Daniel Knoepflmacher, M.D. (Host): Welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics On the Mind. Our topic today is integrated care, a broad category that includes models of healthcare connecting behavioral and mental health services.

In one specific type of integrated care called collaborative care, a psychiatric team provides consultation, education, and coordination of care in collaboration with primary medical providers. This model has been shown to increase access to mental health care, improve behavioral health outcomes, enhance provider and patient satisfaction, and reduce health care system costs. Our two guests have direct experience implementing and practicing collaborative care here at Weill Cornell. Dr. Janna Gordon-Elliott is an Associate Professor of Psychiatry and Dr. Virginia Mutch is an Assistant Professor of Psychology in Psychiatry, both here in the Weill Cornell Medicine Department of Psychiatry. Together, they will help us understand this innovative approach to extending mental health care to many who would otherwise not be able to access it. Janna, Virginia, thank you both for joining me today.

Virginia Mutch, PhD: Thanks for having us.

Host: So great to be here.

I'm going to begin by asking each of you about your stories. Can you tell us about the career paths that led each of you to working in integrated behavioral healthcare?

Janna Gordon-Elliott, MD: Yeah, sure. Thanks. I'll start. This is Janna. During med school you know, like many of us do, I did, I don't know if you had the same experience, Daniel, but I enjoyed a lot of the areas of medicine that I was exposed to and really had a hard time landing on a specialty. In the end, I ended up deciding on psychiatry probably for many reasons, but I really had a strong feeling that I would never experience the work as repetitive, which is definitely the case.

And also that I think I have skills or qualities that maybe were a good fit for the field and that I could also really help patients in this specialty. But I definitely found it hard when like during the second half of internship when we were rotating off of psychiatry, I found it hard to transition off the medical wards and kind of lose or separate from that part of my identity.

So in, in the second year of residency, when we did the consultation liaison psychiatry rotation; it was really great for me to be back around the diagnoses and the algorithms of medicine and neurology and all of those specialties to be working back on the medical floors with all the other specialists. And so I ended up doing a CL fellowship and I've worked now in both inpatient and outpatient medical settings for years.

And I think in the end, the role of psychiatric consultant has been a really good one for me. I love figuring out and addressing what's causing distress for a patient. And in many cases, it's often a, it's something causing distress for the team that's caring for them. Also, I think in CL Psychiatry, we get to be this representative of our specialty.

We're kind of out there showing what it is that we do, teaching psychiatric skills and knowledge to our colleagues and also, I think lastly, reaching patients that we might not otherwise reach in kind of primary psychiatric settings.

Virginia Mutch, PhD: Yeah, so for me the path to working in this setting is somewhat of a zigzag. I pursued a degree in clinical psychology because I was passionate about clinical treatment intervention and research, specifically in the realm of mindfulness and acceptance and where I studied out in Seattle, collaborative care or integrated care was really well established.

And I spent a lot of my training in precepting rooms with medical residents in primary care who were seeing patients. And I got to listen to the preceptors advising the residents about their patients. And occasionally they would invite me into the medical exam room and do a warm handoff or a brief touch with patients presenting with symptoms of depression or anxiety.

But other times those who just needed support in terms of making lifestyle changes, such as problems related to healthcare management. So, I had a lot of exposure to this model when I was in my early training, and then when I continued on to my internship and postdoctoral fellowship and began my early career out on the East Coast, I fell back in love with traditional psychotherapy and didn't have as much of an opportunity for integrated or collaborative care work until I was hired at Weill Cornell and was re-exposed to the models and had more opportunities to develop these programs, and I found it really exciting and familiar.

Host: Well, listening to your stories, I love to hear about the zigzagging and Janna, you saying about things not being repetitive, because that's something that I love about this field. I mean, I say that it's often very hard, the clinical work we do, but it's never boring and you guys really have exhibited that in your paths.

I want to confess that when I was preparing for this episode, I suffered from feeling confused about what terminology to use when we're talking about this subject. I've heard the terms integrated care, which is what I just said in my first question. I've heard primary care, behavioral health, and collaborative care all being used to describe this model where mental health care providers are doing work in primary care settings.

I'm wondering if you could help me and all of our listeners differentiate and define the terms that we're going to be using today.

Janna Gordon-Elliott, MD: Yeah, for sure. Definitely. So, right. So as you said, these terms are all related. And what we'll start is if people can almost imagine it's in their head, there's the broad term, integrated care. That's kind of the umbrella term. And that covers several models of care in which behavioral health clinicians of various sorts are working along with their colleagues in other areas of medicine.

That might be primary care medicine, which is what we'll be focusing on today, but it may also be things like pediatrics. medicine subspecialties, OBGYN, etc. So today we will be talking about being integrated with primary care providers, we will also call PCPs, Virginia and I will probably use that term a lot.

Within the broader umbrella of integrated care, we have a few models of care that vary essentially in terms of how engaged, I guess, the PCP is in the direct care of the behavioral health condition. So, on the one hand, we have something called co-located care, and this is where there are behavioral health providers who are working in the same general setting.

They might be in the actual same location as the PCPs, but they all practice separately. PCPs see their patient, they identify a problem, a behavioral health issue, they refer to the psychiatrist, the psychiatrist takes it over, takes over the direct care of the behavioral health issue and may or may not have more conversations down the road with the PCP even though they're kind of both sharing this patient.

In an ideal world, there would be some back and forth, but really it's kind of two separate lines ofcare, the medical care and the psychiatric care. And then we have that second term you mentioned, the primary care behavioral health model. And that's where it's generally a psychiatrist or a psychologist, and they're embedded into a primary care practice.

And their function is to be available to see patients that the team identifies just in the routine work of the business day, you know, if a patient comes in and is describing depressed mood or stress or things like that, and then they give a warm handoff often to that psychologist or psychiatrist who's able to see them, do some brief work.

The embedded clinician is often partially or in many cases, make many cases fully funded by the practice with the understanding that they're able to they're available, that they're able to expediently address the behavioral health issues and that this overall enhances patient care and allows the PCPS to do, be faster and better at what they do, which is really managing the whole person. And then third, we have that last term that you mentioned. That's the collaborative care model. And this engages the PCP most directly in the care of the patient. So they're not just referring or giving a warm handoff.

They're actually going to stay involved in the behavioral health care of their patient via the help of the psychiatric team. So in this model, you have kind of the main person is actually a non doctoral level behavioral health clinician. In many models, that's a social worker, though it could also be a nurse.

And they're embedded in the primary care practices to manage a lot of the common behavioral health conditions that will come up. It's often things like depression and anxiety. And these things, these are conditions that are detected as part of this, whatever screening practice the PCP's office has.

They all will have a workflow and they may be screening for things like depression or anxiety. And the behavioral health clinicians, what they do is they work; they see the patient, they work directly with the patient, but they also work directly with the psychiatric team. And that psychiatric team may have a psychiatrist in it. And in some cases also a psychologist. And that team oversees the work that that behavioral health clinician, who again, I said is a social worker or a nurse; the psychiatric team oversees their care. And in some cases they may be overseeing social workers who are working in practices across an entire geographic region.

So they can really help out a lot of patients in this way. What the psychiatric team does is they hear from the behavioral health clinician about what's going on with the patients, especially focusing on the people who aren't getting better or maybe are actually getting worse. And they give them some supervision around some of the psychotherapeutic interventions they're doing, which is often things like basic cognitive behavioral skills and some coaching. 

And then they also talk about patients that might be considered for more intensive care which could include medications. And in those cases, what we do is we actually think about medications that we can offer via the PCP. So the psychiatrist hears about the case, they look at the chart. And then they make a recommendation to the PCP about what medication to start.

And then the behavioral health clinician helps with that. They talk to the patient about it, they coach the patient on adherence to medication, check up about side effects, and we follow with the intention to treat the disorder or the issue that was identified by screening. And so we're really working on kind of bringing those scores down and helping people come to have a response or even remission from those presenting situations.

In this model, the behavioral health clinician has direct contact with the patient and the PCP, they're part of the practice, they see the patients and the psychiatrist or the psychiatric team has indirect interactions with the patient and the PCP, but it's via that clinician.

And it really allows the psychiatric consultant to serve a much larger population of patients that they might be able to, if they were doing direct care of patients where they would have to do one on one or face to face time with patients for 30 minutes or so, right? They're able to really have light touches on a whole population of patients.

I'll just quickly add that the integrated models, can't manage all psychiatric conditions. So what we are talking about are people with conditions like depression, anxiety, and some other disorders that we'll mention as well. But really patients with chronic and persistent mental illness are probably not best suited for the collaborative care model.

They instead, probably will need to be in a more standard or traditional psychiatric practice. But overall for lots of disorders, depression, anxiety, stress, and other common issues that come up in primary care most of the time; models like all of these, and especially the collaborative care model, which we'll be talking about most today can be cost effective and also is often preferred by patients and providers.

Host: So the two of you are working in a collaborative care model. Is that correct?

Janna Gordon-Elliott, MD: Yeah, that's correct.

Host: Okay. So, that's the term that I'm going to be using today. And, one of the things that I repeatedly encounter, during discussions I've had on this podcast is the impact of limited access to mental health care in this country. And we all agree that there's a yawning chasm between how many people need mental health care in the U.S. and the limited supply of skilled clinicians who can offer the services that these people need. So I wanted to hear from you about how the collaborative care model addresses this problem.

Virginia Mutch, PhD: Right. So, I would say there's actually two parallel problems that the program addresses. One has to do with how it addresses the cost of mental health care, and then the other has to do with how it's treated. So, the thing is, especially here in New York, there's actually tons of skilled psychiatric clinicians in this area but they're not able to meet patients where they are.

Many psychologists and psychiatrists are out there, but they see patients primarily in private practice and accept few if any insurance providers. So, it's not that there's a limited supply of clinicians that exist. They exist. And those are out there that are encouraging patients to get therapy or be on psychiatric medications, but not many that can actually see patients who need to pay with insurance or who can't pay out of pocket. So, that's where our program comes in. If a patient is able to be seen in primary care, they're able to be seen by a clinician in our program, which completely breaks the barrier to what seems at times like a more elite sphere of care.

In addition, integrated or collaborative care models approach intervention differently than traditional models of care, as Janna alluded to, such that they prioritize whatever's the most interfering with the patient's overall functioning with a direct, efficient, goal oriented treatment plan that involves briefer and fewer appointments overall.

So if you come into your primary care physician's office presenting with symptoms of depression or anxiety or related symptoms, like just difficulty managing your lifestyle or health problems, chronic pain. There's a way in which a clinician can assist with that without having to engage in long term psychotherapy or seeing someone in private practice paying hundreds and hundreds of dollars a session.

Host: That's a really important distinction that it's not just about numbers of clinicians and numbers of patients. It's about this differential between those who need to use their insurance, which is a big part of the population and that this model really helps address. So I'm curious, given the success of this model and addressing these problems, how did it develop? Where was it developed? How was it developed?

Janna Gordon-Elliott, MD: Sure, I'll take that. The collaborative care model, which we've been talking about, it was developed back in the 90s at the University of Washington. And if you can imagine, it's actually not random that it was started in the Northwest, in big states with large regions with very few psychiatrists for any kind of direct or face to face care of patients.

Because as I mentioned, it's really good at kind of having a few centralized psychiatrists who are taking care of large populations of patients via a lot of these behavioral health clinicians embedded in the various practices. And the model was actually, it was based on models of care that were originally designed to manage chronic medical health issues. So things like diabetes and it applies that same chronic health model to psychiatric disorders like depression.

Host: What is the evidence base for this model?

Janna Gordon-Elliott, MD: It's backed by pretty strong evidence. It started with something called the IMPACT trial that was originally published in 2002. It showed that this model, this collaborative care model could significantly improve patient outcomes. And at this point, 20 plus years later there's over 90 randomized controlled trials showing its effectiveness and it's been applied to a range of different psychiatric disorders, depression, anxiety, ADHD, even substance use disorders.

It's also been shown to be effective in patients with medical issues, like diabetes and cancer. And setting wise, it's been shown to work in a lot of different kinds of settings.

So, rural, urban, and it also helps reduce treatment disparities, importantly, among different racial and ethnic groups. And it's also been shown to be financially sustainable.

Host: Very important. And how prevalent is it now across the country?

Janna Gordon-Elliott, MD: Right. So it started in the Pacific Northwest, but it's now expanded to different areas of the country and into a range of different types of healthcare systems. It's quite commonly used in places like the Veterans Health Administration and many federally qualified health centers, but also a lot of private healthcare organizations have been adapting it.

Implementing the collaborative care model is definitely not easy. We've seen that, Virginia and I ourselves. Because up front, easier in many ways to do one of those other models, right? It's easier to hire a psychiatrist or a psychologist and put them near the PCPs or embed them into the clinic. The collaborative care model really does require a lot of adaptation on behalf of the institution and also all the personnel who are working. A lot of adjustments that need to be made by the people who do billing, the compliance teams for sure. And also just the individual providers like the PCP getting used to the different model.

But because of its proven effectiveness and the fact that when it's done right, it also actually starts paying for itself; it seems that there's increasing incentive on the part of healthcare systems to implement it.

So our institution got the chance to pilot it back in 2022. There was pressure and encouragement on the part of overseeing bodies like the Accountable Care Organization to implement broad screening of depression in primary care. And it was clear that, of course, if you're going to screen, you have to have ways to manage patients who screen positive, right?

So, with some pilot money that we got from the ACO and with also money from primary care; we were able to pilot this program in primary care here at Weill Cornell and also in some of our network primary care systems in Westchester and Queens. And alongside of our programs, the institution and also other members of our department, have begun implementing collaborative care in some of our other practices like obstetrics and gynecology and in pediatrics.

So it's been an exciting few years. We've been working to build up this infrastructure really for collaborative care in many different settings.

Host: It's why it's so great to have the two of you on because you have this direct on the ground experience of actually implementing this from scratch. So, I'm eager to ask you more questions about it. I want to, speaking of being on the ground, I want to take it from the perspective, let's say of a patient.

So, let's say I'm someone who's coming to see my primary care doctor for an annual visit. I am facing lots of significant life stressors. I'm feeling anxious and depressed. Not an uncommon scenario, I think, in our practices. Can you describe what I would experience as a patient in a clinic with collaborative care?

Janna Gordon-Elliott, MD: Yeah, I'll just tell you a little bit about kind of the basic overview and then maybe, Virginia, if you can tell us a little bit more about kind of the patient experience. So, okay, so we'll take a patient who sees a primary care provider here before their visit. It's usually at the annual wellness visit, they'll be sent several questionnaires to fill out, and that will include a depression screen. A high total score on the depression screen, including any positive response to the question about suicide, will prompt an alert in the electronic health record. And the PCP will see this alert, and also the behavioral health clinicians working on, in that practice, the social workers that I was mentioning before, who do all the direct care.

They will also see that alert and then the PCP or one of those behavioral health clinicians will then assess the patient further, right? There was a positive screen. And if the patient is not in established treatment with a psychiatrist or is otherwise interested in being part of our program, the PCP will refer them to our program.

And then the patient will have an intake, which is pretty standard with one of our behavioral health specialists. It will look very much like kind of a traditional intake for psychiatric care, but they will really focus on current symptoms and current goals and that's I think, what the collaborative care model really does well is it tries to keep things kind of present focused.

And then the behavioral health clinician will follow that patient for a period of time. They'll do a combination of scheduled visits, also some phone check ins, some messaging over the portal for patients who prefer that. And the goal overall is to help them work on some skills and reduce their symptoms of depression.

And then weekly we will talk about patients who are not doing as well as we would like, they're not progressing, not improving, and we'll talk about whether medications might be needed. We'll also talk about more psychological interventions we can do with them. And so Virginia and I both kind of chime in at that meeting.

If a medication is needed, I write a brief note in the electronic health record and get that message to the PCP. And then the PCP writes the order, and this is what's really important because I haven't seen the patient, right? So I'm not going to write an order. PCP writes the order and then our behavioral health clinician communicates to the patient about that and then follows for side effects within a couple of weeks.

So it ends up being actually more than what a PCP really would be able to do on their own when they might not be able to see the patient again for let's say a month and maybe the medication would just stall, right? We can follow it, check response, check side effects, and titrate until we actually get a good effect.

We also have collaborative care going in a few of our network primary care practices in Westchester and Queens. And there we have our team, including the psychiatrist, Dr. Derek Tate, and Dr. Jesse Allen Dicker, the psychologist.

Virginia Mutch, PhD: Yes, we have a great team. Right, so Janna, as you suggested, I can add a little bit more about the patient experience as the supervisor of the behavioral health clinicians. So, so you as the patient would work with these behavioral health clinicians to set some goals and identify some pathways to getting there, which involves both lifestyle changes and in some cases, medication.

With regard to lifestyle changes, your clinician will offer you some ideas about ways in which you could make some changes in order to improve your mood, or feel more confident in terms of facing certain fears, or augment some lifestyle habits to improve your stress and coping. And at times, these appointments with the behavioral health clinician might feel like traditional therapy.

And other times, they might feel a bit like Janna mentioned, like receiving a coaching call, or the behavioral health clinician has a briefer check in. Say, for example, like, how did it go practicing those breathing skills? Did you try the new book club? Did you go for that run? Okay, what was the impact on your mood?

They might give you some ideas for things to try and then you go home and practice some of them on your own in between appointments. So unlike traditional therapy where you're expecting to sit for 45 or 60 minutes every time and having long like, exploratory, insight oriented conversations; in this context, what you're really getting is hands on concrete tools for thinking through acute stressors that you're dealing with and getting some opportunity to practice independently, employing some of those tools and seeing what works.

So again, as Janna mentioned, your clinician may make additional recommendations about potential medications that you could benefit from without having to see the psychiatrist or pay for seeing a psychiatrist. The behavioral health clinician assesses how well the meds are working. Are you having any side effects or issues?

Let's think about how to troubleshoot those. So you are receiving expert recommendations, but without having to spend the time, money, energy in order to make those kinds of appointments. And again, we track how our patients progress through their program and if symptoms abate, patients graduate. Some patients still do need more traditional psychiatric care, including face to face treatment with psychologists and psychiatrists like myself and Janna, and when we do have to step up a patient's care, we actually have the opportunity at Weill Cornell to send them to our own short term clinic which allows for continuity of care, and this is still an important option for us as well.

Host: That's important last piece that there's some patients that might need an extra level of care. Got it. Well, this is great helping to understand what the patient experience is. I want to turn to the experience of you guys. What have you witnessed firsthand to be the benefits of the collaborative care model?

Virginia Mutch, PhD: Yeah, think the biggest benefit is that far more patients have access to psychiatric services through the behavioral health care clinician who consults with the psychiatrist and psychologist. And what this really means is that we have normalized psychiatric care and incorporated psychiatric health care into routine medical care.

I come from a therapeutic orientation known as acceptance and commitment therapy, or ACT. And ACT says that pain with acceptance, still pain. But pain with non acceptance becomes suffering. So when we accept that we're experiencing pain instead of denying it or resisting it, what we can actually do is something about it.

And that's where the behavior in behavioral health care comes in. We can make specific recommendations about what to do when you're feeling depressed or anxious, or even just having trouble managing your diabetes, for example. Like what behavior or lifestyle changes can you make to help yourself move the needle and reconnect you to what you find to be value living or providing meaning. And what's cool is that this doesn't require a long term, multiple years long treatment from a very expensive psychologist or psychiatrist in private practice, that this is something you can do through a series of light touches, either by phone or in person or video in a relatively short period of time for a relatively inexpensive cost.

And I think it's been wonderful to be able to normalize behavioral health care and to provide access to more folks who can benefit from it.

Janna Gordon-Elliott, MD: Yeah, and I'll just add that as a psychiatrist, I feel able to help way more patients than I think I'd be able to in the more traditional models that we all trained in where I'm spending maybe 30 to 60 minutes with a patient. I'm writing a long kind of intake note, I'm having to make phone calls on behalf of patients and all that.

There's always going to be a role for that and it's very valuable and satisfying. In this model, I get to see many patients get better, which has been satisfying.

Host: Well, it's great to see of these benefits, to hear about all these benefits. I want to turn to some of the challenges, I guess, thinking from an acceptance and commitment frame of mind. What is some of the pain that you guys have had to accept along the way? And I can think about key components of implementing a model like this. You are interfacing with so many different stakeholders. You're providing education. I imagine with patients, you're having to manage expectations, and then accessing all of the resources that are needed.

So let's start with patients. So do you encounter people who are expecting weekly psychotherapy or just in general, more than you're able to offer? And when that occurs, how do you manage those expectations?

Virginia Mutch, PhD: Yes, as much as the proliferation of mental health services, especially here in New York, is wonderful, and we want to increase access to mental health services, and we want to normalize and destigmatize access to mental health services; the downside of that is that we get messaging in social media, our popular culture, that everyone deserves a therapist.

Right. You've heard everyone should be in therapy. And while to some extent we believe that everyone should be caring for their mental health, not everyone needs a mental health provider. And certainly not everyone needs a long term therapist that they see in an ongoing exploratory way. And so some patients who come in to see us are disappointed to learn that there are lighter touches involved in collaborative care if what they're expecting is something else.

But what our team offers is much more tangible, concrete, specific, tailored interventions, and sometimes that's a bit of a reacculturation process for patients. But we try to manage their expectations by focusing on their goals and asking questions like, if this were to be helpful to you, what would you most like to see change?

All right, let's focus on that, and if you feel like you still need long term psychotherapy, you know that's always available to you. You're always welcome to pursue that, but I think I can offer something useful, specific and tailored to you in a different kind of context. So let's try that first.

Janna Gordon-Elliott, MD: Yeah, and similar to what Virginia is saying, there, there's also patients who really want to see a psychiatrist and are not happy with this idea or don't really understand why the psychiatrist doesn't come and see them themselves. Generally we haven't found much pushback for that. The behavioral health clinician explains what the model is and we actually think it's gone really well, at least in our program.

And I do think that really that's a credit to them. The behavioral health clinicians do a really good job of making it clear how involved the psychiatrist is. And of course, there are going to be cases where we think a patient, based on what we've heard, will need direct care with a psychiatrist. This may be based on their diagnosis or the severity of their symptoms. And so in those cases, we step them up to the care that they need.

So the patients obviously are our main focus here, but there's other important stakeholders. One very important one are the primary care providers. And I wanted to hear about the challenges that you guys have come across in working with them, in supporting them and providing the education that's needed.

Yeah, so for me, this has definitely been one of the most fun parts, collaborating with our colleagues in primary care, but it hasn't been totally linear. Offering a path for rapid referral to patients with symptoms of depression, buys us some good points, I think, with our non psychiatry counterparts. But then when it comes to the actual how to of the whole thing, like what they do next and what the next step is and how the referral goes, that all has been a little bit harder to always implement as smoothly as possible.

Janna Gordon-Elliott, MD: So, we've done a lot of iterative education about the referral process, including what is necessary on the PCP's end to refer the patient and which kind of patients we actually think are best sent to us versus some other referral options that they have. Then once we're caring for the patient, some issues will arise.

For example, when medications are being recommended, again just like the patient may be a little confused about why the psychiatrist isn't seeing them, the PCPs will sometimes experience some hesitation or resistance kind of saying, well, if you have a psychiatrist, why aren't you placing the order, which is understandable given how busy they are.

And also that this is a novel model for a lot of them. And so we do have to do kind of a little bit of interaction there, explain the model again. And it has been, you know, a little bit of, have to flex those skills of kind of working with many different individuals and the different kind of practices and workflows that they have.

But overall, it really has worked really well. And it's been also helped to a wonderful primary care champion who's helped talk about the program with all the other primary care providers and help smooth the adjustment for all of us.

Host: Well, I, imagine, Janna, that your experience as a consultation liaison psychiatrist comes in handy for that part of the job.

Janna Gordon-Elliott, MD: Oh yeah. I think definitely. Right. I mean, I think we all, it doesn't matter what we're doing, we all have to get used to working with different kinds of folks and meeting them in terms of figuring out what they need. And I think that we've been able to use some of those skills here in this program.

Host: What about you all? I mean by that, the behavioral health team.

Virginia Mutch, PhD: One challenge for myself as the clinical supervisor is when our behavioral health clinicians share that they are seeing certain patients who really are coming in with a lot of different problems, and some of them seem really significant and like they require long term treatment or an ongoing course of therapy, and that's not what we can offer directly, or, that's not truly what the patient is interested in or can afford.

And we're recognizing that it may not even be what's necessary. We're just so used to thinking that way. And so for example, maybe there's a patient who's coming in with longstanding or chronic PTSD, but what they're really wanting to focus on is their sleep. And that's really what the priority is for them.

And so in our program, we might say, listen, we acknowledge that you have this trauma history, but we think we can make a really big dent in what's bothering you by getting you some concrete sleep hygiene skills. So we're going to start with that. And that's going to almost feel like a band aid at first, but in actuality, maybe that moves the needle enough on your overall functioning and engagement and meaningful activity in your life.

If you're sleeping well, you can expand your functioning in these other areas of your life. Maybe that patient goes on to do longer term in depth, evidence based trauma work. Maybe they don't, but it's hard to get over the all or nothing approach that perhaps if we can't address every problem a patient has, we can still do something extraordinarily useful and get them back engaged in meaningful living.

Host: I hadn't thought about that, that you're trained in this holistic manner and this is really problem focused work. So that would be an adjustment that, that you'd have to make as a clinician.

Virginia Mutch, PhD: Yeah, for sure. I mean, like traditional psychotherapy for sure. And this is also extraordinarily useful for folks who can't or not interested in or for whom that's maybe just not appropriate.

Host: What about other stakeholders that I haven't covered in these questions?

Janna Gordon-Elliott, MD: Yeah, and I think for me and Virginia, we've been in this interesting situation where we're not just learning to implement collaborative care; we're also starting it up in a system that has been completely unfamiliar with it. So, with that, there's been a lot of challenges and roadblocks in terms of getting the system going.

We're responsible to multiple stakeholders, like the Accountable Care Organization that's helped pilot, helped fund part of our pilot, as well as primary care practices that we're working in. We need to show our value, and also this like a cost effective program. Ultimately we won't get anywhere if the program just feels like it's a good thing, right?

We actually have to show that there's clinical improvement in our patients, and we have to make it financially sustainable. So we work closely with folks in billing, compliance, information technology. We're still struggling a little to figure out ways to make it sustainable in certain settings or with certain pairs.

And also in some ways to retrofit this model into an organizational model that wasn't specifically designed for it. So, I'll say it's been a learning process, but a good one.

Host: Well, all that you guys have learned, I mean, and you being able to talk about it here, I hope it inspires others to expand this here and elsewhere. It's still a relatively new approach to mental health care. And I'm wondering, thinking about the future, how do you think we can best train future collaborative care providers, whether that's psychiatrists, psychologists, or social workers? This is a question that's near and dear to my heart as a training director. So I'm curious to hear what you guys think.

Virginia Mutch, PhD: Yeah, for sure. And like we were just talking about, like, I believe there will always be a place for traditional psychotherapy or psychiatric services. That's something I still very much enjoy providing, but I think the more we can normalize providing brief intervention or intervention that's co-located in a primary care practice, the better.

So the more that we can train primary care residents side by side with psychiatry or psychology or social work trainees to kind of work through what the flow looks like, hand in hand and tandem; the more we can educate these future providers in terms of medication language or a general flow of primary care, and the more we can have these providers in real time do a quick conceptualization process, a quick sort of treatment planning in real time.

So, what's the most important priority for this patient? What do I think I can do in a limited scope? What do I think is going to move the needle the most for this patient? Yes, you know, we can always have our bigger conceptualization process as providers, and we can always see patients for longer term psychotherapy.

But if I'm in this context, how do I quickly determine what are the priorities for this patient and how can I get at them? What do they need? And how can I teach them to do what I think will be useful for them in a way that they can then take with them and do independently in the longterm?

Janna Gordon-Elliott, MD: Yeah, and it's clear, and Daniel, you probably know more about this than I do at this point, but that very soon there will be a requirement for residents in psychiatry to have exposure to integrated models of care within their core experiences. So anticipating that, we're going to have to work on that, and we hope to be able to implement it really soon.

I do think in the future, psychiatrists who want to work in outpatient settings within academic institutions, seeing patients with disorders like depression and anxiety; these kind of integrated models will be the main option for that. I think institutions are really going to prioritize these kinds of models because of financial reasons, limited space and probably also due to some cultural shifts.

So, all that to say, in the coming months, I expect we'll be able to come up with ways to get residents exposure to integrated models, including the collaborative care model, maybe as a longitudinal rotation during the third year, for example. We've also started this for our consultation liaison psychiatry fellow, and that's gone really well.

So that's been promising. We also would like to create pipeline programs for developing and recruiting future behavioral health clinicians. Those are the social workers I was mentioning who are the glue that hold together this program. They do all the direct care of the patient. So we really need to find people who have the confidence and the skills to do that.

So I can imagine taking on social work interns who will train under our social workers, perhaps, and learn about the process, and then maybe go on to work in collaborative care models like ours in the future, and maybe even ours actually in our program ourselves. So that would be great.

Host: I look forward to collaborating with you on collaborative care training. care training Uh, and given the growth that you've seen in collaborative care here at Weill Cornell, what do you think the future will bring for this approach, both here in our community, but also around the country?

Virginia Mutch, PhD: I mean, I think the hope is for true integration, that we do not want mental health care to be siloed or siphoned off from the rest of one's medical care. We want it to be integrated, normalized, de-stigmatized, and part and parcel of your checkup. You know, so the same way I check my pulse and my heart rate annually with my doctor, I also want to check, you know, is my lifestyle in line with my values and what I think is going to be ultimately helpful for me.

So yes, of course, like we said, there's always a place for long term psychotherapy. We never want to get rid of that. That's not the goal, but to proliferate this type of work might save us as a society, a great deal in terms of healthcare costs and get people feeling healthier and happier in a quicker and less expensive manner.

Janna Gordon-Elliott, MD: Yeah, and I'll just add to that, that I'm also really excited to just see this program expand some more. We've started piloting it for anxiety and it would be great at some point to be able to offer it as well for other common behavioral health conditions in primary care, like even mild to moderate substance use disorders.

We've also started conversations with other clinical services that might be able to utilize the collaborative care model, like endocrinology, where we think this model can enhance the care of patients with diabetes, also patients being followed for weight management. In addition, we have a goal to establish an enterprise wide infrastructure for all of us who are currently implementing the collaborative care.

So right now that's primary care, pediatrics, OB, and I hope more as we continue to expand. So ideally in this infrastructure, if we can imagine it, there might be people from billing, compliance, IT, and people who then really develop an expertise in this model. So that there are, for example, there are builds in place in the electronic health record every time we're going to start the collaborative care model in a new practice.

It'll just be so much easier, I think, to do these things when we have an infrastructure for it in this way, so that we're not all just kind of remaking our own version of the model. With more institutional expertise specific to the model, I really think that's going to help us provide efficient care, collect good data, and also ideally, what our ultimate goal is, is about helping patients get better.

Host: Yes, that is the goal. And, Janna, Virginia, I just really want to commend you on all of the work you've done in this area. It was so wonderful to have you on today to speak about collaborative care. I mean, this is such an important initiative. It's already made a difference in our community. I expect and hope that it's going to grow further in our institution around the country and just listening to the both of you speak about this, I can say I learned a lot and I'm sure everyone who's listening did as well. So thank you for giving us this comprehensive introduction to collaborative care.

Virginia Mutch, PhD: Thank you so much for having me.

Janna Gordon-Elliott, MD: Thank you so much for having me.

Host: And thank you to all who listened to this episode of On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on many major audio streaming platforms. That includes Spotify, Apple Podcasts, YouTube, and iHeartRadio. If you like what you heard today, give us a rating and subscribe so you can stay up to date with all of our latest episodes. I'll say that those ratings really do make a difference. So if you liked what you heard, please do give us that rating and please tell your friends. We'll be back again next month with another episode. Until then, wishing you good health in body and mind. 

Promo: Every parent wants what's best for their children, but in the age of the internet, it can be difficult to navigate what is actually fact based or pure speculation. Cut through the noise with Kids HealthCast, featuring Weill Cornell Medicine's expert physicians and researchers, discussing a wide range of health topics, providing information on the latest medical science.

Finally, a podcast to help you make informed choices for your family's health and wellness. Subscribe wherever you listen to podcasts. Also, don't forget to rate us five stars.

disclaimer: All information contained in this podcast is intended for informational and educational purposes. The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition.

We urge you to always seek the advice of your physician or medical professional with respect to your medical condition or questions. Weill Cornell Medicine makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the information featured in this podcast. And any reliance on such information is done at your own risk.

Participants may have consulting, equity, board membership, or other relationships with pharmaceutical, biotech, or device companies unrelated to their role in this podcast. No payments have been made by any company to endorse any treatments, devices, or procedures. And Weill Cornell Medicine does not endorse, approve, or recommend any product, service, or entity mentioned in this podcast.

Opinions expressed in this podcast are those of the speaker and do not represent the perspectives of Weill Cornell Medicine as an institution.