I want to tell you a story that is both personal and also parallels the evolution of primary care and collaborative care over the past decade and predicts its future.
I arrived in San Diego to take over the Division of Family Medicine at UCSD in the fall of 2001. I came from “the East” where I had been at George Washington University Medical Center and School of Medicine (GW) for the preceding 20 years. My clinical primary care practice fortuitously shared a waiting area with the outpatient mental health team. It was a short walk to the therapists’ offices and in the course of wandering over to seek help on various patients I met a clinical psychologist with whom I developed a close working and collegial relationship. When I needed help with a patient I would seek his counsel and/or refer the patient over to the group with an “Attention Pat” comment on the referral. I ended up hiring him to be the psychologist in our new family medicine residency program. We did an international consultation together for an Eastern European country’s developing academic family medicine program, and he introduced me to the concept of motivational interviewing, among other things. I began to realize that without this kind of key help the practice of primary care/family medicine would be a lot harder. I began to talk with a psychiatrist who headed the 3rdyear clerkship about deeper collaboration, but then circumstances changed significantly at GW and I decided to move. Long story made short, I ended up taking up the leadership of the UCSD Division of Family Medicine.
One of the most pleasant and propitious surprises on arrival was that there was an outstanding group of academic PhD marriage and family therapists (MFT) from the University of San Diego (USD) who were in discussions with our UCSD Psychiatry Department about transferring their activities to UCSD from the Sharp Family Medicine Residency which, unfortunately, was winding down to closure. Todd Edwards and JoEllen Patterson were the dynamic duo I was privileged to meet. Unfortunately, these discussions were mired down with our Psych folks in what seemed like a circular and non-progressing research-oriented discussion. Being the new kid on the block, I was able to ingratiate myself with the Chair of Psychiatry and got him to “let our people go” and actually set up a clinical operation where we could deliver co-located care along with directly observed behavioral science teaching sessions (fondly referred to as “BS Sessions”) within our family medicine offices.
This began our decade-long effort to “do good” rather than just talk about studying how to do good. And the journey has reflected every aspect of the maturation of collaborative care that I have witnessed during my 15-year tenure with CFHA. I had the privilege of being at the founding meeting of CFHA in DC in 1996. One of my colleagues at GW, Karen Weihs, was a skilled researcher-clinician, an FP-psychiatrist who was one of the first-generation conceivers of CFHA. I was intermittently active for the next 5 years before coming to San Diego, and once we began to deliver collaborative care I became more involved and have been a regular CFHA attender since Seattle, where we presented on our initial UCSD efforts. During this period, STFM extended a key organizational avuncular helping hand as CFHA adopted the mantel of the sun-setting Family in Family Medicine conference and its faithful attendees.
Our system has been somewhat unique all along in that we use trainees from USD’s Marriage and Family Therapy Program along with both a supervising PhD MFT and a psychologist who are both on our department of family medicine faculty. This solves some of the financial challenges and is a disseminatable component of what we’ve built. In short, we bill patients for co-pays only for student and intern visits, which respectively either contributes to supervision costs or for paying the interns their nominal hourly pay. If patients wish to see a licensed person we have them see the supervisors and bill insurance accordingly. Medicaid patients are seen by students/interns on a reduced-fee sliding scale. Additional supervision costs are borne by our clinical budget as a justifiable expense for having this clinical service – which clinicians recognize the benefits of and are willing to pay for just like they do for general nursing support.
The system of collaboration we built initially relied on physician education and orientation, physician referral of patients they identified as needing help with common mental health and family issues, and a paper referral system, which actually introduced our faculty to “genograms” as a baseline referral data requirement (pretty sneaky, eh?). Therapists shared space in our offices and saw patients in exam rooms mostly, and offices sometimes if needed and available. Each of these elements has seen substantial evolution over the ensuing years as our national discussion, experience, and knowledge about collaborative care has grown and been shared largely through CFHA efforts. I will detail these a bit.
- Culture – We started with surveying faculty and residents about their views on the importance of mental health and behavioral health issues; their ability to engage and assist patients with these problems; their need for help in such efforts; and their belief that these problems in fact could be helped. We went from “Who are these behavioral people?” to a now universal awareness of how ubiquitous such mental/behavioral problems are in primary care and what such teammates and colleagues bring to the table in successfully caring for the whole patient. We now tout our collaborative care team as a selling feature of our practice to potential faculty and to candidates for our family medicine residency.
- Affiliation/Space – Initially our interns were employed by the Psychiatry Department, and when we hired our first supervising faculty MFT – Michele Smith – and our first clinically active psychologist – Bill Sieber – we had to do so with approval from Psychiatry. Over the course of the first few years we wrested that control from Psychiatry and have directly hired and overseen all our licensed folks and interns within family medicine. As we have grown we have dealt with space wars about who should be seeing patients in increasingly limited exam room space to now incorporating our collaborative care needs into our most recent building plans for new office construction.
- Medical Records/Communication – We computerized our practice in 2005 with the EPIC electronic medical record (EMR) system and converted our referral system into the computerized medical record. We now do all referrals through the EMR, which has increased both use and tracking efficiency. However, as many have experienced, we lost our genogram abilities; we hope this is temporary and are working on ways to re-computerize this most useful social data recording function. We dealt with the HIPAA challenges and achieved the ability for our therapists to write their notes in a reasonably unrestrictive manner within the EMR so that they include enough useful data to apprise collaborating family docs of the issues, therapeutic approach, and progress being made on their referred patients. Our docs are universally cc’d on ALL notes from collaborative care. In fact, this initially decreased oral and interpersonal communication, but this has since rebounded strongly under our new T-Care system (see below).
- Referral Process/T-Care – Under the new leadership of Zephon Lister we have developed T-Care – a effort directed at identifying patients who may benefit from collaborative care. Rather than just allowing the docs to identify patients needing referral we now have collaborative sessions where MFT students work with docs in their assigned exam rooms to review the roster of patients together and determine who might need collaborative care services. Sometimes the MFT student goes in first, and sometimes with the doc, and sometimes even staying after a while with the patient. These initial shared collaborative sessions intimately teach the doc and the MFT student about each others’ mental/behavioral health and communication abilities, help identify problems and issues that were NOT known to the doc beforehand, and facilitate follow up referrals to our CC team. The time to “collegial level peer relationship” between new MFT students and our physician staff has been cut dramatically through these T-Care joint sessions. Initially, each MFT student spends a couple sessions with each doc so they can “get to know each other.” By rotating around between docs, everyone gets to know everyone in a few months rather than a year or more. Once the MFT students get to know everyone they can provide T-Care services for 2-3 docs a session, identifying patients on all their schedules who might benefit from collaborative care services.
- Screening – Finally, with this structure of care in place and with our ability to use data from our EMR we were able to respond to the new US Preventive Services Task Force recommendation for universal screening for depression if and only if the care system has a way to respond to those patients identified by screening. We had spent years developing our service arm and it was time to complete the work by embarking on the task of identifying ALL the patients in need of such services. We were able to initiate universal PHQ2-PHQ9 sequenced screening on all our patients over an amazingly short 3-4 week period this past spring. We are now preparing to add anxiety screening. Each of these efforts involves teaching our medical assistants new skills and developing EMR data recording capabilities and back-end data analysis reports to evaluate efficiency and measure outcomes (referrals to CC, diagnostic labeling of problem list, medication prescribing and effects on medical co-morbidities). We are excited to further expand our efforts to cover all common mental and behavioral health issues in our practices.
What this progression details is the inner workings of our development of increasingly sophisticated collaborative care and how important this has been to our practice. This has been true with regard to specifically providing mental/behavioral and family therapy services for our patient population. But even more important going forward is how effective this effort has been in generating a GENERAL TEMPLATE for incorporating additional team members’ efforts within the new practices we are trying to build today. Now collectively referred to as the “patient centered medical home” (PCMH) and supported by STFM and all primary care specialties, this concept is solidly built on the concept of team-delivered care, with many health professionals working together to provide the care that any patient population needs to care for their chronic illnesses and to stay as well and functional as possible. We have used our successful collaborative care template to replicate the introduction of pharmacy services, acupuncture/TCM services, and RN care-management services. We are, in fact, now planning the introduction of health coaching services, to complete the full range of team skills for our PCMH practices. For these coaching services we will actually employ our MFT students in true behavioral health counseling roles in addition to more traditional mental health roles. Thus, our CC efforts have really led and guided our efforts to develop a fully functional, one-stop-shopping patient-centered medical home.
We believe, from our own experience and from the influential work CFHA leadership has done leading to the successful incorporation of the requirement to attend to mental/behavioral conditions in order to qualify for PCMH status – as certified by the National Center for Quality Assurance (NCQA), that collaborative care will be central to the new PCMHs primary care is developing all across the nation. This is why we agree wholeheartedly with the words of our past CFHA President, Frank deGruy, “Without collaborative care – the PCMH fails!”
This is the second in a series of collaborative blog posts between the Collaborative Family Healthcare Association and the Society of Teachers of Family Medicine.