The Collaborative Care Model: Managing Behavioral Health in a Primary Care Setting

Posted on: March 24, 2023Pittsburgh

At UPMC Shadyside Family Health Center (SHY FHC), located across the street from UPMC Shadyside Hospital, a significant proportion of the patient population served comes from racially or ethnically diverse backgrounds. These include BIPOC individuals, immigrants or other international members of the community, the LGBTQIA+ population, individuals with disabilities, etc.⁴ Furthermore, with regards to mental health care, racially or ethnically diverse patients are more likely to be misdiagnosed or underdiagnosed. Examples of barriers to proper care include stigma, general distrust of the healthcare system and lack of culturally competent or diverse providers.³

It has been found that treating mental illness in the primary care setting can lead to better long-term outcomes for patients through improving access to behavioral health care and reducing stigma.² As part of our efforts to reduce these barriers, the Collaborative Care Model (CCM) has been instituted to integrate behavioral health care in the primary care setting at SHY FHC. Developed by the University of Washington AIMS Center, this model allows for the behavioral health of a patient to be managed by not just the primary care provider (PCPs), but also a psychiatrist and a behavioral care manager.¹

This year, I have been fortunate to serve as the Behavioral Care Manager as part of the CCM at SHY FHC. Through referrals from PCPs and clinical screenings such as the PHQ-9 (depression), I am able to maintain a regularly updated registry of patients with whom I communicate with via phone or in-person. Through these patient interactions, I can spend time learning about the patient’s medications, their access to behavioral health services such as therapy, and any other factors affecting their mental well-being. I can even provide outside therapy referrals or referrals to our newly-established in-house therapist. I am then able to provide our consulting psychiatrist and the patient’s PCP a detailed update on the patient’s progress, which can allow for changes to be made in the patient’s treatment plan if necessary.

I have learned so many valuable skills and resources in my role as a care manager. I have developed interviewing skills that allow me to have more patient-focused interactions and gained a greater understanding of pharmacological treatments and types of therapy used in behavioral health care. I have also been able to learn more about several other barriers that our underserved populations face such as housing, transportation, insurance, etc. and how other members of SHY FHC help our patients work to overcome them.

I enjoy this role so much because of the collaboration that occurs between multiple members of a care team, and the fact that I am able to connect with patients that may otherwise have their needs go unnoticed. The registry allows me to track a patient’s most recent visit and when they should be contacted next to ensure continuity of care. I have had patients that I have made contact with who were able to re-establish care and get the treatment that they needed because I was able to reach out to them and check in on them. There is nothing more gratifying than being able to hear of a patient’s improvement or express their happiness that someone has reached out to them to check in on them. Through my time in this role, I have begun to understand how much collaboration and continuity of care are vital to the successful treatment of a patient. Developing trusting relationships with these often-overlooked patients in a multidisciplinary care team is an incredibly effective way to ensure that access to behavioral care is provided to those really need it.

Citations: