Transcription:
Collaborative Behavioral Health Program Addresses Need for Integrated Health Care

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And I invite you to listen as we explore the Collaborative Behavioral Health Program at Northwestern Medicine and how the program is helping to address behavioral health access challenges that many patients face.

Joining me is Dr. Lisa Rosenthal. She's the Chief of Consultation Psychiatry, and an Associate Professor in the Department of Psychiatry and Behavioral Sciences at Northwestern Medicine. Dr. Rosenthal, it's a pleasure to have you join us today. Can you start by giving us a little bit about the history of the Collaborative Behavioral Health Program at Northwestern Medicine? What services are provided? Why did you see a need for this kind of program? What is it that you do?

Lisa Rosenthal, MD (Guest): Well, first of all, thank you so much for inviting me. It's a great pleasure to be here. I'll try to remember all the questions you just asked, but you may have to remind me. Collaborative Behavioral Health is also known as the Collaborative Care Model. This was a model developed in the 1990s based on the influence of other models for chronic disease.

So within medicine, we've gotten pretty good at understanding how to help patients manage chronic illness and thereby lower their morbidity and mortality. Things like hypertension, it's kind of a no brainer. Everybody gets screened for their blood pressure. And if somebody's blood pressure is uncontrollable with their primary care doctor, they get referred to a specialist who can help them.

In Psychiatry, we really wanted to emulate that model. And so between 1990 and 1996, there were nine different trials looking at this Collaborative Care Model led by doctors at the University of Washington, Wayne Cayton and Jürgen Unützer, among others, who looked at this idea that depression and maybe other psychiatric disorders could be treated and modified in the same way that we modify other chronic diseases. And the beauty of this model is that it treats an entire population. The reason that I personally became interested in it is because of that, because of the idea that psychiatric symptoms and illnesses are pervasive. And as you've already pointed out, access is difficult for medical care of all kinds, but particularly psychiatry.

And if we don't proactively find patients and screen patients, we're probably missing those who could benefit most from treatment. So, when you take a patient with depression, in standard models, we wait for the patient to declare themselves depressed and then talk to their doctor about it. Or we wait for a doctor to say, I think this patient has depression.

And after either of those things occurs, a patient is referred to specialty care. However, we know that the vast majority of patients with depression and anxiety are actually stay within primary care and are treated there. And while our primary care colleagues are pretty darn good at treating these simple diseases, they don't do it quite in the same way that psychiatrists do. For example, they tend to use much lower doses of medication and they don't necessarily follow up in the same way that a psychiatrist or psychologist would in helping patients really reach remission. So, the Collaborative Care Model does a number of things. First of all, it screens, whole population. The initial studies were screening for depression, for example.

Then once the patients are screened, they can be further assessed in a systematic way. They are added to a database and registry and followed over time with verified and validated screening measures that tell us if they're getting better or not. And we use evidence-based treatments to try to get them better. And those evidence-based treatments in psychiatry generally include medications and or talk therapies. So, a few beautiful things about this is first of all, we treat the patients to target. We keep very careful track of them, but also the idea of screening is what really drew me to the model. Because by screening an entire population, you lower disparities.

You don't rely on the idea that a patient could identify themselves. You know, patients don't show up saying, doc, I've got hypertension and you don't rely on physician impression, which we know is subject to bias and other interpretation. So, the Collaborative Care Model looks at all patients in a population and has been demonstrated to lower morbidity and mortality, not just from psychiatric causes, but from other causes.

For example, a New England Journal study showing that hemoglobin A1C and hypertension outcomes were improved in patients getting collaborative care for depression. So, those things are great. And there was no reason from my mind why we wouldn't do that here at Northwestern, because we got to keep up with the times and with a lot of effort and a little bit of luck, Northwestern approved a pilot project in Collaborative Care back in 2017.

That was in one of our primary care academic clinics. And from there, there was a grant from the women's board of the hospital to roll out collaborative care and study the implementation of collaborative care in all of what's called the central region of Northwestern, which is 13 primary care clinics.

And just about a year ago, we finished our rollout to all 13 clinics, which have embedded care managers, consulting psychiatrists, and screening for depression and anxiety.

Host: What an amazing answer and an amazing comprehensive approach this is for something that many people, as you say, they don't on their own, always come to their doctors and say, I have depression. There's still this stigma around mental health issues that people tend to bring in. So as you're telling us some of the behavioral health access challenges that you've seen, whether it's because of disparities or access locationally, in what ways does your program get to those? How are you reaching out? Tell us a little bit about that.

Dr. Rosenthal: Well, when you talk about access, there's a lot of different factors as you just sort of pointed out. It's not just identifying the patients, but it's also referring them. And then having the patient be able to get to the referral successfully. Only about 25 to 50% of patients who have depression are thought to be accurately diagnosed by primary care doctors, about 40 to 50% of those complete referrals to psychiatry. And very few who were diagnosed in the first place actually recover within primary care. That is before the Collaborative Care Model.

So yes, we screen to identify patients and we try to bring the care to them within primary care. That said, I don't personally believe that Collaborative Care Models change access to psychiatric specialty clinics. And in fact, they may make it worse, because we do have patients who, when we screen them and do the initial assessment, we realize this isn't simple depression or anxiety that they really would benefit from a specialist. And we even in our program have a great deal of difficulty getting patients access to specialty care within psychiatry.

So I think that overall collaborative care may actually increase the demand for psychiatric specialty care, but we increase access certainly within primary care and other types of clinics.

Host: Well you mentioned the primary care physician of the patient, how do you collaborate with them and what other collaboration is required? This really is a multidisciplinary approach. As you were talking about A1C and hypertension and depression, and we're learning more about sleep and it's relationship, obesity, it's relationship. And obviously in this COVID time. So, tell us a little bit about how you work with all the different specialties, including the primary care physicians.

Dr. Rosenthal: Well, that's the perfect question because it's our strength and our weakness. I would say that for our own project, as I mentioned, we were supported by a grant from the women's board of the hospital to study implementation of collaborative care and thank goodness for the research team's support, because we were able to, especially before COVID, go into each clinic in person, meet with all the docs and the staff, explain our program and talk about screening and we try to have fairly regular follow-up with all the different levels of providers who treat our patients, right? Because the medical assistants room the patients, and they do initial depression screening, a two step questionnaire called the PHQ 2. And then if that is positive, we want the primary care doctors to follow up with further screening.

Usually the depression screening is called the PHQ 9. We also have anxiety screening that we want the PCPs to complete and if they are positive, then the patients can be referred to us. It has been a bit of a challenge with some providers. Some people automatically just love the idea of collaborative care. They find it helpful and wow, you're going to assist this patient and you're going to spend time talking to them on the phone and giving them support and telling them about your treatment plans. That's what the care manager will do. They will meet with the patient in person or by phone, whichever the patient prefers and they will communicate treatment recommendations.

They'll follow up with screening tools and follow the patient until they're well. I would say that some doctors aren't thrilled about this model because there are some oddities of it. I'm a collaborating psychiatrist with behavioral care manager in a couple of clinics. And I would say that several of the doctors say, well, you've never seen the patient, so I'm not sure I trust your recommendations.

And of course the old model of psychiatry is that a psychiatrist would in-person assess every patient and make a treatment plan. The problem is there's a terrible shortage of psychiatrists and for some more basic forms of depression and anxiety, the treatment plans are also fairly basic just as you don't necessarily need a cardiologist to treat basic hypertension.

So, you know, we check in a lot with our providers and I try to make myself available for any type of psychiatric question that comes along. What I find is that some docs love us and they're going to call me for a difficult patient or an eating disorder, or even their cousin who needs a referral. And others just are not that thrilled to have us embedded in their clinic or interacting with their patients. And that's been a little bit of a challenge. I would say for the most part we've been warmly embraced.

Host: I think it's a wonderful program and so important gosh, before this, but especially now, when there is this mental health crisis going on in this country today. Dr. Rosenthal, how does a patient qualify for the program? What makes it stand apart?

Dr. Rosenthal: Well, it's not real hard to qualify. Basically you have to have a positive depression or anxiety screen on one of our tools, the PHQ 9 or the GAD 7. Of course, a lot of intellectual debate about what those basic screening tools are actually picking up. In my own opinion, it's some sort of dysphoria, it's not clearly major depressive disorder or other mental illness, but it is type of, as I said, dysphoria, that seems to have a significant impact on medical outcomes. And so these screening tools are pretty basic, but if they're positive, a patient can be referred for our program as long as they are within the central region. We also have a program that we help support in the north region of Northwestern as well.

Host: Well, you should definitely come back on and we can discuss those screening tests for another podcast, because that would make an interesting discussion. As we get ready to wrap up, what else would you like behavioral health specialists looking to launch a similar program to keep in mind, and I'd like you to just briefly touch on how COVID has impacted this program and what you've seen going on in the country today. And if your program can really tackle some of the epidemic of mental health that we're seeing right now.

Dr. Rosenthal: Well, great question. So the, I mentioned that the University of Washington were some of the earliest people who studied collaborative care and they have a wonderful center called the AIMS Center. A-I-M-S Center at the University of Washington. Their website has a plethora of information for the nuts and bolts, as well as the evidence-based for collaborative care. There are also free trainings. So online modules through the American Psychiatric Association, and there's now an association for behavioral care managers who do this unusual job, for training. So, I would suggest anybody who's interested, first familiarize themselves with the Collaborative Care Model. And then we can talk more about financing the model. Most insurers are paying for it technically, but getting them to do so has been a little bit of a challenge. COVID is a separate issue. And I would say the biggest problem for us has been that when patients were seen by Telehealth, we weren't doing all our good quality measures and screenings.

And that I don't think was limited just to a depression. It's hard to measure your patient's hypertension when you're doing Telehealth. So we saw during COVID, our referrals drop precipitously because of the lack of screening. And we relied much more on what we were hoping to avoid, which is patients talking about their mood or clinicians becoming worried about them.

And during COVID and the Telehealth through most of 2020, and early 21, we were accepting any referrals, even without positive screening tools. Fortunately, we've now gone back to much more regular screening and there's less impact on us directly. That said of course, rates of depression and anxiety are quite high in the population.

I would say one more thing though, which is that for the most part, people are normal, right? We have reactions to terrible events. We are stressed. We're unhappy. We're worried. That doesn't mean we have a mental illness that needs to be treated. And I would say for the most part, in my experience can and should differentiate between psychiatric illness that requires treatment and normal coping because 50% of the population being worried and anxious does not mean that 50% of the population has generalized anxiety disorder.

Host: Well said, absolutely true. What an informative episode this was. What a great initiative that you're doing at Northwestern Medicine. Thank you so much, Dr. Rosenthal for joining us today and really tellng us about the Collaborative Behavioral Health Program at Northwestern Medicine. To refer your patient, or for more information, you can visit our website at breakthroughsforphysicians.nm.org/psych to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.