the health care system alike. For years, I’ve listened to many of my primary care colleagues lament the lack of psychiatric services in their area to help them with the mental health needs of their patients.
With CoCM, sometimes called the CoCare process, primary care physicians work closely with a consulting psychiatrist and a behavioral health care manager to address behavioral health issues. The primary care doctor consults regularly with a consulting psychiatrist and behavioral health care manager to help facilitate the treatment plan. This provides a holistic treatment plan for the patient.
An essential feature of this model is the patient-centered team care approach. Primary care and behavioral health providers collaborate in such a way the patient receives effective care in a familiar, convenient location. This approach fosters increased patient engagement, which can lead to better patient outcomes.
Another core feature is population-based care. Providers track patients in a registry to monitor progress and ensure they receive follow-up care. Team members call patients who aren’t improving or who appear to be disengaging to try to improve their treatment trajectory.
These features represent a meaningful step beyond simple “curbside consultation” or even referral to a psychiatrist or behavioral health specialist for regular face-to-face sessions. When developing a treatment plan, the entire gamut of options is considered. These include psychotherapy, relaxation techniques, mindfulness training, behavioral activation medications, exercise and other complementary interventions.
Specific treatment goals include measuring the patient’s progress toward the goal. We use evidence-based tools to help promote improvement and provide a clear path forward if patients aren’t improving as expected.
Initiating the process
To initiate the process, the medical provider identifies a mental health issue in a patient he or she is treating. The provider then notifies the care manager, who gathers information about the identified patient and their problems, organizes that information and presents it during a meeting with the CoCM psychiatric consultant. PHQ-9 and GAD-7 screening tools are used to help gather baseline information, as mood and anxiety symptoms are typically at the heart of the patient’s complaints.
The CoCM psychiatrist analyzes the results of the questionnaires and requests additional information as needed. He or she then provides an opinion and written recommendation.
The psychiatrist also has access to the practice’s medical record so pertinent information, such as current medications and laboratory results, is available to help formulate the diagnosis and suggest further treatment. The behavioral health care manager helps to convey the psychiatrist’s opinion back to the treating primary care provider and coordinates care with behavioral health providers outside the primary care practice.
The psychiatrist doesn’t see the patient. He or she also doesn’t usually consult directly with the medical doctor but works closely with the behavioral health care manager.
I typically spend about 30 minutes on evaluating a new patient and about 15 to 20 minutes, depending on the complexity of the case, for established patients. I schedule two hours per week to meet with the care manager for the practice where I work. I conduct all reviews remotely, using a video platform when needed, to meet with the care manager. We can simultaneously refer to the patient’s chart in the electronic medical record or talk by phone. Treatment goals generally include driving the PHQ-9 and GAD-7 scores to 5 or lower ideally, or at least a 50% reduction in the baseline scores.
Criteria for selecting a member to participate in the CoCare process
The conditions that trigger a CoCare consultation tend to fall into several general categories:
- The patient’s core problem isn’t being sufficiently addressed by the medical provider’s initial treatment efforts. So many consultation efforts involve dosage adjustment, medication selection and treatment augmentation.
- A more detailed diagnostic picture is needed. The PHQ-9 and the GAD-7 questionnaires often just serve as a starting point of the evaluation. I may ask the care manager to also obtain a baseline SMS-5 Self-Rated Level 1 Cross-Cutting Symptom Measure to aid the process.
- Unidentified bipolar depression is suspected. In these cases, I employ the Mood Disorders Questionnaire or the Composite International Diagnostic Interview to help explore this possibility.
- Substance use is another complicating factor in a patient’s life. It can be assessed using the SBIRT method, also known as Screening, Brief Intervention and Referral to Treatment. Screening instruments such as the Alcohol Use Disorders Identification Test and the Drug Abuse Screening test can be used to begin the process.
These are just a few of the tools we use to address some of the more common conditions we encounter.
No matter how sensitive and attuned the providers and the care manager are — how skilled the psychiatric consultant — some problems are clearly beyond the scope of the primary care practice to manage. In such cases, establishing referral procedures to the appropriate level of care is essential. A practice must also identify emergency mental health services needed for acute situations and ensure they’re readily accessible.
It's gratifying to help my primary care colleagues provide effective and comprehensive mental health services to their patients in the context of their own practice. It’s additionally gratifying to be part of a movement whereby preciously scarce psychiatric resources can be leveraged to identify and treat mild or moderately ill patients who previously had no such access to psychiatric expertise.
Resources
Please check out the following resources for more information:
Editor’s note: Check out the recent podcast on the Collaborative Care Model, featuring Dr. Henry, along with Dr. William Beecroft, medical director for behavioral health for Blue Cross Blue Shield of Michigan, and Dr. David Winston, primary care provider in Ann Arbor.
Dr. Henry is an East Lansing-based psychiatrist. He initially trained and practiced as a family practitioner and then completed a psychiatric residency. He’s been serving as a psychiatric consultant for physicians using the Collaborative Care Model for the past two years.*Blue Cross Blue Shield of Michigan doesn't own or control this website. |
