Today’s psychiatric residents train within the context of an evolving global health care system. A landscape of shifting policies and regulations, limited resources, and the search for cost effective, positive outcomes have created the need for innovative, mindful approaches to patient-centered care. Integrated care – providing mental health services within the context of primary care – is receiving increasing attention, and yet few training programs teach the unique skills a psychiatrist needs to be an effective member of an integrated care team. The groundbreaking Integrated Care Pathway (ICP), a training program for residents in the Department of Psychiatry and Behavioral Sciences at the University of Washington, is doing just that.
“Our program prepares emerging psychiatrists to help meet a serious social challenge,” says Anna Ratzliff, M.D., Assistant Professor of Psychiatry and Behavioral Sciences and co-leader of the ICP. “One in five counties in the United States has a shortage of mental health professionals, and 96 percent of counties have a shortage of those who can prescribe medication. We help ready our residents to be active participants in the future of psychiatry – a workforce of mental health professionals able to effectively work in evidence-based, integrated care teams. There will never be enough of us, so we have to work smarter.”
All UW psychiatry residents receive training about the integrated care approach to medicine, and spend a portion of their clinical rotations in a medical setting practicing consultation-liaison psychiatry. For those with more interest, the ICP offers a wide range of opportunities to learn about integrated care, from low-engagement options, like signing up for a quarterly newsletter and attending monthly journal club dinners, to more involved options, such as participating in a Collaborative Care Rotation and completing an Area of Distinction project. “We want to meet residents where they’re at,” says Amy Bauer, M.D., Assistant Professor of Psychiatry and Behavioral Science and Dr. Ratzliff’s co-leader of the ICP. “We always encourage participation but cater to their interest level.”
Collaborative Care Rotation
Those residents wanting to explore integrated care in an in-depth way can complete a Collaborative Care Rotation. Collaborative Care is a specific model of integrated care developed at the UW that has proven to be effective in treating common mental health conditions in primary care, such as depression. A care team consisting of the patient, a primary care provider, a care manager, and a psychiatric consultant uses established principles of chronic illness care to track a population of patients, monitor patient progress, change treatments if necessary, and stay mindful of which patients aren’t improving.
Each resident shadows a faculty member who serves as a psychiatric consultant on a Collaborative Care team. Residents participate in rotations for a minimum of six months and spend one half-day each week performing the duties of a psychiatric consultant. This includes participating in weekly consultations with a care manager (either over the phone or on site), providing recommendations for psychotherapy and/or medication, and using a patient registry to track the progress of each of their patients. The resident’s mentor reviews their work and introduces them to other clinical opportunities, integrated care research, and career development opportunities.
“The attending mentors are amazing,” says Sara Clark, M.D., chief resident for outpatient services at UW Medicine’s Harborview Medical Center, a graduate of the six-month Collaborative Care Rotation. “The program designers are very thoughtful, hardworking individuals with huge hearts for serving a greater population.” Dr. Clark really values how this rotation and approach can provide what psychiatrists often cannot provide on their own. “Patients have the benefit of a whole team planning and providing their care. They are reassured by knowing that they are getting evidence-based quality care to help them get better.” Building on the existing skills of the PCPs and care managers – through consultation and sometimes formal training – ICP residents help create more knowledgeable primary care settings. Dr. Clark has observed that “PCPs and care managers become informed in a way that helps them provide targeted, personal care for each of their patients with mental health needs.”
One resident spoke of her initial hesitation to “buy into” this model because it seemed to remove the psychiatrist from direct patient care, a notion Dr. Ratzliff refers to as the “backseat driver.” “But over the course of the rotation, I came to understand and appreciate the value of it in terms of getting quality psychiatric care to a larger number of patients who would otherwise have very limited access to mental health [care].” The model helped this particular resident better understand “who can be managed successfully in primary care, who needs referral, and how to best utilize a range of available providers when optimal care is not available.”
Areas of Distinction in Integrated Care
Residents wanting to influence and improve integrated care are encouraged to develop their own projects. They may choose to design an educational tool, conduct a quality improvement project, or conduct a health services research project – all to enhance the primary care setting’s role in treating patients with common mental health conditions. A mentor provides guidance in defining the scope of the project and the desired outcome, whether it’s a paper, presentation, or tool. Dr. Ratzliff recalls one resident who researched cultural information and resources that were relevant to helping engage a patient from a country in South America. Another carried out health services research, looking at health outcomes within the Asian population to determine if Collaborative Care would be beneficial.
Psychiatrists Ready for the Future
Mentors in the ICP demonstrate commitment and cooperative attitudes, model and teach valuable skills, and encourage lifelong learning to prepare residents to keep integrated care moving in its current trajectory toward becoming a successful wave of the future. Resident satisfaction with the varied training opportunities at UW is high, and participants go on to use their newly acquired skills in a variety of settings.
“Our hope for our residents is that they carry their knowledge of integrated care with them throughout their career, whether they work in an integrated setting or not,” says Dr. Ratzliff. “The more psychiatrists who understand the principles of effective integrated care grounded in evidence-based practices, the better we’ll be at treating our patients in informed, cost-effective, and efficacious ways.” Through the services of past, current, and subsequent residents in the program, providers in primary care settings will be increasingly able to treat their patients with mental health challenges.
For more information about teaching psychiatry residents about integrated care.
This story was written by Nina Rogozen, a freelance writer and editor in the Seattle area.