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The value of integrated care.

Psychiatrists and primary care physicians need to work together to meet the needs of psychiatric patients. In Texas, we have developed an integrated community program that has as its centerpiece just this kind of collaboration. The results are still unfolding--but are highly encouraging so far.

The Harris County (Tex.) Hospital District (HCHD) is one of the largest public health care providers in the country. It is affiliated with two major medical schools--the Baylor College of Medicine and the University of Texas Health Science Center in Houston. HCHD also operates three hospitals, including Ben Taub General Hospital; 11 primary care centers; seven school-based centers; a center for homeless health care; and a center for patients with HIV/AIDS.

In addition, HCHD partners with several other Houston area community treatment centers, where 90% of all patient encounters take place.

In 2004, one-fourth of all HCHD patient encounters revealed at least one psychiatric diagnosis. Until that year, all the HCHD psychiatric patients (except those at the center for HIV/AIDS patients) were seen at the county's only psychiatric outpatient clinic, at Ben Taub General Hospital. As a result, HCHD patients had to wait 4-6 months for an appointment at the clinic.

Against that backdrop, psychiatrists and primary care physicians decided that an integrated care system had to be created to provide more efficient psychiatric services to all patients within HCHD.

Integrated psychiatric services are highly appreciated by patients and health care providers. They help remove barriers to psychiatric care by directly placing psychiatrists into patients' familiar primary care centers. These services also allow psychiatry to achieve more parity as a medical specialty.

Managed care companies are beginning to see the value of integrated services. In 2005, private insurers began to pay more reimbursement for psychiatric services provided by primary care physicians than by psychiatrists.

In July 2004, HCHD launched a pilot project and placed me as a psychiatrist in three primary care centers. I worked shoulder to shoulder with primary care physicians, and my tasks included seeing scheduled patients at the centers and providing consultations to primary care physicians. The goal was furthering psychiatric interventions--by primary care physicians.

I am proud to report that the 2004 pilot project proved quite successful. In fact, as a result of the project, primary care physicians asked that psychiatrists be placed on site at all centers within HCHD--as well as at several partner health care pavilions. That pilot project led to the establishment of HCHD's Community Behavioral Health Program (CBHP) last July.

I became CBHP's director, and we hired several new psychiatrists and 10 master's-level psychotherapists. We also moved out several psychiatrists from Ben Taub General Hospital for a day or two a week into the community centers.

We teamed with HCHD social work services, which already had social workers at each community center and in several other area programs.

Medical students, nursing students, psychology interns, and primary care and psychiatry residents have since joined CBHP. Simultaneously, we assembled a steering committee of psychiatrists, primary care physicians, psychotherapists, substance abuse counselors, nurses, social workers, and administrative community center directors.

During the last 6 months, we placed a team of psychiatrists, psychotherapists, substance abuse counselors, residents, and students into several of HCHD's 11 primary care centers. Each center offers 1-2 days of psychiatric services, 3-5 days of individual and group psychotherapy services, and 2-4 days of social work services per week.

In the next 6 months, we plan to staff the six additional school-based centers with behavioral care.

To help walk-ins visiting with primary care physicians or others in crisis, psychiatrists are physically based at each center. We also encourage curbside consultations by primary care physicians while they are seeing their patients.

Another important component of this effort is helping educate our colleagues in primary care about psychiatric illnesses. Toward that end, Abbott Laboratories has sponsored a series of lectures on topics focused on recognizing psychiatric disease and prescribing the appropriate psychiatric medications. We are currently distributing DVDs of the lectures to our primary care physicians for review.

Our current research focuses on treatment outcome data. We soon plan to undertake substance abuse research projects as well.

The goal is to connect patients with behavioral care services as soon as possible. That's why we decided that every member of the medical team should be able to directly accept patients and refer them to one another. The idea is to minimize waiting periods.

We psychiatrists have also informed our primary care team that we wish to operate like other medical subspecialists, such as cardiologists. Cardiologists evaluate and stabilize patients and then return them to primary care physicians for ongoing care. Likewise, we would like to stabilize patients and follow up with them--until we feel comfortable returning them with recommendations to their primary care physicians for maintenance. We psychiatrists also want to be viewed as "integrated consultants." We believe the primary care physician remains at all times the master of the patient's care.

HCHD patients are now able to secure a new appointment with a psychiatrist within 4 weeks. A patient with more urgent needs can be seen by our psychiatrist, psychotherapist, or substance abuse counselor as a walk-in on the same day.

We need to continue to look seriously at the benefits of partnering with our primary care colleagues. This is the kind of collaboration that benefits everyone--particularly our patients.

DR. OSTERMEYER is director of the Psychiatric Outpatient Clinic at Ben Taub General Hospital, Houston, and of the Harris County Hospital District Behavioral Health Program. She is also an assistant professor of psychiatry and family & community medicine at Baylor College of Medicine, Houston.

BY BRITTA OSTERMEYER, M.D.
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Author:Ostermeyer, Britta
Publication:Internal Medicine News
Article Type:Column
Geographic Code:1USA
Date:Apr 1, 2006
Words:939
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