Would Ending Siloed Health Care Improve Patient Outcomes?

David Katzelnick, M.D.
Chair, Division of Integrated Behavioral Health
Mayo Clinic Rochester Minnesota
We acknowledge the collaboration of National Network of Depression Centers in developing this series.

In my last post, I shared how people can become both engaged in and influence the quality of their mental health care. However, even more quality gains can be had by integrating the delivery of mental health care into the primary care setting.

Physical and mental health are intrinsically linked and should not be treated in isolation. For example, better outcomes are achieved when care is coordinated for an individual experiencing both depression and cardiovascular disease. Treating the individual’s depression increases the likelihood of the patient adhering to a long-term heart disease treatment plan including lifestyle changes, while the regular exercise recommended for management of heart disease can help manage depression.

One study of Medicare patients with diabetes and/or coronary artery disease found that when patients also experience depression, treatment costs rise by 65 percent. Yet our health system tends to isolate physical and mental health care in physically distinct settings with little communication and care coordination between providers. The result is a costly segregated system in which the whole is less than the sum of its parts.

Treat patients where they enter the system
Primary care is the setting where most people first seek care for a mental health condition and is the sole setting for more than one-third of individuals receiving mental health care. But most primary care providers don’t have the support, time, or resources needed to screen and treat individuals with mental health care needs. Only one-third to one-half of people with symptoms of major depression who seek care in a primary care setting are diagnosed with depression. As a result, depression and other mental health conditions frequently go untreated.

If diagnosed, individuals are often prescribed antidepressants. In fact, approximately 70 to 80 percent of all antidepressants are prescribed in the primary care setting. However, medication is not always needed and many people, especially those with mild depression, can be treated just as effectively with therapy.

Even when an individual does receive a referral from their primary care provider, less than half follow through. Sometimes that’s because the person becomes overwhelmed by the challenges of the condition and unable to engage with a psychiatrist or a therapist; and sometimes it’s too difficult to find a provider. Often if a person does find a provider in their insurance network or treatment they can afford, it takes weeks or more to get an appointment. The distance between the primary care setting and mental health treatment is both literally and figuratively too great for many to overcome.

But there is a better way. To meet patients’ whole health needs and make better use of limited mental health resources, we must integrate mental health and physical care. That means bringing mental health care to where people already are—the primary care setting.

Models for coordinated care
When care is coordinated, we can expect to see both better outcomes and lower costs. One such example is TEAMcare, developed collaboratively by the University of Washington and the Group Health Research Institute. This comprehensive team-based program in over 30 health settings throughout North America is designed to improve quality of both mental health and medical care in patients with comorbid depression and diabetes and/or coronary heart disease.  TEAMcare is already demonstrating success and serves as a ready-to-implement model for Patient Centered Medical Home and Accountable Care Organization programs.

Care of Mental, Physical, and Substance-use Syndromes (COMPASS) is another team-based pilot program designed to improve outcomes and lower costs. Funded by a grant from the Centers for Medicare and Medicaid Services (CMS), COMPASS is offered at primary care clinics in eight states.

In the next post, I’ll provide more details about the success of the COMPASS program and share ways in which you can advocate to make care coordination the norm, not the exception.

Questions

  • Have you experienced coordinated care? What do you like about it? What do you dislike?
  • In what ways does your primary care provider engage you about your mental health and well-being?
  • What do you think your primary care provider should be doing to provide care to the whole of you?

Bio
David J. Katzelnick, M.D., is the chair of the Division of Integrated Behavioral Health at the Mayo Clinic Rochester Minnesota and a member of the Executive Board of the National Network of Depression Centers (NNDC). His major clinical and research interests are in mood and anxiety disorders, psychopharmacology, diagnosis and treatment of mental disorders in primary care and medication education. He is currently Mayo Co-PI for the COMPASS Centers for Medicare and Medicaid Services (CMS) grant, which has the goal of spreading a collaborative care management model to manage patients with depression and diabetes and/or cardiovascular disease.

Disclaimer: The project described was supported by Grant Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

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1 comments
Regine Ryder
Regine Ryder

I made my psychiatrist open my files to other health care providers after I found out that my primary care physician could not see them. I had no idea that the law treats mental and physical health different in this regard as well.