1. Trainees in the Integrated Care Model: The Future is Now
RACHEL MORENZ, Brent Beenders, Steven DobscHa

2. Disclosures
None

3. Goals & Objectives
1.      Understand the importance of training residents in the integrated care model and how this could impact overall healthcare delivery
2.      Review existent models and any known outcomes for training residents in integrated care, such as PPMC at the Portland VA
3.      Discuss prior experiences being either a resident or attending in an integrated care model: successes and challenges
4.      Discuss visions for the future: What would be most beneficial for a resident to learn training in an integrated care model, from both a patient care, systems, and career development perspective? How could training sites support this?

4. Integrated care. Why Now?
Who provides the majority of mental health care in the United States?
What is the current relationship between demand for mental health care and supply of psychiatrists?
What are some of the options to help fix this problem of supply and demand?
Sell it. Why do we need integrated care? Who currently provides the majority of MH care? Are there enough psychiatrists to treat all those who desperately need care?

5. The triple Aim THE IHI triple aim:
Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations; and
Reducing the per capita cost of health care.
Examine this and you see the backbone of what is supporting the movement towards integreated care models. Interstingly the move towards integrated care began even before the triple aim was formulated!

6. integrated Behavioral health care: What is it?
“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost- effective approach to provide patient-centered care for a defined population”
Carefully draw out this definition, emphasize characteristics of the triple aim
Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus

7. What are the approaches to integrated care?
Co-location
Collaborative care model (CCM)
Improved primary care for patients with severe mental illness (reverse co-location)
Others? Are these mutually exclusive? I’d argue no. CCM probably needs to be more carefully defined as in terms of practice model it is the most unfamiliar as it involves collaboration primarily with a team and not the patient to make treatment decisions. Research support for CCM in treatment of depression.

8. Collaboration: what does it look like?
Type of collaboration employed:
1. Referral-triggered periodic exchange: Information exchanged periodically with minimally shared care plans or workflows
2. Regular communication/coordination: Regular communication and coordination, usually via separate systems and workflows, but with care plans coordinated to a significant extent
3. Full collaboration/integration: Fully shared treatment plans and documentation, regular communication facilitated and/or clinical workflows that ensure effective communication and coordination.
Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus

9. American Psychiatric Association and Academy of Psychosomatic Medicine
American Psychiatric Association and Academy of Psychosomatic Medicine. Dissemination of Integrated Care Within Adult Primary Care Settings: The Collaborative Care Model. Report 2016.

10. The Collaborative care model:
IMPACT, TEAMcare… lots potentially discussed on this slide
AIMS Center: Advancing Integrated Mental Health Solutions

11. What’s my liability when practicing integrated care?
The 4 elements: Duty, Breach of Duty, Causation, Damages.
Legal duty requires a doctor-patient relationship.
Is there a legal relationship when the primary role of the psychiatrist is consultative?
Curbside vs formal consultation.
Few have written on this but there is some literature out there. The number of cases is at this point low. We’ll discuss a few factors about liability briefly here, it is important to have this information as if we are unable to provide excellent care in an efficient manner and maintain our malpractive insurances and livelihoods then the move toward integrated care is already dead.
Bland DA, et al. Resource document on risk management and liability issues in integrated care models

12. Liability and the various rolls of the psychiatrist in the integrated care setting
Supervisory Role
Collaborative Role
Consultant Role
Liability runs from high to low, each role would merit a brief description to clarify relative liability in each role. Within a single setting there may be multiple roles/relationships.
Bland DA, et al. Resource document on risk management and liability issues in integrated care models

13. Resident experience
Brent
Portland VA PPMC

14. How are we currently teaching Integrated care?
When does training start?
Undergraduate medical education:
Still predominantly exposed to “traditional” psychiatrist role through block rotations in hospitals and clinics
Integrated care rotations usually elective
Starting to have more longitudinal integrated clerkships where have continuity with a panel of patients, allowing bird’s eye view of delivery of care
Summers RF, Rapaport MH, Hunt JB, et al. Training Psychiatrists for Integrated Behavioral Health Care

15. Graduate medical education
ACGME does not require experience in integrated care for psychiatry residents or fellows (but Canada does)
ACGME does not require preventive and primary medical training for psychiatry residents beyond PGY1 year
Reardon 2014 Survey: 78% of 52 general psychiatry program directors offered one or more integrated care rotations
Usually for senior residents
Better prepared after having outpatient and consult-liaison experience
Readon C, Bentman A, Cowley DS, et al. Acad Psychiatry

16. Workplace cultural differences
Primary care environment: flexible boundaries, empathy and compassion, shifting roles, flexible schedule, continuity over time, use of clinical guidelines, disease management, data freely shared between providers
Behavioral health environment: firm boundaries, professional distance and neutrality, consistent roles, fixed schedules, treat and terminate care, individual treatment planning, recovery model, confidential and private data.
Raney, L. Integrated Care: Working at the Interface of Primary Care and Behavioral Health

17. Core competencies of psychiatrist in Integrative care per SAMHSA
Interpersonal communication
Collaboration
Teamwork
Screening and assessment
Care planning
Care coordination
Intervention
Cultural competence and adaptation
Systems-oriented practice
Practice-based learning and quality improvement
Informatics

18. Core competencies and milestones
Summers 2014
Summers RF, Rapaport MH, Hunt JB, et al. Training Psychiatrists for Integrated Behavioral Health Care

19. Details on residency training
American Association of Directors of Psychiatric Residency Training website Virtual Training Office ( accessible to AADPRT members)
Several general collections of best practices and examples of 33 training experiences, including rotation structure, curricula, and evaluations
Majority of rotations are co-located experiences of consultation in primary care
Minority are collaborative care, telepsychiatry, or primary care delivery by psychiatry residents (OHSU is one through their VA PPMC experience!)
Most are ½-1 day per week for 1-12 months

20. Didactics
Lunchtime, pre-clinic, post-clinic teaching sessions, case conferences, and/or journal clubs
Involve trainees from different disciplines
Self-paced online
AADPRT Model Curriculum focusing on collaborative care publicly available on University of Washington’s Advancing Integrated Mental Health Solutions (AIMS) website
Collaborative Care Consultation Psychiatry: A Clinical Rotation Curriculum for Psychiatry Residents. University of Washington AIMS Center: Advancing Integrated Mental Health Solutions

21. UW AIMS

23. Resident Experience Rachel Fairview VA PCMHI Vancouver VA GM Psych
OHSU Family Medicine South Water Front
Portland VA Women’s Clinic

24. Supervision
Usually by psychiatry faculty members present in clinic with resident
Greater resident satisfaction when supervision provided not only clinical case load supervision, but also guidance on administration, practice style, and interpersonal challenges being in primary care setting (Cowley, et al, 2000)
Funding: psychiatry departments, billing revenues in clinic, primary care department, grants
Cowley DS, Katon W, Veith RC. Acad Psychiatry
Readon C, Bentman A, Cowley DS, et al. Acad Psychiatry

25. evaluations Traditional written evaluations
Pre and post knowledge tests
Self-assessments
360-degree evaluations by other team members and patients
Observed interviews by attendings
Patient outcomes
Video simulations to test competencies in telemental health and interventions such as motivational interviewing
Summers RF, Rapaport MH, Hunt JB, et al. Training Psychiatrists for Integrated Behavioral Health Care

26. Noted challenges Sustainable financial support
Finding time in the curriculum
Acceptance of this model by primary care providers (sometimes preference for psychiatrist to just assume care of patient rather than managing mental health problem collaboratively)
Acceptance of this model by psychiatry faculty and trainees
Availability of qualified psychiatry faculty supervisors
Office space
Summers RF, Rapaport MH, Hunt JB, et al. Training Psychiatrists for Integrated Behavioral Health Care

27. Outcomes
Few studies
PPMC rotation at Portland VA: psychiatry residents endorsed greater preparation to address their patients’ medical problems and comfort in making medical referrals, but no greater likelihood of performing medical evaluations or providing medical care after graduation
Residents in Yale Psychiatry Primary Care program: more aware of medical comorbidities and collaboration with primary care providers, but no more likely than peers to choose to provide medical care for their psychiatric patients or incorporate primary care practices into patient care
Dobscha SK, Snyder K, Corson K, Ganzini L. Acad Psychiatry
Rohrbaugh RM, Felker B, Kosten T. Acad Psychiatry

28. Continuing medical education
SAMHSA-HRSA Center for Integrated Health Solutions
APA trainings
Free one on collaborative care model as part of Centers for Medicare and Medicaid Services (CMS) Transforming Clinical Practice Initiative (TCPI)

29. Attending Experience
Steve Dobscha
Portland PPMC

30. Audience discussion and questions

31. References
AIMS Center: Advancing Integrated Mental Health Solutions. University of Washington. Psychiatry & Behavioral Sciences. Division of Populations Health. Last updated Accessed Jan. 31, Bland DA, Lambert K, Raney L; APA. Resource document on risk management and liability issues in integrated care models. Am J Psychiatry May;171(5):suppl 1-7. Collaborative Care Consultation Psychiatry: A Clinical Rotation Curriculum for Psychiatry Residents. University of Washington AIMS Center: Advancing Integrated Mental Health Solutions Core Competencies for Integrated Care. SAMHSA-HRSA Center for Integrated Health Solutions. Pub Accessed Jan Cowley DS, Katon W, Veith RC. Training psychiatry residents as consultants in primary care settings. Acad Psychiatry. 2000; 24: Dobscha SK, Snyder K, Corson K, Ganzini L. Psychiatry resident graduate comfort with general medical issues: impact of an integrated psychiatry-primary medical care training track. Acad Psychiatry. 2005; 29: IHI Triple Aim Initiative. Institute for Healthcare Improvement. Last updated Accessed Jan 31, 2017.

32. References Continued
Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus. AHRQ Publication No.13-IP001-EF. Rockville, MD: Agency for Healthcare Research and Quality Available at: Raney, L. Integrated Care: Working at the Interface of Primary Care and Behavioral Health..Virginia: American Psychiatric Association Pub; Readon C, Bentman A, Cowley DS, et al. General and child and adolescent psychiatry resident training in integrated care: a survey of training directors. Acad Psychiatry Aug; 39 (4): Rohrbaugh RM, Felker B, Kosten T. The VA psychiatry primary care education initiative. Acad Psychiatry. 2009; 33(1): Summers RF, Rapaport MH, Hunt JB, et al. Training Psychiatrists for Integrated Behavioral Health Care. A Report by the American Psychiatric Association Council on Medical Education and Lifelong Learning. 2014: Vanderlip EV, Rundell J, Avery M, et al. Dissemination of Integrated Care Within Adult Primary Care Settings: The Collaborative Care Model. American Psychiatric Association and Academy of Psychosomatic Medicine. Report: Spring 2016: 1-85.