A review of the benefits and limitations of a primary care-embedded psychiatric consultation service in a medically underserved setting

Abstract

A significant percentage of patients with psychiatric disorders are exclusively seen for health-care services by primary care physicians. To address the mental health needs of such patients, collaborative models of care were developed including the embedded psychiatry consult model which places a consultant psychiatrist on-site to assist the primary care physician to recognize psychiatric disorders, prescribe psychiatric medication, and develop management strategies. Outcome studies have produced ambiguous and inconsistent findings regarding the impact of this model. This review examines a primary care-embedded psychiatric consultation service in place for nine years in a family medicine residency program. Psychiatric consultants, family physicians, and residents actively involved in the service participated in structured interviews designed to identify the clinical and educational value of the service. The benefits and limitations identified were then categorized into physician, consultant, patient, and systems factors. Among the challenges identified were inconsistent patient appointment-keeping, ambiguity about appropriate referrals, consultant scope-of-practice parameters, and delayed follow-up with consultation recommendations. Improved psychiatric education for primary care physicians also appeared to shift referrals toward more complex patients. The benefits identified included the availability of psychiatric services to underserved and disenfranchised patients, increased primary care physician comfort with medication management, and improved interprofessional communication and education. The integration of the service into the clinic fostered the development of a more psychologically minded practice. While highly valued by respondents, potential benefits of the service were limited by residency-specific factors including consultant availability and the high ratio of primary care physicians to consultants.

Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States

“…Unfortunately, frequently, PCPs fail to recognize psychiatric disorders, and only 13% of the mental health care delivered is considered to be "minimally adequate." The reasons reported are over-or underprescribed psychotropic medications, rarely being provided structured counseling, and infrequent referral of patients for mental health services (5). PCPs themselves identified multiple barriers to mental health referrals, including patient's resistance, stigma, and inadequate insurance coverage.…”

“…PCPs themselves identified multiple barriers to mental health referrals, including patient's resistance, stigma, and inadequate insurance coverage. For this reason, collaborative models of care were developed, including the embedded psychiatric consultation model (5). In this model, a consultant psychiatrist is available onsite to assist the PCP to recognize psychiatric disorders, prescribe psychiatric medications, and develop management strategies.…”

The Educational Value of Outpatient Consultation-Liaison Rotations: A White Paper From the Academy of Consultation-Liaison Psychiatry Residency Education Subcommittee

“…Overall, the literature describing educational models for outpatient CL experiences is limited, with only 17 articles meeting the search criteria (Table 3). 18,[27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42] We found 10 articles describing individual integrated care programs 18,28,31,32,34,36,38,39,42 and 2 articles providing guidelines on core competencies for integrated care for trainees. 30,40 As shown in Table 2, the educational opportunities for integrated psychiatric care ranged from colocated services and collaborative care to dedicated outpatient psychiatric clinics for the medically ill. Only 3 of the articles describe training opportunities for advanced psychiatric trainees including 2 for CL fellows and one for child and adolescent fellows.…”

“…27,38,39 Similar to the psychiatry residents, primary care and family medicine residents who receive training for mental health in an integrated or collaborative care model find that their training is enhanced. [28][29][30][31][32]42 Collaborative care and integrated care in primary care settings CLP = consultation-liaison psychiatry; COPD = chronic obstructive pulmonary disease; SPMI = serious and persistent mental illness.…”

“…27,29,31,32,34 Specific challenges of the integrated care model with an embedded psychiatry consultant in the primary care settings are uncertainty about appropriate referrals, delayed follow-up with consultation recommendations, and inconsistent patient appointment-keeping. 28…”