SIM practice transformation series - part 3

This is the third in a series of articles that profile the work that practice transformation organizations and practices are doing to integrate behavioral and phyical healthcare. To read the first, please click here, to read the second click here.

What you need to succeed in integrated settings

By Rachel Griffin, NP, a psychiatric nurse, who has experience in healthcare settings at various levels of care integration. She works for two practices in the first cohort of the Colorado State Innovation Model (SIM) and shares her perspectives on how integrated care affects patients and providers, and what unique skill sets behavioral health providers need to succeed in integrated environments.

There is a noticeable difference between seeing patients in a mental health setting compared with a practice where patients also receive primary care, which makes communication among providers much simpler.

I provide psychiatric consultation to the UCHealth Department of Internal Medicine, one of 92 practices in cohort 1 for the Colorado State Innovation Model (SIM), a federal initiative funded by the Centers for Medicare & Medicaid Services. I also provide mental services via telehealth for the UC Health Sterling (Colorado) Primary Care clinic, another SIM cohort 1 practice, and work two afternoons per week in the UC Health Infectious Disease clinic.

Practical experience

We started planning the transition to an integrated care model for the family medicine clinic in Sterling in 2015, and launched the new model (funded in part by SIM) in February 2016. The clinic hired a full-time psychologist and I provide four hours of consultation for psychiatric medications each week via telehealth.

I see patients for an initial evaluation and have one or two follow-ups before I make recommendations for medication and other treatments and refer back to primary care providers for ongoing management of psychotropic medications.

The goal is to provide a light touch. I am able to see more patients if I provide support to primary care providers instead of adding patients to my caseload. Patients with chronic mental illness, those whose conditions significantly impairs their ability to function, are referred to a higher-level mental health facility when possible.

Addressing stigma

This model has been very successful. Primary care providers have expressed gratitude for support from mental health providers and not being solely responsible for managing mental health conditions. Many patients have also expressed greater satisfaction with this model.

Some patients in the community are concerned about the stigma of being seen at a mental health clinic and find it less "scary" to see mental health providers at a primary care doctor's office.

Different skills required

Working in integrated care models requires a lot of flexibility. In a traditional mental health model, your time is protected, fairly standardized and regimented. You get a set amount of time to see each of your patients during set appointment times, and if they miss appointments or come in late they have to reschedule. Integrated care models don't have those same parameters or boundaries. You have to be comfortable being available to see patients as needed. You have to learn how to triage patients, which requires answers to these questions:

  • Is this crisis management or a warm hand-off?
  • What are the key questions that you need to ask to make initial treatment decisions? 

You likely won't get to see that patient for 50 minutes so you have to get essential information quickly. I have had success asking focused questions about a patient’s history, asking medical providers to share background when possible, and asking if they have a specific concern that they’d like me to address.

Using care teams

Working in integrated settings also requires a different level of teamwork. You have to build relationships with primary care providers by discussing cases and making recommendations while realizing that this is a team approach to care. The treatment plan you provide is a suggestion that will be jointly implemented. When I see a patient I will make recommendations for psychiatric medications and assess whether he or she would benefit from additional mental health services. However, the primary care provider is often responsible for prescribing or continuing the use of medications.

There might be times that you aren't in full agreement with a primary care provider about the best course of action and you need to work together without putting a patient in the middle. For example, if a primary care doctor is ultimately responsible for a patient's ongoing medication management, he or she might have questions or concerns about a psychiatric provider’s recommendation and you have to work together to find a successful compromise.

Whole-person care

The key is to take a joint ownership approach and deliver whole-person treatment versus allowing different providers to treat individual parts of a patient. This requires a shift in mindset: The patient as a whole belongs to the team as whole, which is why case conferences to discuss patients are important.

For example, every time I see a patient via telehealth for the Sterling clinic, I send a copy of my notes and treatment recommendations to the psychologist and primary care provider. They often do the same for me when they see a patient with whom I have consulted. We work as a team.

I enjoy knowing that the patients I see have their medical issues addressed and have an easy line of communication between me and the medical providers. It's been a really rewarding project.

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