During my outpatient psychiatry rotations as a resident, I recall working with a patient who seemed to meet criteria for illness anxiety disorder (IAD). Feeling uncertain about the diagnosis, I discussed this patient extensively with my supervisor, who eventually suggested that I reach out to the patient’s PCP to see what they thought. Conveniently, the PCP was located in the same clinic; we were soon able to organize a meeting. In my conversation with them, I was able both to share my concerns, and to confirm that I was not the only physician who had considered IAD. I recall the PCP saying, “I’m so glad you reached out, because I had been thinking something similar during our appointments together, but had no idea how to address it with her. I knew she was in treatment with you, but was not sure if this was being discussed at all.” We had a fruitful and productive conversation about next steps and how we could collaborate to best care for this patient.
The model I had been working in was a “co-location” model, in which the patient’s primary care physician and behavioral health specialist work in the same practice. This certainly made it easier to contact each other and to meet, as well as to view each other’s documentation and lab work — though I wonder if the process of collaboration would have been even easier had we been working within a collaborative care model.
Per the American Psychiatric Association, a collaborative care team is “led by a primary care provider (PCP) and includes behavioral health care managers, psychiatrists and frequently other mental health professionals.” Though the co-location of services is also a part of this model, a major difference is the inclusion of the behavioral health care manager, who can serve as a liaison between the PCP and the consulting psychiatrist and help implement action items from a patient’s treatment plans. They can also help provide other psychosocial interventions to support the patient, and help monitor the patient’s progress. It is not difficult to imagine how this integration of care, particularly in organizing more frequent follow-ups and encouraging positive rapport with the PCP — an important component of managing illness anxiety disorder — could have been quite beneficial in supporting my patient.
Research has shown that the collaborative care model is associated with improved outcomes. One such example comes from the MOMCare initiative, an 18-month intervention that utilized a collaborative care model to treat women with perinatal depression. Results showed significantly lower levels of depression severity, a higher likelihood of receiving greater than or equal to four mental health visits, and a higher likelihood of adhering to antidepressants when compared to standard public health maternity support services. Another example comes from the BRIGHTEN initiative, which implemented the collaborative care model for treatment of depression in geriatric patients. Results showed significant improvements in depression symptoms and general reported mental health.
Collaborative care has also proven beneficial for trainees. After all, while we all start from the same base — a general medical degree with rotations in several major specialties — the process of specialization can inevitably lead to a feeling of being siloed from the others. By incorporating the principles of collaborative care, trainees can help educate their colleagues from different specialties on aspects of their scope of care that overlap, and we can all expand our knowledge base and broaden our horizons. For example, my program recently had one of our internal medicine residents lead a seminar for psychiatry residents on medical causes of fatigue. Fatigue is a common, non-specific concern that several patients present with in psychiatric practice, and during the seminar we discussed a systematic way to conceptualize fatigue as well as considerations when making referrals. Several residents commented afterward that they appreciated hearing from their colleagues in primary care settings and thinking about patient care in a more collaborative fashion.
While the collaborative care model seems to be a better structure for both patients and clinicians, there are unfortunately a few barriers that have prevented widespread implementation. A recent qualitative study conducted in New York showed that billing requirements, reimbursement rates, and “buy-in” from clinicians and leadership were the main themes that came up during interviews with clinic representatives. The authors suggested that having non-clinical staff to help automate and streamline billing and administrative tasks may be helpful, though this would not address low reimbursement rates, which is a complex issue beyond the scope of this article. However, in regards to lack of “buy-in,” this may be an area where education and knowledge about the positive outcomes of the collaborative care model may be beneficial.
Collaborative care not only has the potential to improve our patients’ quality of life, but the quality of life of their clinicians as well, and it is my hope that this model continues to become more popular in the future.
Have you ever worked in a collaborative care model? Share your experience in the comments!
Dr. Avneet Soin is a psychiatry resident in New York City. She is interested in consultation liaison psychiatry and advocacy work, and in her free time enjoys reading and exploring the dessert scene in NYC! Dr. Soin is a 2023–2024 Doximity Op-Med Fellow.
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