Snap, Crackle, Pop of Collaborative Care Options

I just happened to see Psych Practice blogger’s post about the Affordable Care Act and noticed something about our Collaborative Medicine and Behavioral Health (CoMeBeh) program here at The University of Iowa Hospitals and Clinics mentioned in the section on collaborative care.

The relevant excerpt is:

“What about other models? The Family Medicine Department at The University of Iowa Health Center has been running a grant-funded project called, Collaborative Medicine and Behavioral Health (CoMeBeh), in which Family Medicine residents spend one day a week onsite at the Adult Psychiatry clinic practicing general medicine, icluding [sic] routine care such as Pap smears and vaccinations. Thus far, responses from patients, as well as residents, have been extremely positive.

This model provides better quality psychiatric care than the Katon Model. But it also targets a much smaller population, specifically, those patients who are seen regularly in a psychiatry clinic, rather than those seen in a primary care clinic. And unlike the Katon model, it doesn’t encourage psychiatric care for those patients who might need such care, but who might be unwilling to seek it out on their own. (Link)”

I did a double take on the idea that CoMeBeh “…doesn’t encourage psychiatric care…” I think there’s a slight misunderstanding and I asked the Director of CoMeBeh, Dr. Alison Lynch, MD, to clarify the role of the program in facilitating psychiatric care. Dr. Lynch is modest and unsure whether she agrees with either statement about the program, including that it “…provides better quality than the Katon Model,” and that it “…doesn’t encourage psychiatric care for those patients who might need such care, but who might be unwilling to seek it out on their own.”

Below is Dr. Lynch’s impression and clarification about the goal and process of CoMeBeh:

Dr. Alison Lynch, MD

Dr. Alison Lynch, MD

How interesting!  I did not realize that we were on the radar of anyone outside our local community (although I recall and appreciate that you mentioned the CoMeBeh clinic on your blog a year or so ago!).  Regarding this blogger’s post, the writer states that “This model providers better quality psychiatric care than the Katon Model,” and then “it doesn’t encourage psychiatric care for those patients who might need such care.”  Seems contradictory to me, and frankly, I’m not sure I agree with either statement.

That said, the CoMeBeh clinic is a complement to psychiatric care for people we see.  Our target population is people with serious mental illness who do not have a primary care provider, so our recruitment efforts have been primarily aimed at the psychiatry providers in UIHC.  Hence, most of our patients already have a psychiatrist or a therapist.  We have started getting referrals from the case managers at the Johnson County Integrated Health Home, the case managers help their clients establish psychiatric care if needed.  The CoMeBeh services provide primary care with consideration of the potential impact on physical health and well-being that may be a consequence of the person’s mental illness and/or psychiatric treatment.  For example, because cardiovascular disease is a significant problem for many people with SMI, we address health factors such as smoking cessation, exercise, weight management, diet, blood pressure, and cholesterol, to help reduce the risk of CV disease.  We aim to collaborate with the psychiatric provider and rely on the psychiatrist/therapist to continue providing mental health care for the patient.  In the event that there is not a mental health care provider involved, getting connected with mental health care would be on the list of goals (unless the mental health needs are going to managed by the family physician, mainly if depression or anxiety).  As the CoMeBeh psychiatrist, I review patients in the program with the care managers on a regular basis, and we direct patients back to their providers if there are issues that need to be addressed.  If a patient needs to see a psychiatrist and does not have one, we generally arrange for them to be seen in the Family Medicine Psychiatry clinic.

So I don’t know what happened but I’m pretty sure it was just a misunderstanding. What’s nice about this is that the word is out about CoMeBeh and we’re pleased others can see that collaborative care arrangements can accommodate other models which are practical and meet the needs of patients with complex comorbid psychiatric and medical illness.

In other words in the integrated care world in which approaches can seem very similar, sort of like snap, crackle, and pop, there’s value in making room for any model which achieves the goal of making both medical and psychiatric care available without breaking the bank and keeping the psychiatrist in the loop.

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Comments

  1. TOTAL misunderstanding, you have my most sincere apologies, and I will note the confusion in my next post. I think what happened was that I cut and pasted the text, some of which was written by me, and some of which was edited by Steve Balt. What I was trying to say was that CoMeBeh does the opposite of what the collaborative care model does. The collaborative care model refers patients to very limited psychiatric care from primary care clinics, while CoMeBeh provides good primary care to psychiatric clinics. Since more people get primary care than psychiatric care, in general, the collaborative care model has access to many more patients. In other words, patients in the CoMeBeh model are already in psychiatric care, so in that respect, it doesn’t reach out to a more general medical population to provide psychiatric care. I much prefer what the CoMeBeh model does, it just doesn’t cast as wide a net.
    Please let me know if I still don’t get it, and I will correct my mistakes.

    Liked by 1 person

    • Hey, we’re all good! Your section on the PQRS and ACOs reminded me of the CMS penalties for docs who don’t participate in MOC and the irony that if you’re part of an ACO, you’re probably protected to some degree from the byzantine paperwork hassle factor of PQRS:MOC. That was written into ACA (see my January 2014 post, https://thepracticalpsychosomaticist.com/2014/01/14/maintenance-of-certificationpqrs-update/

      My administrator was barely aware of that.

      The coverage vs care section reminded me of one of the topics in the most recent issue of Iowa Medicine, published by the Iowa Medical Society. There are a couple of pieces about how to encourage the development of leadership skills in medical students. Suggestions include more emphasis on teaching them about the business side of medicine.

      If medical students are going to learn more about the business aspects of running a practice (which I never got), they’re going to need more time, which the curriculum doesn’t allow. And they need role models who are successful in private practice, which is not supported in the current US system. My impression is that these leaders are increasingly hard to find as regulatory capture, heavy student loan debt, and governmental and insurance pressures propel many doctors to seek hospital employment.

      You know this from your own experience, http://psychpracticemd.blogspot.com/2014/10/reinvention.html

      I hope things work out for you and your husband.

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  2. C’mon; you knew this was coming…

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