Families, Systems, & Health 2014, Vol. 32, No. 2, 147–148
© 2014 American Psychological Association 1091-7527/14/$12.00 DOI: 10.1037/fsh0000045
COMMENTARY
The American Psychiatric Association Response to the “Joint Principles: Integrating Behavioral Health Care Into the Patient-Centered Medical Home”
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Lori Raney, MD, David Pollack, MD, Joe Parks, MD, and Wayne Katon, MD American Psychiatric Association, Washington, DC
The American Psychiatric Association (APA) thanks the Working Party Group on Integrated Behavioral Health Care for the opportunity to respond to the “Joint Principles: Integrating Behavioral Health Care Into the Patient-Centered Medical Home” (The Working Party Group on Integrated Behavioral Healthcare et al., 2014). The APA Workgroup on Integrated Care supports the recommendations made in these Joint Principles and recognizes the significant benefit of treating behavioral and general medical conditions concurrently. We offer comments on this effort as it pertains to health care in general and psychiatric practice.
achieve this goal. Both approaches are important because primary care doctors see many behavioral conditions. Approximately 20% of patients in primary care settings have depression and anxiety, and most primary care physicians (PCPs) struggle to provide good quality care for these disabling conditions (Katon & Seelig, 2008). These disorders also drive overall health care expenditures, and including evidence-based models for treating behavioral health conditions will help the PCMH meet the goal of cost containment while improving outcomes.
Utilizing Evidence-Based Collaborative Care Models
Location of the PCMH Outside of the Primary Care Setting
It is essential that evidence-based models of integrated care be employed in the patientcentered medical home (PCMH). Although there is little evidence that mental health integration into primary care settings alone improves anxiety or depression outcomes, more than 80 randomized clinical trials (Archer et al., 2012) have shown that the Collaborative Care models (IMPACT, Unützer et al., 2002; and TEAMcare, Katon et al., 2010) can effectively
In public mental health settings where patients with serious mental illnesses (SMI) receive most of their care, psychiatrists are often their primary physicians. With new funds made possible by the Affordable Care Act of 2010, Section 2703 State Plan Amendment options allow the PCMH to be located in community mental health centers. Ideally the delivery system will evolve so that most health services would be provided in an integrated fashion in one setting, but until then it is preferable to proceed with the knowledge that some integrated care arrangements will be in behavioral health and other specialty settings (e.g., specialists treating chronic renal disease assuming the primary physician role).
Lori Raney, MD, Collaborative Care Consulting, Dolores, Colorado; David Pollack, MD, Department of Psychiatry, Oregon Health & Science University; Joe Parks, MD, Missouri Department of Social Services, Jefferson City, Missouri; Wayne Katon, MD, Division of Health Services and Psychiatric Epidemiology, Department of Psychiatry, University of Washington Medical School. Correspondence concerning this article should be addressed to Lori Raney, MD, Chair of American Psychiatric Association’s Work Group on Integrated Care & Medical Homes, Collaborative Care Consulting, PO Box 248, Dolores, CO 81323. E-mail: [email protected]
Personal Physician Ideally the PCMH physician would be the physician who sees the patient most frequently, and therefore has the greatest opportunity to coordinate care and influence patient health be-
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haviors. For some patient populations this may not be a primary care physician.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Physician-Directed Medical Practice In the case of PCMHs that are not based in primary care clinics, including PCPs as members of the health care teams can be accomplished by connecting with the patient’s PCP through memoranda of understanding, shared electronic health records, and/or community health navigators. Whole-Person Orientation The document asserts that the PCMH is not complete without behavioral health fully incorporated into its operations. Persons with behavioral health conditions usually have multiple chronic medical conditions, in particular the SMI population. A behavioral health organization serving as the PCMH would likewise be incomplete without having general medical care fully incorporated. Quality and Safety In discussing the partnership that includes behavioral health clinicians, we advocate the inclusion of the full range of clinicians deemed essential in the growing evidence base for collaborative care, including psychiatrists and nurse practitioners, psychologists, social workers, and other master’s-level clinicians, some of whom may have specialized roles, responsibilities, and areas of expertise, in addition to and beyond any shared and interoperable roles/competencies. The value of provider-to-provider consultation cannot be overestimated, especially when PCPs need expert consultation and advice regarding the assessment, diagnosis, and treatment of persons with complex and comorbid behavioral health conditions. Multiple treatment plans contribute to fragmentation, errors in care, and confusion. It is a key function of safety and quality that PCMHs assure that each patient has a team using one treatment plan to address both general medical and behavioral health needs. An accreditation of behavioral health organizations must require policies and processes that assure their active collaboration with and support of any PCMH available to the persons they serve.
Additional Critical Issues Separate and unique confidentiality requirements for behavioral health conditions are deeply associated with the still-too-present discrimination and stigma connected to mental disorders. Requiring additional levels of consent, beyond what is required in general medical care, is a significant impediment to the integration of behavioral health into PCMHs and the effective delivery of care by PCMHs to persons with behavioral health conditions. These laws should be modified or repealed to allow the full integration of clinical care. In summary, the APA is grateful for the work that has been done to fully recognize the need for sufficient treatment of behavioral health and primary care conditions in the PCMH, whether that PCMH is based in a fully integrated primary care clinic or a behavioral health setting. References Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., . . . Coventry, P. (2012). Collaborative care for depression and anxiety problems. The Cochrane Database of Systematic Reviews, CD006525. doi:10.1002/14651858 .CD006525.pub2 Katon, W. J., & Seelig, M. (2008). Population-based care of depression: Team care approaches to improving outcomes. Journal of Occupational and Environmental Medicine, 50, 459 – 467. doi: 10.1097/JOM.0b013e318168efb7 Katon, W. J., Lin, E. H. B., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., . . . McCulloch, D. (2010). Collaborative care for patients with depression and chronic illnesses. The New England Journal of Medicine, 363, 2611–2620. doi:10.1056/NEJMoa1003955 The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . deGruy, F. (2014). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm.1633 Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., . . . Langston, C., for the IMPACT Investigators. (2002). Collaborative care management of late-life depression in the primary care setting. JAMA: Journal of the American Medical Association, 288, 2836 –2845. doi: 10.1001/jama.288.22.2836 Received February 28, 2014 Revision received March 12, 2014 Accepted March 12, 2014 䡲
© 2014 American Psychological Association 1091-7527/14/$12.00 DOI: 10.1037/fsh0000045
COMMENTARY
The American Psychiatric Association Response to the “Joint Principles: Integrating Behavioral Health Care Into the Patient-Centered Medical Home”
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Lori Raney, MD, David Pollack, MD, Joe Parks, MD, and Wayne Katon, MD American Psychiatric Association, Washington, DC
The American Psychiatric Association (APA) thanks the Working Party Group on Integrated Behavioral Health Care for the opportunity to respond to the “Joint Principles: Integrating Behavioral Health Care Into the Patient-Centered Medical Home” (The Working Party Group on Integrated Behavioral Healthcare et al., 2014). The APA Workgroup on Integrated Care supports the recommendations made in these Joint Principles and recognizes the significant benefit of treating behavioral and general medical conditions concurrently. We offer comments on this effort as it pertains to health care in general and psychiatric practice.
achieve this goal. Both approaches are important because primary care doctors see many behavioral conditions. Approximately 20% of patients in primary care settings have depression and anxiety, and most primary care physicians (PCPs) struggle to provide good quality care for these disabling conditions (Katon & Seelig, 2008). These disorders also drive overall health care expenditures, and including evidence-based models for treating behavioral health conditions will help the PCMH meet the goal of cost containment while improving outcomes.
Utilizing Evidence-Based Collaborative Care Models
Location of the PCMH Outside of the Primary Care Setting
It is essential that evidence-based models of integrated care be employed in the patientcentered medical home (PCMH). Although there is little evidence that mental health integration into primary care settings alone improves anxiety or depression outcomes, more than 80 randomized clinical trials (Archer et al., 2012) have shown that the Collaborative Care models (IMPACT, Unützer et al., 2002; and TEAMcare, Katon et al., 2010) can effectively
In public mental health settings where patients with serious mental illnesses (SMI) receive most of their care, psychiatrists are often their primary physicians. With new funds made possible by the Affordable Care Act of 2010, Section 2703 State Plan Amendment options allow the PCMH to be located in community mental health centers. Ideally the delivery system will evolve so that most health services would be provided in an integrated fashion in one setting, but until then it is preferable to proceed with the knowledge that some integrated care arrangements will be in behavioral health and other specialty settings (e.g., specialists treating chronic renal disease assuming the primary physician role).
Lori Raney, MD, Collaborative Care Consulting, Dolores, Colorado; David Pollack, MD, Department of Psychiatry, Oregon Health & Science University; Joe Parks, MD, Missouri Department of Social Services, Jefferson City, Missouri; Wayne Katon, MD, Division of Health Services and Psychiatric Epidemiology, Department of Psychiatry, University of Washington Medical School. Correspondence concerning this article should be addressed to Lori Raney, MD, Chair of American Psychiatric Association’s Work Group on Integrated Care & Medical Homes, Collaborative Care Consulting, PO Box 248, Dolores, CO 81323. E-mail: [email protected]
Personal Physician Ideally the PCMH physician would be the physician who sees the patient most frequently, and therefore has the greatest opportunity to coordinate care and influence patient health be-
147
148
RANEY, POLLACK, PARKS, AND KATON
haviors. For some patient populations this may not be a primary care physician.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Physician-Directed Medical Practice In the case of PCMHs that are not based in primary care clinics, including PCPs as members of the health care teams can be accomplished by connecting with the patient’s PCP through memoranda of understanding, shared electronic health records, and/or community health navigators. Whole-Person Orientation The document asserts that the PCMH is not complete without behavioral health fully incorporated into its operations. Persons with behavioral health conditions usually have multiple chronic medical conditions, in particular the SMI population. A behavioral health organization serving as the PCMH would likewise be incomplete without having general medical care fully incorporated. Quality and Safety In discussing the partnership that includes behavioral health clinicians, we advocate the inclusion of the full range of clinicians deemed essential in the growing evidence base for collaborative care, including psychiatrists and nurse practitioners, psychologists, social workers, and other master’s-level clinicians, some of whom may have specialized roles, responsibilities, and areas of expertise, in addition to and beyond any shared and interoperable roles/competencies. The value of provider-to-provider consultation cannot be overestimated, especially when PCPs need expert consultation and advice regarding the assessment, diagnosis, and treatment of persons with complex and comorbid behavioral health conditions. Multiple treatment plans contribute to fragmentation, errors in care, and confusion. It is a key function of safety and quality that PCMHs assure that each patient has a team using one treatment plan to address both general medical and behavioral health needs. An accreditation of behavioral health organizations must require policies and processes that assure their active collaboration with and support of any PCMH available to the persons they serve.
Additional Critical Issues Separate and unique confidentiality requirements for behavioral health conditions are deeply associated with the still-too-present discrimination and stigma connected to mental disorders. Requiring additional levels of consent, beyond what is required in general medical care, is a significant impediment to the integration of behavioral health into PCMHs and the effective delivery of care by PCMHs to persons with behavioral health conditions. These laws should be modified or repealed to allow the full integration of clinical care. In summary, the APA is grateful for the work that has been done to fully recognize the need for sufficient treatment of behavioral health and primary care conditions in the PCMH, whether that PCMH is based in a fully integrated primary care clinic or a behavioral health setting. References Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., . . . Coventry, P. (2012). Collaborative care for depression and anxiety problems. The Cochrane Database of Systematic Reviews, CD006525. doi:10.1002/14651858 .CD006525.pub2 Katon, W. J., & Seelig, M. (2008). Population-based care of depression: Team care approaches to improving outcomes. Journal of Occupational and Environmental Medicine, 50, 459 – 467. doi: 10.1097/JOM.0b013e318168efb7 Katon, W. J., Lin, E. H. B., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., . . . McCulloch, D. (2010). Collaborative care for patients with depression and chronic illnesses. The New England Journal of Medicine, 363, 2611–2620. doi:10.1056/NEJMoa1003955 The Working Party Group on Integrated Behavioral Healthcare; Baird, M., Blount, A., Brungardt, S., Dickinson, P., Dietrich, A., . . . deGruy, F. (2014). Joint principles: Integrating behavioral health care into the patient-centered medical home. Annals of Family Medicine, 12, 183–185. doi:10.1370/afm.1633 Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., . . . Langston, C., for the IMPACT Investigators. (2002). Collaborative care management of late-life depression in the primary care setting. JAMA: Journal of the American Medical Association, 288, 2836 –2845. doi: 10.1001/jama.288.22.2836 Received February 28, 2014 Revision received March 12, 2014 Accepted March 12, 2014 䡲
