Therefore, not only are patients with SMI less likely to receive preventive care, they are also less likely to receive potentially lifesaving treatments for SMI. Because those with SMI might not be able to advocate for themselves in these matters, psychiatric clinicians can improve their patients’ lives by advocating for appropriate medical care despite multiple barriers.
Bridging the gap: Managing mental health in primary care
Research from the 1970s and 1980s demonstrated that most persons who sought help for depression or anxiety received treatment from their PCP, many of whom felt limited by their lack of behavioral health training. Moreover, many patients failed to receive a psychiatric diagnosis or adequate treatment, despite efforts to educate primary care physicians on appropriate diagnosis and treatment of mental illness.
Katon et al25 at the University of Washington developed the collaborative care model in the early 1990s to help improve treatment of depression in primary care settings. This model involved:
• case load review by psychiatrists
• use of nurses and other support staff to help monitor patients’ adherence and treatment response
• use of standardized tools such as the Patient Health Questionnaire to monitor symptoms
• enhancement of patient education with pamphlets or classes.
Studies evaluating the success of collaborative care models found overall improved outcomes, making it the only evidence-based model for integration of behavioral health and primary care.26 As a result, the collaborative care model has been implemented across the United States in primary care clinics and specialty care settings, such as obstetrics and gynecology.27
Regrettably, access to primary care has been hampered by:
• population growth
• a shortage of PCPs
• enrollment of a flood of new patients into the health care marketplace as a result of mandates of the Affordable Care Act (ACA).
In many settings, a psychiatrist might be the patient’s only consistent care provider, and could be thought of as a “primary care psychiatrist.”
To resolve this predicament, mental health professionals need to recognize the unique medical conditions faced by people with SMI, and also might need to provide treatment of common medical conditions, either directly or through collaborative arrangements. Psychiatrists who are capable of managing core medical issues likely will witness improved psychiatric and overall health outcomes in their patients. Consequently, psychiatrists and mental health professionals are increasingly called on to be advocates to improve access to medical services in patients with SMI and to participate in health systems reform.
Managing medical conditions in mental health settings
Although traditional collaborative care involves mental health providers working at primary care sites, other models have emerged that manage chronic disease in behavioral health settings. Federally funded grants for primary behavioral health care integration have allowed community mental health centers to partner with federally qualified health centers to provide on-site primary care services.28
In these models, care managers in mental health clinics:
• link patients to primary care services
• encourage lifestyle changes to improve their overall health
• identify and overcome barriers to receiving care
• track clinical outcomes in a registry format.
Currently, 126 mental health sites in the United States have received these grants and are working toward greater integration of primary care.
In addition, the ACA provided funding for “health homes” in non-primary care settings, which includes SMI. These health homes cannot provide direct primary care, but can deliver comprehensive care management, care coordination, health promotion, comprehensive transitional care services between facilities, individual and family support, and referral to community social support services. In these health homes, a PCP can act as a consultant to help establish priorities for disease management and improving health status.29 The PCP consultant also can support psychiatric staff and collaborate with providers who want to provide some direct care of medical conditions.30
Last, some behavioral health sites are choosing to apply for Federally Qualified Health Clinic status or add primary care services to their clinics, with the hope that sustainable funding will become available. Without additional funding to cover the limited reimbursement provided by public payers, such as Medicaid and Medicare, these models might be unsustainable. Current innovations in health care funding reform hopefully will offer solutions for sites to provide medical care in the natural “medical home” of the SMI population.
Bottom Line
Psychiatric providers are in a favorable position to develop and oversee a partnership with primary care physicians with the goal of addressing significant and often lethal health disparities among those with mental illness. Psychiatric providers must use evidence-based practices that include assessment and prevention of cardiopulmonary, metabolic, infectious, and oncologic disorders. True primary care–behavioral health integration must include longitudinal “cross education” and changes in health care policy, with an emphasis on decreasing morbidity and mortality in psychiatric patients.