models of collaboration

MENTAL HEALTH 0095-4543/99 $8.00 + .OO

MODELS OF COLLABORATION

Alan D. Lorenz, MD, Larry B. Mauksch MEd, and Barbara A. Gawinski, PhD

In order for primary care clinicians to address the complex needs of their patient population they must be able to collaborate with mental health professionals. The peculiar need for this collaboration arises from the mind-body split embedded in our cultural heritage and the resulting professional separatism. A brief review of that history is followed by sec- tions on the spirit of collaboration, the spectrum of collaboration, key ingredients for effective collaboration, and some thoughts about the future of collaboration.

THE MIND-BODY SPLIT

Since the dawn of western medicine (5th century B.C.), the care of patients has been divided into care for the body and care for the mind. Though concerned about the whole person, Hippocrates' ability to excel in the treatment of the more mechanical afflictions of humanity (e.g., frac- tures) forever established an occupational niche for medicine. Training in medicine always has been structurally based, and from the time of Hip- pocrates, medical school begins with anatomy. As a result, physicians tend to self-select; they are trained to think spatially and structurally. Organi- zation of data tends to be hierarchical, and events are thought of more in terms of cause and effect.

This article is adapted from the authors' book Models of Collaboration: A Guide for Mental Health Professionals Working with Health Care Practitioners.'2

From the Departments of Family Medicine (ADL, BAG) and Psychiatry (ADL), the Univer- sity of Rochester School of Medicine; the University of Rochester School of Nursing (ADL), Rochester, New York; and the Department of Family Medicine, University of Washington, (LBM) Seattle, Washington

PRIMARY CARE

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The evolution of care for the other half of the mind-body split has been more diverse. Hippocrates left care of the mind to philosophers. For much of western history, care of the mind was woven into care for the spirit through organized religion. At the beginning of the 20th century, a new genre of professionals began to care for the mind. Freud, James, Janet, and other psychiatrists, psychologists, and therapists addressed the psy- che of their patients. In addition, the social work movement of the early 20th century produced social workers to care for people (especially un- derprivileged) in the context of their families and communities.

Nursing has had a unique position in the history of health care. Mod- ern nursing began with Florence Nightingale’s successes in the Crimean War. Following this, professional nursing flourished because of its initial role as a source of cheap labor in the hospital, and because patients re- covered more quickly with professional nursing care. Nursing blended sophisticated physical care of patients and attention to their emotional needs. Unfortunately, the successful integration of mind and body prac- ticed in nursing has been underappreciated up to now.

THE SPIRIT OF COLLABORATION

Collaboration is an attitude and an interpersonal process that em- bodies cooperation and a spirit of working together. Professionals with divergent training work within a convergent framework. Competition and turf battles are left behind as professionals rise above power struggles and petty status competition. Collaboration is a way for professionals to provide quality, comprehensive, and efficient care.

Collaboration recognizes each party’s presence, expertise, and special talents. It is not a leaderless, amorphous, inefficient group process. The team leader varies depending on the situation. For an acute myocardial infarction, a patient needs urgent intensive medical intervention. Coun- seling about smoking, eating habits, and managing stress has to wait. Likewise, if a patient is acutely suicidal, care for their hypercholesterol- emia is a lower priority.

This spirit of collaboration applies equally well to patients, families, and communities. If professionals can work together, the next logical step is to include the patients and those who care about them. Sometimes a family member has the needed expertise. For example, a man’s wife often has more insight and abiIity to aIter her husband’s diet than does the primary care clinician, psychologist, or nutritionist. Collaboration means working together as a team with a flexible hierarchy.

THE SPECTRUM OF COLLABORATION

Human suffering covers a wide spectrum, from the simple to the complex, and patient care needs to accommodate this wide range. Simple problems may be handled easily by a single clinician, whereas more com-

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plex situations call for more intensive collaboration. What makes a situation complex depends on a multitude of contextual variables: illness, family, community, culture, and clinician expertise and interest. Over time, these variables may change and the need for collaboration may intensify or fade. Five bands of the collaboration spectrum are: parallel delivery, informal consultation, formal consultation, co-provision of care, and ex- pansion of the health care network.

Parallel delivery occurs when the division of labor is clear and the problems addressed do not flow into each other in any significant

way; mental health and health care professionals are connected typically through a referral and benefit from the knowledge that a

partner is available, though each functions independently. Informal consultation focuses primarily on the consultant helping the

consultee address a clinical concern; typically, the consultant has no contact with the patient or family. In formal consultation, the

consultant may have direct contact with the patient and family; the relationship with the consultee is more contractual. Co-provision of

care involves sharing professional responsibility for patient care; the professionals often see the patient and family together. Co-provision

of care is generally not hierarchical, although professional leadership in treatment may vary depending on the problem.

Collaborative networking expands the provider team to include extended family and other medical specialists or educators,

as well as community resources.’*

Several groups of patients usually require more intensive collaboration along the spectrum. Patients with somatization disorder may be the most obvious example, but any patient with a large overlap of biomedical and psychosocial problems should be included. Patients with severe chronic medical illnesses or chronic pain may have both complex biomedical problems along with significant psychosocial distress. Patients with terminal illnesses deserve biopsychosocial and spiritual care. Situa- tions of domestic violence or substance abuse often require intensive collaboration. All of these patients require rapt attention to both biomedical and psychosocial dimensions, and their needs often exceed the capabilities of any one discipline or clinician.

A primary care clinician’s training, expertise, and interest in the psychosocial dimension of a patient’s life also influences the final color of collaboration. All primary care clinicians provide some form of counseling as they address their patient‘s needs, and some clinicians provide very sophisticated psychological services. Primary care clinicians become more adept with experience, exposure to the burgeoning literature on treating psychological problems in a primary care setting, and with each succes- sive collaboration. Primary care clinicians’ interest in psychosocial issues also varies. For example, some clinicians may enjoy treating their patients with substance abuse problems, but have a low threshold for collaborating on other problems. Collaboration also varies depending on how much the clinicians like working together. Some professionals like working together in teams, and others prefer more independence. Some have more per-

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meable professional boundaries, whereas others want a clearer demarca- tion of who is in charge of what.

The spectrum of collaboration is wide, and each situation is unique. Both acute, problem-focused situations and extensive complex cases may require collaboration anywhere along the bandwidth. Despite this vari- ability, there are certain universal characteristics to collaboration.

KEY INGREDIENTS FOR EFFECTIVE COLLABORATION

Certain universal components are present in all collaborative appli- cations. The key ingredients for health and mental health collaboration are relationship, common purpose, paradigm, communication, location of service, and business arrangement. This section describes the key ingredients and offers suggestions for promoting a working alliance.

Relationship

Good working relationships take time to develop. They often start around a single patient and grow with each new shared patient. More complicated patients serve as catalysts for intensifying collaborative relationships. Over time and with continued experience, professionals’ respect for each other’s abilities increases and trust grows.

Collaborative relationships require the same fundamentals as other good relationships. Mutual respect for another physician’s expertise is essential. Successful experience promotes respect, but awareness of limi- tations fosters shared responsibility. The primary care clinician must recognize the level of training and expertise that mental health professionals bring to patient care. Likewise, the mental health professional must recognize the importance of the doctor-patient relationship. When mutual respect is communicated to the patients, treatment efforts are at least ad- ditive, if not synergistic.

Mutual respect is a necessary precursor to establishing a flexible hierarchy. Primary care clinicians must be willing to step down and share authority. Most primary care clinicians feel relief when sharing the ”burden of care” for complicated patients. In this day of shortened hospital stays and more severely ill patients being cared for at home, the family has become an ever more important “health care provider.” Allowing mental health professionals to practice their expertise and facilitate family involvement can go a long way toward promoting efficient, effective, and comprehensive care for patients.

Common Purpose

Effective collaboration depends on a common purpose. This common purpose may be as simple as promoting the general welfare of the patient.


Recognizing this, however, can help professionals stay united. Within this overarching purpose may be more specific short-term goals.

Collaboration can take place when the parties involved have very different short-term goals, so long as these goals are not mutually exclusive. Expecting all parties to share the same goals at the outset is un- realistic. When different goals appear to be the source of conflict, a review of each party’s specific short-term goals and the overall common purpose puts each party’s needs in perspective and brings everyone together around a common purpose. Making the general purpose of any collaboration clear often facilitates the process of creating a unified plan. Speci- fying the short-term goals of each party focuses and clarifies their invest- ment. For example, one productive way for the primary care clinician to foster the mental health professional’s work is to recommend that patients come in to the first therapy appointment with a specific list of goals.

Paradigm

Sharing the same paradigm makes for an easier transition to collaborative relationships; however, not all collaborators view the process of change in the same way. Differing paradigms are not necessarily a problem unless they are mutually exclusive. Disagreements among collaborators about what is really happening may be rooted in paradigmatic differences. These disagreements are impossible to resolve without ac- knowledging presuppositions. Recognizing and respecting differences prevents power struggles among collaborators, and overlapping themes are often discovered. The blending of paradigms produces creative solutions (e.g., the biopsychosocial model).

Communication

Clear communication promotes effective collaboration. The subcul- tures of mental health and biomedical health have different vocabularies and different rules around the style, form, and frequency of communication. Recognizing these differences and finding common ground will avoid misunderstandings. The primary care clinician needs to use terms that are understandable to others and should avoid using jargon and ac- ronyms. Taking the time to learn the meaning of the other professionals’ language also promotes clear communication.

Introducing the patient is the first step in collaboration. A face-to-face introduction is best, but a phone call, a referral letter, or even a brief note suffices. Important information to share includes pertinent family history, psychosocial history, medical problems, medications, and the purpose of the referral. Collaborators should stay in touch by way of periodic updates. Primary care clinicians often complain that once a referral for therapy is made, the patient disappears into a black hole. Establishing expectations about the frequency of contact avoids these misunderstandings.

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Recognizing differences in norms around confidentiality also de- creases patients’ disappearing into therapy. For primary care clinicians, the envelope of confidentiality automatically includes all involved with the provision of health care. In the mental health culture, a much stronger prohibition against sharing information exists. The envelope of confidentiality is typically smaller and the boundary less permeable. The demar- cation of this boundary can shift with ongoing negotiation among all parties about what information can be shared. The primary care clinician can facilitate communication by obtaining consent for mutual exchange of information at the time of referral.

Location of Service

Collaborators may practice together, may practice separately, or practice in some combination of together and separate. For example, they may have more than one office and practice together some days, and separately on other days of the week. When a primary care clinician enters an established practice, there may be no mental health professional located close by. As time goes on, the primary care clinician can invite a mental health professional to see patients in the office on either a part-time or full-time basis. Occasionally, a primary care clinician may insist that a mental health professional be hired along with him or her to insure on-site collaboration.

Co-location may be affected by availability of other professionals. For example, in rural Montana, a primary care clinician may have only one social worker in town to serve the needs of the entire community. Or, there may be no one available except by phone. Alternatively, tremendous or- ganizational support for co-location may place a health psychologist right across the hall from the primary care clinician.

The advantages of co-location are numerous. Availability and ease of communication top the list. Common hallways promote contact; seeing the other professional reminds one of the most recent patient visit and a quick update on recent events can take place. Being co-located offers an opportunity for joint appointments. Patients find it reassuring to see their clinicians working side by side. For example, the primary care clinician might be able to “pop in” for a minute to review how things are going and check how the medicine is working. The primary care clinician can briefly introduce the mental health professional to the patient to connect a face to a name. This reduces the no-show rate for that all-important first visit. Issues of confidentiality also seem to be less prominent in co-location, and some practices have both clinicians’ share charts.

The disadvantages of co-location center mostly around issues of independence. Some professionals, particularly mental health, prefer the independence of another site. Being co-located may mean being sub- sumed under the rubric of the primary care clinician’s care. Medical offices often are noisy and chaotic, whereas a counseling office is more tranquil. Some patients prefer the privacy of going to another office for mental health services; they may prefer a more clearly demarcated boundary be-


tween their minds and bodies. In the end, whatever the arrangement, collaboration can still take place.

Business Arrangement

The business arrangement between collaborators and the method of payment for services have powerful influences on the nature of collaboration. There may be no obvious way to bill for conversations between professionals without the patient present, or a patient's insurance may dictate who the patient can see and for how long. Three different kinds of financial designs are most common in collaborative care: "employer- employee," "separate but equal," and "all under one roof." Whatever the arrangements, acknowledge the influence of these variables, identify any associated problems, and seek out creative solutions.

In an employer-employee relationship, there is an obvious power differential in the health care hierarchy. Some professionals prefer the clar- ity of the boundaries in this kind of relationship. Few primary care clinicians, however, directly employ mental health professionals in their offices.

Many primary care clinicians, either employed by a hospital or in a private practice, collaborate with mental health professionals who are in private practice. Mental health professionals may contract for space, office services, and agree to share charts and appointment systems. This "separate but equal" arrangement promotes a sense of professional equality and mutual respect. Many mental health professionals prefer this kind of arrangement to preserve control over time, availability, and environment. This arrangement promotes a flexible hierarchy that often carries over to the patients and families. Billing issues, however, often become complicated and closeness and tight teamwork take longer to achieve.

In the "all under one roof" business arrangement, both sets of professionals are employed by the same employer, for example, a managed care organization. In this increasingly common scenario, the mental health professional experiences more successful integration into a comprehensive health care delivery system. Communication with primary care clinicians is simplified, and billing issues are managed by the employer. Under an overarching biopsychosocial umbrella, coordination of care is simplified.

Direct reimbursement for collaborative care is unusual. Collaborative conversations can be compared with time spent writing referral letters, or time talking to patients on the phone; reimbursement is included in the (eventual) office charges and is therefore indirectly paid for. Some clinicians take time out from the face-to-face visit with the patient to make time to communicate with another clinician. Some insurance plans (including Medicare) are now reimbursing for supervision of care. In a cap- itated care setting, whatever treatment is efficient and cost-effective is re- warded. As Patterson and Scherger note, "New models of integrating mental health providers with primary care physicians will be able to flour-

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ish under managed care since capitation liberates the providers from hav- ing to worry about coding, charges, and reimbursement from a common office.”8 Of course, this point does not apply in a setting where mental health care is carved out.

SUGGESTIONS

Getting Started

tient.

paradigm for change.

Contact a mental health professional with whom you share a pa-

Select an individual you like, respect, and who shares a similar

Share overarching goals and general expectations. Discuss beliefs about confidentiality and clarify “off-limit” issues for special situations. Look for someone close by to prevent distance barriers. Propose sharing office space or the same building, at least part-time. Establish referral and appointment systems that serve the patients’ best interests. Decide whether to share charts. If not sharing charts, agree on frequency and form of communication for each kind of patient (e.g., call about a suicidal patient; otherwise a referral letter, treatment goals, monthly updates, or termination summary). Discuss details of the business arrangement and insurance reimbursement.

Keep It Growing

Model respect and good manners. Recognize and solicit the expertise of the mental health professional. Keep in mind the general purpose of collaboration. Consider each party’s short-term goals. Identify common goals and goals that are different. Do not take differences personally; be curious about another person’s perspective.

THE FUTURE OF COLLABORATION

Close collaboration between primary care clinicians and mental health professionals is bound to increase for a variety of reasons. Current research demonstrates a high prevalence of mental health problems in primary care. Twenty percent to 30% of patients in primary care meet the criteria for a DSM-IV diagnosable mental health p r~b lem.~ , ’~ Another 15% to 25% have a significant, though “subthreshold,” mental health problem that causes considerable distress.5~’~ This adds up to virtually half of all primary care patients seen in an ambulatory setting. In addition to the


suffering, the costs for these mental health problems are staggering. For example, in 1990 the annual cost of depression alone in the United States was approximately $43.7 billion.2 Psychiatric illnesses, primarily depression, somatization, anxiety, and substance abuse account for the majority of disability days per month, even when controlling for physical illness. This is not only a national finding but a cross-cultural phen~menon.~

To properly care for the needs of primary care patients, and reduce the costs to society for these conditions, more collaboration between mental health professionals and primary care clinicians is required. Recent research demonstrates primary care clinicians do a better job detecting, treating, and referring mental health problems when working in a collaborative relationship. This research also shows that physician behavior re- verts back to older styles when collaboration ceases6

All primary care clinicians receive some training in the provision of mental health care, but not enough to meet the need. The process of collaboration itself extends and deepens this training, and with each collaborative encounter, the primary care clinician becomes more sophisticated. It is predicted that in the future, more opportunities to expand the formal training will be available; however, primary care clinicians already have greater demands on their time and this will likely increase.'o,'l Alone, they will never be able to meet the mental health needs of the population. In the future, primary mental health providers will be recognized to fill the gap. Primary care will be increasingly viewed as a team endeavor.

A renewed emphasis on the doctor-patient relationship will foster more collaborative approaches with patients and their families. There will be no more noncompliant patients. A better relationship with family care- givers is crucial to helping care for more severely ill patients in their homes. It will become ever more important to have all care providers, including family, be "on the same page." This active sharing of care between patients, family members and professionals should increase patient satisfaction and improve outcomes while containing COS~S.~ , '~

Collaborative health care represents the creation of a new health care paradigm.' Collaborative health care delivery systems will mirror the complexities of human suffering. Clinicians from multiple disciplines will combine resources and strategies, and will share responsibility for their patients and with their patients.

References

1. deGruy, Fv: Mental health care in the primary care setting: A paradigm problem. Fam-

2. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER: The economic burden of depression

3. Kaplan SH, Greenfield S, Gandek B, et al: Characteristics of physicians with participatory

4. Kessler L, Cleary P, Burke J: Psychiatric disorders in primary care. Arch of Gen Psych,

ilies, Systems and Health The Journal of Collaborative Healthcare 15:3-26, 1997

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5. Kroenke K, Spitzer RL, deGruy FV, et al: Multisomatoform disorder: An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch of Gen Psych, 54:352-358,1997

6. Lin EB, Katon WJ, Simon GE, et al: Achieving guidelines for the treatment of depression in primary care-Is physician education enough? Medical Care, 35:831-842,1997

7. Ormel J, Von Korff M, Ustun B, et al: Common mental disorders and disability across cultures: Results from the WHO collaborative study on psychological problems in general health care. JAMA, 272:1741-1748, 1994

8. Patterson J, Scherger JE: A critique of health care reform in the United States: Implications for the training and practice of marriage and family therapy. Journal of Marital and Family Therapy, 21:127-135, 1995

9. Reigier DA, Narrow WE, Rae DS, et al: The de facto US mental and addictive disorders service system. Arch Gen Psych, 50:85-94,1993

10. Rivo M, Satcher D: Improving access to health care through physician work force reform: Directions for the 21st century. JAMA, 270:1074-1078,1993

11. Schwartz A, Ginsburg P, LeRoy L: Reforming graduate medical education: Summary report of the Physician Payment Review Commission. JAMA, 270:1079-1082, 1993

12. Seaburn DB, Lorenz AD, Gunn WB, et al: Models of collaboration: a guide for mental health professionals working with health care practitioners. New York, Basic, 1996

13. Spitzer RL, Williams JB, Kroenke K, et al: Utility of a new procedure for diagnosing mental disorders in primary care: The Prime-MD 1000 study. JAMA 272:1749-1756,1994

14. Stewart M: Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal, 152:1423-1433, 1995

Address reprint requests to Alan D. Lorenz, MD

Canal Park Family Medicine 1900 Route 31

West Wayne Plaza Macedon, NY 14502

e-mail: ANLZauhura .cc . rochester. edu

models of collaboration

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