Collaborative Care, Community C-L
Primary care providers (PCPs) provide nearly half of all care for common mental health conditions yet accessing timely psychiatric consultation is exceedingly difficult. Integrated Behavioral Health (IBH) models strive to improve access, outcomes, and costs and have yielded significant advantages compared to usual primary care. A common broad definition of IBH – delivering behavioral health care through primary care services – includes a range of approaches including linking behavioral health expertise via hub-based immediate telephone consultation, utilizing behavioral health-trained care managers, patient-centered medical homes, and co-locating into primary care clinics. A Cochrane systematic review has shown that collaborative care, the IBH model with the strongest evidence base, significantly improves depression and anxiety outcomes in the short, medium, and long-term.
Electronic consultation (e-Consultation) is a valuable approach within integrated care systems and can satisfy a significant number of the requests for specialist advice. Many questions can be addressed through a chart review without in-person evaluations. e-Consultations can thus reduce unnecessary visits to consultants and provide recommendations for patients reluctant (or unable) to make a scheduled appointment. Additional benefits of e-Consultations include short wait times, scalability, and a user-friendly interface. Increased availability of billing codes to support this modality allows for greater feasibility and may be of particular benefit for Medicaid recipients.
Several models of e-Consultations have been successfully implemented in the US. We will present models from Cambridge Health Alliance (CHA), Boston Medical Center (BMC), and the University of California Davis (UCD). Common features of these valuable programs include asynchronous communication, ease of access, timely response, and PCP education. Each program will be described, and utilization data will be reported. Advantages and operational requirements of each model will be presented - with audience participation invited - with the goal of encouraging local implementation efforts.
The UCD team will summarize implementation and program data for an e-Consultation program across 14 primary care sites. At UCD, e-Consultations are an important component of a stepped IBH program. This model includes universal screening, e-Consultations, collaborative care model (CoCM), telepsychiatry services, and embedded psychiatry consultants.
At CHA, a safety-net organization, e-Consultations were implemented in 2015, as part of a larger CoCM in all 12 primary clinics within the system. Two consultation services are provided: Telephonic consultations are used for time-sensitive issues; e-Consultations for more routine questions. About 30 consults per month were performed and yielded high user satisfaction.
BMC provides e-Consultations upon request to PCPs but has expanded this concept by making recommendations when: 1) a patient fails to show for an in-person consultation and 2) when a psychotherapist raises the question of whether a medication may be indicated.