In this chapter, we discuss chronic disease management models, review their basic elements, and consider ways in which they may be adapted to neuropsychiatric care.
While having an extensive knowledge of neuropsychiatry is vital to patient care, implementing this knowledge through an effective and efficient model of care delivery is fundamental to increasing patients’ access to such expertise.
The US system of health care delivery is most adept at caring for patients with episodic or acute illnesses. Chronic conditions, defined as those lasting more than 3 months and not self-limited,1 are very difficult to manage in the current system due to its fragmented and largely hospital-centric design. Given the chronic nature of most neuropsychiatric conditions, it is essential that we focus our attention on how to optimize patient outcomes through our care delivery. This is especially the case given the rise in incidence of neuropsychiatric disorders with the aging population.
Chronic disease management principles have been recognized for several decades as leading to better outcomes than usual care in a variety of chronic diseases such as diabetes, cancer, and heart disease. Wagner, Von Korff, and colleagues1,2 were instrumental in formalizing the concept of the collaborative chronic care model for nonpsychiatric illness management in primary care. Key components of their model include:
Emphasizing the role of patients and their families in carrying out care
Collaborating within the health care team to adhere to evidence-based treatment algorithms
Ongoing symptom self-monitoring by patient and adjustment of care as indicated
Close attention to and support for optimizing patient functioning in their communities
The importance of addressing the mental health needs of primary care patients was articulated as early as 1960 by the Cherokee Health Systems.3 However, over the last 20 years, there has been an explosion of interest in applying chronic disease management principles to the mental health needs of the population. While largely driven by the chronic nature of most mental illness, other motivating factors include the inadequate supply of mental health clinicians and the common preference of patients to be managed by their primary care physicians (PCPs).4 A variety of models integrating behavioral health into primary care have evolved. Features may include an on-site, “co-located” mental health clinician available to treat primary care patients directly, discuss cases during team meetings, or provide curbside consults during clinics. Figure 36-1 shows the range of integration models, and Figure 36-2 shows the collaborative care model (CCM) workflow.
Levels of behavioral health integration.
Illustration of the collaborative care workflow.
CCM is now considered by many to be the most effective and efficient approach to integrating mental health care into primary care. One such model, IMPACT ...