New model improves care of patients with mental health needs
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A model that triages primary care patients with unresolved mental health conditions and refers them to appropriate care was seen as “logical and beneficial” to patients and “efficient and cost-effective” to stakeholders, researchers wrote.
Previous clinical trials have shown that traditional collaborative care models can effectively manage mild to moderate depression and anxiety in the primary care setting; however, patients with more severe conditions “typically require more care than this model provides,” Courtney Benjamin Wolk, PhD, an assistant professor at the Penn Center for Mental Health at the University of Pennsylvania, and colleagues wrote in Annals of Family Medicine.
To that end, they developed and implemented the Penn Integrated Care (PIC) program.
In the PIC program, primary care clinicians use the electronic health record to refer patients with mental health symptoms to an intake, triage and referral management resource center, where patients are assessed over the telephone.
“A mental health intake coordinator conducts a structured assessment with the patient by phone using validated measures,” Wolk told Healio Primary Care. “Then, guided by an algorithm, the resource center determines the appropriate level of care for the patient and connects them to that care.”
Some patients, Wolk continued, are referred to outpatient mental health specialty care, while others are referred to a mental health provider embedded within in the primary care practice for collaborative mental health care.
“Those with very mild symptoms are given self‐directed resources,” she added.
Wolk noted that “a major impetus” for the PIC program was the recent implementation of collaborative care CPT codes — 99492 through 99494 — which are critical to the ensuring the financial well-being of the program.
“They are time-based codes that allow for time spent by any member of the collaborative care team, including the primary care clinician, mental health care manager and consulting psychiatrist to be reimbursed,” she said. “The collaborative care codes have been a game changer for the integration of mental health services in primary care.”
The PIC program was initially implemented in eight primary care practices. Wolk and colleagues conducted an analysis to evaluate the effectiveness of the program.
In 12 months, 5,931 patients were referred to the PIC Resource Center. Among the 3,645 patients who were screened, 961 (26.4%) received an appointment with the mental health professional within the primary care practice, 2,553 (70%) were referred to community-based mental health care, 17 (0.5%) received self-management resources, and 114 (3.1%) declined treatment referrals.
Among patients with two or more PIC encounters, 32.6% with depression and 39.5% with anxiety achieved remission of symptoms, according to the researchers. Stakeholder groups who were interviewed about the program perceived it as effective, and patients said the program was “helpful” and a “great experience.” Meanwhile, primary care clinicians “appreciated that they had a place to refer patients,” the researchers wrote.
“By taking these triage, assessment and referral management activities off the plate of the clinicians in the primary care practices, it allows those clinicians more time to focus on delivering evidence‐based mental health interventions to the patients most likely to benefit from this level of care,” Wolk said. “We think Penn Integrated Care is an efficient model for connecting patients to care and it allows all members of the team to work at the top of their license.”
She acknowledged that similar programs may need to be tailored based on “unique needs and resources,” but added that “our primary care clinics and clinicians love having this highly integrated program.”
“They tell us that they are able to provide better overall care to their patients because of it,” she said.
All eight practices that implemented the program continue to use it, “demonstrating 100% sustainability,” the researchers wrote. It has since been expanded to two additional primary care practices and approved for implementation in four more practices.
Perspective
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This is a promising model to improve access to mental health services.
Even in urban and suburban areas, patients’ ability to establish with coordinated psychiatric services can be limited. Even in primary care, it can be difficult to coordinate this care for our highest-risk patients. All too often, these patients “fall through the cracks.”
Many times, the very conditions they are being referred for make self-advocacy and coordination of their own care challenging to impossible. The ability to make this referral directly through the patient’s EMR makes it easy for providers to utilize. Including an option for self-referral by patients allows for access without direct engagement by the primary care provider. An embedded mental health practitioner would be able to accurately triage patients to the right level of support services. A psychiatrist to consult regarding medication changes and options would be invaluable and decrease the need for these patients to fully establish with a psychiatrist for the long term.
This model could be replicated by other mental health service providers and would dramatically increase coordination and quality of care that these patients receive.
Assistant Professor, Associate Program Director and Medical Director, Rowan Family Medicine of Stratford
Rowan University School of Osteopathic Medicine
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