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The Early-Career Consultation Psychiatrist: Preparing Psychiatry Residents for the Integrated Care Wave
Author's Accepted Manuscript
The Early-Career Consultation Psychiatrist: Preparing Psychiatry Residents for the Integrated Care Wave (750 word limit) Hsiang Huang MD, MPH, Andres Barkil-Oteo MD, MSc
PII: DOI: Reference:
S0033-3182(14)00007-3 http://dx.doi.org/10.1016/j.psym.2014.01.002 PSYM428
To appear in:
Psychosomatics
Cite this article as: Hsiang Huang MD, MPH, Andres Barkil-Oteo MD, MSc, The Early-Career Consultation Psychiatrist: Preparing Psychiatry Residents for the Integrated Care Wave (750 word limit), Psychosomatics, http://dx.doi.org/10.1016/j. psym.2014.01.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Early-Career Consultation Psychiatrist: Preparing Psychiatry Residents for the Integrated Care Wave (750 word limit) To the Editor The U.S. health care system is now moving towards one filled with Patient Centered Medical Homes (1) and Accountable Care Organizations in the context of the Patient Protection and Affordable Care Act (PPACA), with the goal of achieving the triple aim of improved experience care, improved population health, and decreased health care costs (2). Behavioral health treatment is recognized as an essential component to achieve the triple aim across the health sector (3). Behavioral health professionals, including psychiatrists, will be expected to fill new roles in this changing health care environment. One of the most promising new roles for psychiatrists is to improve the care for people with comorbid psychiatric and mental illness using Collaborative Care models (4). The Collaborative Care model is based on a focus on population care, measurement-based care, and stepped care (5-7). The model consists of an interdisciplinary team that includes the primary care provider (PCP), a non-physician behavioral care manager (CM), and a psychiatric consultant. The CM assists the PCP in coordinating behavioral health care for a panel of patients. Using a registry, the CM tracks depression outcomes and facilitates “stepped care” for patients not improving on specified treatment outcomes. Importantly, the CM also provides a range of evidence based counseling approaches (e.g. behavioral activation, problem solving treatment, and motivational interviewing) and routinely consults with psychiatric consultant on
patients with persistent psychiatric symptoms. The psychiatrist makes treatment recommendations which are communicated to the PCP. Early Career Psychosomatic Medicine (ECPM) psychiatrists are well positioned to take a lead in leadership and training roles given their experience and expertise in the treatment of the medically and psychiatrically complex patient (8). Specifically, we argue that ECPM psychiatrists should take a leading role in working in Collaborative Care systems as well as training psychiatry residents in this model of care. Most psychiatry training programs have yet to formalize curricula teaching skills in Collaborative Care with few notable examples (9), thus the ECPM psychiatrist can help fill this educational gap and prepare psychiatry residents for the Integrated Care wave. Specifically, PM psychiatrists can approach residency programs to formally teach skills in Collaborative Care using ready-made modules. For instance, the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington has created a set of modules in Collaborative Care (approved by AADPRT) (uwaims.org). Alternatively, for residency programs that do not have clinical settings supporting Collaborative Care, a shorter module can be used to provide an appreciation of population health, the Collaborative Care model, and a focus on key integrated care skillsets such as using validated instruments and provision of stepped care. The authors are working on a curriculum that is available for download and open for feedback and suggestions (goo.gl/lgq5CL). Yet another way for ECPM psychiatrists working in primary care settings to teach residents is to mentor residents in their clinics. For instance, the Cambridge Health
Alliance Psychiatry Residency program (Cambridge, MA) has recently begun an ‘Integrated Care’ resident elective at 2 primary care clinics. In this 6 month elective, an ECPM psychiatrist (HH) supervises residents caring for patients in an integrated care setting. Residents evaluate/treat patients using measurement-based care and perform case reviews for PCPs. There is also a biweekly journal club with a focus on psychiatric epidemiology and mental health services research. Although the sites are not yet running Collaborative Care models, key elements of integrated care skills are being taught in preparation for the inevitable implementation of a fully integrated model. This is a training model that other residencies can adopt with the help of the PM psychiatrist. In conclusion, the current efforts to reform the health care system bring challenges and opportunities for behavioral health professionals to expand their roles and add value to the treatment of people with mental illness across the health sector. One of the clearest examples of this expanded role is in Collaborative Care models. There is currently a need for training psychiatry residents for these expanded roles. ECPM psychiatrists who are looking for opportunities to expand their educational activities should seize this opportunity to train residents in Collaborative Care skills using the many resources available online.
Hsiang Huang, MD, MPH Cambridge Health Alliance Instructor in Psychiatry, Harvard Medical School Cambridge, MA
Andres Barkil-Oteo, MD, MSc Assistant Professor of Psychiatry Yale School of Medicine New Haven, CT
Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article
References: 1. Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010 May;29(5):835‐43. 2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008 May‐Jun;27(3):759‐69. 3. Katon WJ, Unutzer J. Health reform and the Affordable Care Act: the importance of mental health treatment to achieving the triple aim. J Psychosom Res. 2013 Jun;74(6):533‐7. 4. Katon W, Unutzer J. Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim. Gen Hosp Psychiatry. 2011;33(4):305‐10. 5. Von Korff M, Tiemens B. Individualized stepped care of chronic illness. West J Med. 2000;172(2):133‐7. 6. Katon W. Collaborative depression care models: from development to dissemination. Am J Prev Med. 2012 May;42(5):550‐2. 7. Thota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, McKnight‐Eily LR, et al. Collaborative Care to Improve the Management of Depressive Disorders: A Community Guide Systematic Review and Meta‐ Analysis. American Journal of Preventive Medicine. 2012;42(5):525‐38. 8. Integrated Behavioral Health and Primary Care: Competencies and Skills of Psychosomatic Medicine Psychiatrists. [cited 2014 12/28]; Available from: http://www.apm.org/education/health‐ reform‐toolkit/index.shtml#pricare. 9. Cerimele JM, Katon WJ, Sharma V, Sederer LI. Delivering psychiatric services in primary‐care setting. Mt Sinai J Med. 2012 Jul‐Aug;79(4):481‐9.
The Early-Career Consultation Psychiatrist: Preparing Psychiatry Residents for the Integrated Care Wave (750 word limit) Hsiang Huang MD, MPH, Andres Barkil-Oteo MD, MSc
PII: DOI: Reference:
S0033-3182(14)00007-3 http://dx.doi.org/10.1016/j.psym.2014.01.002 PSYM428
To appear in:
Psychosomatics
Cite this article as: Hsiang Huang MD, MPH, Andres Barkil-Oteo MD, MSc, The Early-Career Consultation Psychiatrist: Preparing Psychiatry Residents for the Integrated Care Wave (750 word limit), Psychosomatics, http://dx.doi.org/10.1016/j. psym.2014.01.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Early-Career Consultation Psychiatrist: Preparing Psychiatry Residents for the Integrated Care Wave (750 word limit) To the Editor The U.S. health care system is now moving towards one filled with Patient Centered Medical Homes (1) and Accountable Care Organizations in the context of the Patient Protection and Affordable Care Act (PPACA), with the goal of achieving the triple aim of improved experience care, improved population health, and decreased health care costs (2). Behavioral health treatment is recognized as an essential component to achieve the triple aim across the health sector (3). Behavioral health professionals, including psychiatrists, will be expected to fill new roles in this changing health care environment. One of the most promising new roles for psychiatrists is to improve the care for people with comorbid psychiatric and mental illness using Collaborative Care models (4). The Collaborative Care model is based on a focus on population care, measurement-based care, and stepped care (5-7). The model consists of an interdisciplinary team that includes the primary care provider (PCP), a non-physician behavioral care manager (CM), and a psychiatric consultant. The CM assists the PCP in coordinating behavioral health care for a panel of patients. Using a registry, the CM tracks depression outcomes and facilitates “stepped care” for patients not improving on specified treatment outcomes. Importantly, the CM also provides a range of evidence based counseling approaches (e.g. behavioral activation, problem solving treatment, and motivational interviewing) and routinely consults with psychiatric consultant on
patients with persistent psychiatric symptoms. The psychiatrist makes treatment recommendations which are communicated to the PCP. Early Career Psychosomatic Medicine (ECPM) psychiatrists are well positioned to take a lead in leadership and training roles given their experience and expertise in the treatment of the medically and psychiatrically complex patient (8). Specifically, we argue that ECPM psychiatrists should take a leading role in working in Collaborative Care systems as well as training psychiatry residents in this model of care. Most psychiatry training programs have yet to formalize curricula teaching skills in Collaborative Care with few notable examples (9), thus the ECPM psychiatrist can help fill this educational gap and prepare psychiatry residents for the Integrated Care wave. Specifically, PM psychiatrists can approach residency programs to formally teach skills in Collaborative Care using ready-made modules. For instance, the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington has created a set of modules in Collaborative Care (approved by AADPRT) (uwaims.org). Alternatively, for residency programs that do not have clinical settings supporting Collaborative Care, a shorter module can be used to provide an appreciation of population health, the Collaborative Care model, and a focus on key integrated care skillsets such as using validated instruments and provision of stepped care. The authors are working on a curriculum that is available for download and open for feedback and suggestions (goo.gl/lgq5CL). Yet another way for ECPM psychiatrists working in primary care settings to teach residents is to mentor residents in their clinics. For instance, the Cambridge Health
Alliance Psychiatry Residency program (Cambridge, MA) has recently begun an ‘Integrated Care’ resident elective at 2 primary care clinics. In this 6 month elective, an ECPM psychiatrist (HH) supervises residents caring for patients in an integrated care setting. Residents evaluate/treat patients using measurement-based care and perform case reviews for PCPs. There is also a biweekly journal club with a focus on psychiatric epidemiology and mental health services research. Although the sites are not yet running Collaborative Care models, key elements of integrated care skills are being taught in preparation for the inevitable implementation of a fully integrated model. This is a training model that other residencies can adopt with the help of the PM psychiatrist. In conclusion, the current efforts to reform the health care system bring challenges and opportunities for behavioral health professionals to expand their roles and add value to the treatment of people with mental illness across the health sector. One of the clearest examples of this expanded role is in Collaborative Care models. There is currently a need for training psychiatry residents for these expanded roles. ECPM psychiatrists who are looking for opportunities to expand their educational activities should seize this opportunity to train residents in Collaborative Care skills using the many resources available online.
Hsiang Huang, MD, MPH Cambridge Health Alliance Instructor in Psychiatry, Harvard Medical School Cambridge, MA
Andres Barkil-Oteo, MD, MSc Assistant Professor of Psychiatry Yale School of Medicine New Haven, CT
Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article
References: 1. Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010 May;29(5):835‐43. 2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008 May‐Jun;27(3):759‐69. 3. Katon WJ, Unutzer J. Health reform and the Affordable Care Act: the importance of mental health treatment to achieving the triple aim. J Psychosom Res. 2013 Jun;74(6):533‐7. 4. Katon W, Unutzer J. Consultation psychiatry in the medical home and accountable care organizations: achieving the triple aim. Gen Hosp Psychiatry. 2011;33(4):305‐10. 5. Von Korff M, Tiemens B. Individualized stepped care of chronic illness. West J Med. 2000;172(2):133‐7. 6. Katon W. Collaborative depression care models: from development to dissemination. Am J Prev Med. 2012 May;42(5):550‐2. 7. Thota AB, Sipe TA, Byard GJ, Zometa CS, Hahn RA, McKnight‐Eily LR, et al. Collaborative Care to Improve the Management of Depressive Disorders: A Community Guide Systematic Review and Meta‐ Analysis. American Journal of Preventive Medicine. 2012;42(5):525‐38. 8. Integrated Behavioral Health and Primary Care: Competencies and Skills of Psychosomatic Medicine Psychiatrists. [cited 2014 12/28]; Available from: http://www.apm.org/education/health‐ reform‐toolkit/index.shtml#pricare. 9. Cerimele JM, Katon WJ, Sharma V, Sederer LI. Delivering psychiatric services in primary‐care setting. Mt Sinai J Med. 2012 Jul‐Aug;79(4):481‐9.