Integrated Care or Collaborative Care?

This is an update to a previous post on integrated care in early July, Integrated Care Marginalizing Psychiatrists or Optimizing Access to Psychiatric Treatment? – The Practical Psychosomaticist. The source is the 2nd in a series of article in the August issue of Psychiatric News, PsychiatryOnline | Psychiatric News | News Article Pioneer in Team-Based Care.

The first article was in the July issue, PsychiatryOnline | Psychiatric News | News Article Collaborative Care Well-Suited.

The first order of business is to try to clarify the distinction between integrated care and collaborative care, terms which I admit I’ve been using interchangeably. Integrated care is like having a co-located psychiatrist in the primary care clinic. Collaborative care is more like the model in which a care manager coordinates care between a primary care clinician and a psychiatrist. It’s sort of like the difference between having your salad dressing in or on the side.

Well, maybe not.

Recall, the major concern with collaborative-care models is that it may marginalize psychiatrists, partly by jeopardizing reimbursement. Dr. Wayne Katon, MD, a pioneer in collaborative care research, clarifies this issue by focusing on newer payment models. For example, at The University of Washington, the hospital pays for the psychiatrist and the care manager. Alternatively, insurance companies may pay for psychiatric supervision as well as care manager time.

These newer payor models are still evolving, so some psychiatrists may want to adopt a wait-and-see position for now. However, as the Affordable Care Act (ACA) gains momentum, sitting on the fence could get increasingly uncomfortable.

I think the other concern about collaborative care models is the patient load. I don’t know how psychiatrists might feel about going over a caseload of 50-100 patients in an hour with a case manager. It sounds like it would be quite an adjustment.

In the same August issue of Psychiatric News, an interesting summary of what ACA will mean for psychiatrists was written by Dr. Sosunmolu Shoyinka, MD. He envisions large numbers of patients seeking mental health care in “integrated settings”, although there won’t be enough psychiatrists to meet the need. That sounds familiar.

Dr. Shoyinka says psychiatrists will need to provide leadership in “planning and operationalizing mental health services” and to provide more direct medical care. This will stretch our scope of practice. Already I’ve seen articles like that in the American Journal of Psychiatry suggesting that psychiatrists become more comfortable in the management of diabetes mellitus by prescribing drugs like metformin [1].

What do you think?

1. Jarskog, L. F., et al. (2013). “Metformin for Weight Loss and Metabolic Control in Overweight Outpatients With Schizophrenia and Schizoaffective Disorder.” Am J Psychiatry.
OBJECTIVE The purpose of this study was to determine whether metformin promotes weight loss in overweight outpatients with chronic schizophrenia or schizoaffective disorder. METHOD In a double-blind study, 148 clinically stable, overweight (body mass index [BMI] >/=27) outpatients with chronic schizophrenia or schizoaffective disorder were randomly assigned to receive 16 weeks of metformin or placebo. Metformin was titrated up to 1,000 mg twice daily, as tolerated. All patients continued to receive their prestudy medications, and all received weekly diet and exercise counseling. The primary outcome measure was change in body weight from baseline to week 16. RESULTS Fifty-eight (77.3%) patients who received metformin and 58 (81.7%) who received placebo completed 16 weeks of treatment. Mean change in body weight was -3.0 kg (95% CI=-4.0 to -2.0) for the metformin group and -1.0 kg (95% CI=-2.0 to 0.0) for the placebo group, with a between-group difference of -2.0 kg (95% CI=-3.4 to -0.6). Metformin also demonstrated a significant between-group advantage for BMI (-0.7; 95% CI=-1.1 to -0.2), triglyceride level (-20.2 mg/dL; 95% CI=-39.2 to -1.3), and hemoglobin A1c level (-0.07%; 95% CI=-0.14 to -0.004). Metformin-associated side effects were mostly gastrointestinal and generally transient, and they rarely led to treatment discontinuation. CONCLUSIONS Metformin was modestly effective in reducing weight and other risk factors for cardiovascular disease in clinically stable, overweight outpatients with chronic schizophrenia or schizoaffective disorder over 16 weeks. A significant time-by-treatment interaction suggests that benefits of metformin may continue to accrue with longer treatment. Metformin may have an important role in diminishing the adverse consequences of obesity and metabolic impairments in patients with schizophrenia.

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Comments

  1. Thanks Jim. Feel free to post the link. I am following your blog on my profile. The Google blogger interface is not the best. I am referring to the DIAMOND project and the parallel Minnesota state government at http://mncm.org/

    All clinics treating depression are mandated to submit PHQ-9 scores of anyone they treat for major depression.

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  2. Hi Jim,

    My thoughts on the subject are well documented on my blog. The whole idea of reviewing cases with case managers and not knowing those patients well should trigger an alarm for any well trained psychiatrist. The closest approximation in my training was working and supervising case managers in a community support team. In that case I knew all of the patients well including their medical problems. When the case managers identified a problem, I could make rapid and well thought out decisions based on my knowledge of the patient.

    Flash forwarding to a few years ago where we now have everybody in Minnesota who is seen for depression taking the PHQ-9 and their scores managed by a case manager and a psychiatrist who has never seen the patient. That model has several flaws including:

    1. There is really no evidence that depression screening in primary care is cost effective or improves outcomes. When you think of what you are getting from a PHQ-9 score, I would be surprised if a careful study could illustrate much of anything.

    2. The state agency following these scores in order to tweak them as “pay for performance measures, clearly has no idea how to analyze the longitudinal data in any relevant way. I have certainly criticized it and they continue to modify their methodology on an ongoing basis.

    3. It is quite typical of health care system rhetoric these days to make it seem like the customer is getting something for nothing. When I recently read that only 1 in 7 mild asthmatics gets adequate control of their symptoms it is pretty clear that primary care physicians have a lot more to do than screen for depression. I would also hearken back to screening for pain as the “fifth vital sign” as suggested by the Joint Commission in 2000 and the potential problems with false positives and exposure of many more people to drug therapy that is often problematic.

    I like the idea of expanding the medical role of psychiatrists. There are many health care professionals with considerably less training who do not hesitate to expand into many roles. The main problem is that most of the psychiatric infrastructure and billing is set up for psychiatric medication refills, rather than a comprehensive role. The problem with the PPACA is that it is more rationing and shifting more leverage and money to health care companies.

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    • George, I just can’t say enough about the clarity you bring to this issue. I tried to comment on one of your blog posts at your site, though, and couldn’t seem to get the hang of it. Would it be all right for me to just put a link in my blog roll to your site?

      And when you talk about the collaborative care effort in Minnesota, are you referring to the DIAMOND model?

      Thanks again!

      Jim

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