Mental Health, Primary Care Collaborations Can Work

NEW YORK – Integrating mental health care into primary care settings offers clear benefits for patients and providers. However, careful planning is key to making these models work, clinicians said at the American Psychiatric Association’s Institute on Psychiatric Services.

Among the challenges psychiatrists, social workers, and other mental health clinicians face when trying to merge their services into a primary practice are resistance to collaboration among primary care physicians and other non–mental health clinicians, stigma regarding mental health diagnoses and treatment, communications issues, and the difficulties of treating complex patients, said Dr. Orit Avni-Barron, a psychiatrist at the Gretchen S. and Edward A. Fish Center for Women’s Health at Brigham and Women’s Hospital in Boston.

"When you work with people who are [primary care physicians], dermatologists, or surgeons, they don’t exactly know what mental health [services] can do for them," she said. "They expect things to be fast and to be a certain way, and we need to manage those expectations. In addition, because ours is an outpatient setting, we deal with very medically complex patients who have multiple Axis III diagnoses – a lot of medical issues – in addition to Axis I and Axis II problems," she added.

The five essential elements for effective integration of mental health services are self-definition, interdisciplinary team work, effective communication, limit setting, and education, Dr. Avni-Barron said.

‘Not Hidden in a ... Corner’

Mental health teams must clearly define their role within a practice, said Suzanne Etre, one of two clinical psychiatric social workers at the Fish Center. Given their large staff-to-patient ratio (three MDs and two social workers comprising 2.9 full-time equivalent staff), the mental health staff decided that the only practical approach was to define the service as short term by offering assessments and consultations. Staff physicians perform medical evaluations, recommend medications, and follow patients until they are stable.

Staff social workers help patients with cognitive-behavioral and solution-focused interventions, and also assist with adjustment disorders or bereavement issues. Patients with trauma or more extensive needs for psychiatric services are referred to other providers.

The mental health staff work with primary care physicians within the clinic, share expertise in patient management, and build trust through repeated interactions and scheduled team meetings so that each team member understands the capabilities and limits of the mental health service.

"We try to optimize the value of repeated interaction so that we’re not hidden in a little corner of the practice, and we repeatedly try to build that trust – them with us and us with them. It really helps us to clarify what our roles are," Ms. Etre said.

Setting Limits Key to Success

Primary care practices with a small mental health staff cannot be everything to everyone, and therefore must establish clear limits for both patients and clinicians working in the practices, said Lynn Curran, also a clinical psychiatric social worker at the Fish Center.

Mental health staff members model how to set boundaries and support the ongoing efforts of other clinicians in the practice to maintain them, she said.

The mental health staff members are available for support in situations in which primary care physicians might feel uncomfortable, such as addressing the needs of an urgent care visit patient who appears vaguely suicidal. In such cases, a nurse or primary care physician can have a curbside consult with the mental health clinician on site, or the psychiatric worker might go to the treatment room and role-play the most effective interaction.

The benefits of limit setting, Ms. Curran said, are a reduction in excessive phone calls or patients visits, and an overall reduction in the use of services.

Staff Buy-in Is Essential

At the University of Toronto, this model is called "collaborative care," but the essential goals are the same, said Dr. Diana Kljenak, who is affiliated with the university. She described her experience working to integrate mental health services with six Toronto-area health centers and a hospital-based mental health program. The collaborative arrangement is collectively known as the Toronto Urban Health Alliance (TUHA).

Getting clinical staff and leadership to buy in into the concept is crucial for success. "You can’t do much on your own; you do need leadership support to develop collaborative care," Dr. Kljenak said.

As in Massachusetts, mental health workers in Toronto have to make maximum use of limited resources. Under the TUHA model, mental health staff are colocated in primary care facilities in settings that are familiar to patients and that are not stigmatizing.

Each community health center has a psychiatrist and mental health staffer who provide consultations and services for clients who might not be insured, such as refugees or recent immigrants. Such patients also might not be proficient in English or have a community health center physician.

Psychiatric services are provided on site one-half day each week, and mental health workers are available to health center clinicians for telephone consultations weekdays from 9 a.m. to 5 p.m. Health center clinicians also have 24-hour direct psychiatric emergency services privileges.

"If clinicians want to refer a patient to a psychiatry emergency department, we make sure that they have easy access, [and] that once they get in contact with us and discuss the case with us, they don’t have to wait for hours for medical clearance," Dr. Kljenak said.

All staff members of each community health center receive twice-yearly half-day education in mental health issues identified as being of primary importance to community clinicians.

"Collaborative mental health care is not a fixed model or a specific approach. Its goal is to strengthen the accessibility and delivery of mental health services in primary health settings through interprofessional collaboration, and to provide more coordinated and effective services for individuals with mental health needs," Dr. Kljenak said.

Dr. Avni-Barron, Ms. Etre, Ms. Curran, and Dr. Kljenak reported having no conflicts of interest to disclose.

NEW YORK – Integrating mental health care into primary care settings offers clear benefits for patients and providers. However, careful planning is key to making these models work, clinicians said at the American Psychiatric Association’s Institute on Psychiatric Services.

Among the challenges psychiatrists, social workers, and other mental health clinicians face when trying to merge their services into a primary practice are resistance to collaboration among primary care physicians and other non–mental health clinicians, stigma regarding mental health diagnoses and treatment, communications issues, and the difficulties of treating complex patients, said Dr. Orit Avni-Barron, a psychiatrist at the Gretchen S. and Edward A. Fish Center for Women’s Health at Brigham and Women’s Hospital in Boston.

"When you work with people who are [primary care physicians], dermatologists, or surgeons, they don’t exactly know what mental health [services] can do for them," she said. "They expect things to be fast and to be a certain way, and we need to manage those expectations. In addition, because ours is an outpatient setting, we deal with very medically complex patients who have multiple Axis III diagnoses – a lot of medical issues – in addition to Axis I and Axis II problems," she added.

The five essential elements for effective integration of mental health services are self-definition, interdisciplinary team work, effective communication, limit setting, and education, Dr. Avni-Barron said.

‘Not Hidden in a ... Corner’

Mental health teams must clearly define their role within a practice, said Suzanne Etre, one of two clinical psychiatric social workers at the Fish Center. Given their large staff-to-patient ratio (three MDs and two social workers comprising 2.9 full-time equivalent staff), the mental health staff decided that the only practical approach was to define the service as short term by offering assessments and consultations. Staff physicians perform medical evaluations, recommend medications, and follow patients until they are stable.

Staff social workers help patients with cognitive-behavioral and solution-focused interventions, and also assist with adjustment disorders or bereavement issues. Patients with trauma or more extensive needs for psychiatric services are referred to other providers.

The mental health staff work with primary care physicians within the clinic, share expertise in patient management, and build trust through repeated interactions and scheduled team meetings so that each team member understands the capabilities and limits of the mental health service.

"We try to optimize the value of repeated interaction so that we’re not hidden in a little corner of the practice, and we repeatedly try to build that trust – them with us and us with them. It really helps us to clarify what our roles are," Ms. Etre said.

Setting Limits Key to Success

Primary care practices with a small mental health staff cannot be everything to everyone, and therefore must establish clear limits for both patients and clinicians working in the practices, said Lynn Curran, also a clinical psychiatric social worker at the Fish Center.

Mental health staff members model how to set boundaries and support the ongoing efforts of other clinicians in the practice to maintain them, she said.

The mental health staff members are available for support in situations in which primary care physicians might feel uncomfortable, such as addressing the needs of an urgent care visit patient who appears vaguely suicidal. In such cases, a nurse or primary care physician can have a curbside consult with the mental health clinician on site, or the psychiatric worker might go to the treatment room and role-play the most effective interaction.

The benefits of limit setting, Ms. Curran said, are a reduction in excessive phone calls or patients visits, and an overall reduction in the use of services.

Staff Buy-in Is Essential

At the University of Toronto, this model is called "collaborative care," but the essential goals are the same, said Dr. Diana Kljenak, who is affiliated with the university. She described her experience working to integrate mental health services with six Toronto-area health centers and a hospital-based mental health program. The collaborative arrangement is collectively known as the Toronto Urban Health Alliance (TUHA).

Getting clinical staff and leadership to buy in into the concept is crucial for success. "You can’t do much on your own; you do need leadership support to develop collaborative care," Dr. Kljenak said.

As in Massachusetts, mental health workers in Toronto have to make maximum use of limited resources. Under the TUHA model, mental health staff are colocated in primary care facilities in settings that are familiar to patients and that are not stigmatizing.

Each community health center has a psychiatrist and mental health staffer who provide consultations and services for clients who might not be insured, such as refugees or recent immigrants. Such patients also might not be proficient in English or have a community health center physician.

Psychiatric services are provided on site one-half day each week, and mental health workers are available to health center clinicians for telephone consultations weekdays from 9 a.m. to 5 p.m. Health center clinicians also have 24-hour direct psychiatric emergency services privileges.

"If clinicians want to refer a patient to a psychiatry emergency department, we make sure that they have easy access, [and] that once they get in contact with us and discuss the case with us, they don’t have to wait for hours for medical clearance," Dr. Kljenak said.

All staff members of each community health center receive twice-yearly half-day education in mental health issues identified as being of primary importance to community clinicians.

"Collaborative mental health care is not a fixed model or a specific approach. Its goal is to strengthen the accessibility and delivery of mental health services in primary health settings through interprofessional collaboration, and to provide more coordinated and effective services for individuals with mental health needs," Dr. Kljenak said.

Dr. Avni-Barron, Ms. Etre, Ms. Curran, and Dr. Kljenak reported having no conflicts of interest to disclose.

NEW YORK – Integrating mental health care into primary care settings offers clear benefits for patients and providers. However, careful planning is key to making these models work, clinicians said at the American Psychiatric Association’s Institute on Psychiatric Services.

Among the challenges psychiatrists, social workers, and other mental health clinicians face when trying to merge their services into a primary practice are resistance to collaboration among primary care physicians and other non–mental health clinicians, stigma regarding mental health diagnoses and treatment, communications issues, and the difficulties of treating complex patients, said Dr. Orit Avni-Barron, a psychiatrist at the Gretchen S. and Edward A. Fish Center for Women’s Health at Brigham and Women’s Hospital in Boston.

"When you work with people who are [primary care physicians], dermatologists, or surgeons, they don’t exactly know what mental health [services] can do for them," she said. "They expect things to be fast and to be a certain way, and we need to manage those expectations. In addition, because ours is an outpatient setting, we deal with very medically complex patients who have multiple Axis III diagnoses – a lot of medical issues – in addition to Axis I and Axis II problems," she added.

The five essential elements for effective integration of mental health services are self-definition, interdisciplinary team work, effective communication, limit setting, and education, Dr. Avni-Barron said.

‘Not Hidden in a ... Corner’

Mental health teams must clearly define their role within a practice, said Suzanne Etre, one of two clinical psychiatric social workers at the Fish Center. Given their large staff-to-patient ratio (three MDs and two social workers comprising 2.9 full-time equivalent staff), the mental health staff decided that the only practical approach was to define the service as short term by offering assessments and consultations. Staff physicians perform medical evaluations, recommend medications, and follow patients until they are stable.

Staff social workers help patients with cognitive-behavioral and solution-focused interventions, and also assist with adjustment disorders or bereavement issues. Patients with trauma or more extensive needs for psychiatric services are referred to other providers.

The mental health staff work with primary care physicians within the clinic, share expertise in patient management, and build trust through repeated interactions and scheduled team meetings so that each team member understands the capabilities and limits of the mental health service.

"We try to optimize the value of repeated interaction so that we’re not hidden in a little corner of the practice, and we repeatedly try to build that trust – them with us and us with them. It really helps us to clarify what our roles are," Ms. Etre said.

Setting Limits Key to Success

Primary care practices with a small mental health staff cannot be everything to everyone, and therefore must establish clear limits for both patients and clinicians working in the practices, said Lynn Curran, also a clinical psychiatric social worker at the Fish Center.

Mental health staff members model how to set boundaries and support the ongoing efforts of other clinicians in the practice to maintain them, she said.

The mental health staff members are available for support in situations in which primary care physicians might feel uncomfortable, such as addressing the needs of an urgent care visit patient who appears vaguely suicidal. In such cases, a nurse or primary care physician can have a curbside consult with the mental health clinician on site, or the psychiatric worker might go to the treatment room and role-play the most effective interaction.

The benefits of limit setting, Ms. Curran said, are a reduction in excessive phone calls or patients visits, and an overall reduction in the use of services.

Staff Buy-in Is Essential

At the University of Toronto, this model is called "collaborative care," but the essential goals are the same, said Dr. Diana Kljenak, who is affiliated with the university. She described her experience working to integrate mental health services with six Toronto-area health centers and a hospital-based mental health program. The collaborative arrangement is collectively known as the Toronto Urban Health Alliance (TUHA).

Getting clinical staff and leadership to buy in into the concept is crucial for success. "You can’t do much on your own; you do need leadership support to develop collaborative care," Dr. Kljenak said.

As in Massachusetts, mental health workers in Toronto have to make maximum use of limited resources. Under the TUHA model, mental health staff are colocated in primary care facilities in settings that are familiar to patients and that are not stigmatizing.

Each community health center has a psychiatrist and mental health staffer who provide consultations and services for clients who might not be insured, such as refugees or recent immigrants. Such patients also might not be proficient in English or have a community health center physician.

Psychiatric services are provided on site one-half day each week, and mental health workers are available to health center clinicians for telephone consultations weekdays from 9 a.m. to 5 p.m. Health center clinicians also have 24-hour direct psychiatric emergency services privileges.

"If clinicians want to refer a patient to a psychiatry emergency department, we make sure that they have easy access, [and] that once they get in contact with us and discuss the case with us, they don’t have to wait for hours for medical clearance," Dr. Kljenak said.

All staff members of each community health center receive twice-yearly half-day education in mental health issues identified as being of primary importance to community clinicians.

"Collaborative mental health care is not a fixed model or a specific approach. Its goal is to strengthen the accessibility and delivery of mental health services in primary health settings through interprofessional collaboration, and to provide more coordinated and effective services for individuals with mental health needs," Dr. Kljenak said.

Dr. Avni-Barron, Ms. Etre, Ms. Curran, and Dr. Kljenak reported having no conflicts of interest to disclose.