Integrated Care in Psychiatry: Redefining the Role of Mental Health Professionals in the Medical Setting

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Integrated Care in Psychiatry: Redefining the Role of Mental Health Professionals in the Medical Setting

edited by Paul Summergrad, MD, and Roger G. Kathol, MD. Springer-Verlag, New York, NY, 2014, 235 pages, $79.00 (hardcover).

The integration of behavioral health care with other health care services has been called "timely," but we are starting to recognize that "urgent" is the more appropriate word. Barriers to access, untoward consequences of a fragmented system, and rising societal and personal costs are among the problems that necessitate sweeping changes in the provision of health care in the United States. From the academy to the clinic, we will all be affected by the formation of "accountable care organizations" based on such concepts as the "patient-centered medical home" and the "Triple Aim."

Responding to an important need for clarification of the health care transformation now occurring, Drs Summergrad and Kathol have assembled an informative collection of reviews from clinicians and researchers at the forefront of our changing system. These editors are uniquely suited to this task, having each completed residencies in both internal medicine and psychiatry and having each run programs dedicated to the care of patients with severe mental illness with comorbid serious medical illnesses. Dr Summergrad, Chair of the Department of Psychiatry at Tufts University School of Medicine, just completed a productive term as President of the American Psychiatric Association. Dr Kathol, a professor of internal medicine and psychiatry at the University of Minnesota, is known for his development of health care programs and systems designed to facilitate the care of patients with combined medical, mental, and substance use disorders.

The 13 essays in this volume span a range of topics. The editors’ introductory chapter frames their objectives for this book, which are not only to summarize the current state of care but also to explore the changes that will occur over the next decade and beyond. The editors and authors hope to provide a resource to psychiatrists that will help them understand the value they can bring to their nonpsychiatric health care provider colleagues and to the care of patients with combined medical and behavioral disorders. They wish, too, to provide early-career and midcareer psychiatrists with a look at the future.

Chapter 2 discusses the prevalence of comorbidity of mental and medical disorders. Issues in the delivery of integrated care are addressed in chapters 3 and 4. Chapters 6 and 7 describe the psychiatrist’s changing role in our evolving systems of care. In chapters 8 through 11, the integration of care for several specific patient populations is explored. The final 2 chapters discuss how we can train our workforce to embrace an integrated care model (chapter 12) and the evidence base underlying current models of care (chapter 13).

Overall, the book is articulately written and meticulously edited. I was particularly impressed by several chapters. Chapter 4, by Anfang and Liptzin, examines the economic challenges of psychiatric service delivery in medical settings. These authors review the historical context that underlies the discontinuity between reimbursement systems for psychiatric versus other medical services, a rift that parallels the care of these patient subpopulations in separate treatment settings. They review their own experience in care integration, which includes both the colocation of behavioral care providers in 2 primary care practices and the development of a statewide consultation service supporting the behavioral needs of children treated in pediatric care. They propose that payment reform must be linked with service delivery reform in order to facilitate true incorporation of psychiatric services into comprehensive care.

In chapter 6, Ms Lattimer, Executive Director of a large case manager organization, provides a thoughtful discussion of the role of case management with multimorbid patients. She explains the objectives of case management and describes its evolution in our changing care system. "Integrated case management," as she explains, goes beyond traditional case management by focusing on the complexity of a patient’s health concerns rather than on specific diagnoses. Psychological and biological factors are both given important weight in the care manager’s multidomain assessment of a patient’s needs. Case managers’ effectiveness is assessed not on the basis of process measurement, such as number of calls made, but rather on clinical, functional, and fiscal outcomes as well as patient satisfaction.

In chapter 12, Dr McCarron and colleagues address the importance of training the next generation of psychiatrists in integrated medical-psychiatric care. They recognize the increasing provision of behavioral health services in primary care settings and outline practical steps for adapting training to these service delivery changes. Evolving systems of care, for these authors, are opening up new opportunities for better care of patients. These opportunities will require psychiatrists who have been trained differently from their predecessors. One practical suggestion for updating training is to move the 4 months of required primary care experience in psychiatric training from inpatient medical units to settings particularly relevant to psychiatrists’ later professional activity, for example, collaborative work in outpatient primary care settings with increased exposure to preventive medicine, consultation-liaison, and subspecialties such as sleep and pain medicine.

I highly recommend this book for its snapshot of current practice and its glimpse of a future that has already begun to arrive in full force. Psychiatry in coming decades will assume a closer relationship to other areas of medicine. Some may mourn a loss of autonomy or may fear abandonment of a psychologically sophisticated conceptualization of behavioral symptoms, but the benefits to patients, society, and ultimately even to our profession make a strong case in support of our shift to integrated care.

James M. Ellison, MD, MPH

james.m.ellison@christianacare.org

Author affiliation: Christiana Care Health System, Wilmington, Delaware.

Potential conflicts of interest: None reported.

J Clin Psychiatry 2016;77(2):e172

dx.doi.org/10.4088/JCP.15bk10258

© Copyright 2016 Physicians Postgraduate Press, Inc.