Consultative Approaches to Leveraging the Psychiatric Workforce for Larger Populations in Need of Psychiatric Expertise

Access to psychiatric expertise is a major concern. In 2017, the workforce of 45,580 U.S. psychiatrists was considered insufficient to meet demand by a margin of 2,800 practitioners, a 6.4% shortage. This shortage is predicted to at least double by 2025. There are numerous reasons for this trend, including the number of medical students selecting psychiatry, impending retirement for over half of the psychiatric workforce, geographical maldistribution of psychiatrists, and many psychiatrists not accepting insurance due to low reimbursement rates (1). As a result, according to the Merritt Hawkins “2019 Review of Physician and Advanced Practitioner Recruiting Incentives” (2), psychiatry was the second most requested specialty to fill vacancies nationally. Given this situation, what can psychiatrists do differently to better address the demand for their services?

Consultative Approaches in Primary Care Beyond “One Patient, One Provider”

More than any other approach, the collaborative care model (CoCM) has demonstrated evidence of its ability to effectively extend the expertise of psychiatrists across larger populations than they could see in traditional outpatient care, using a consultative approach (3). In this model, psychiatric providers act as consultant team members with shared responsibility and work with a behavioral care manager who has a caseload of patients. The team’s focus is on providing effective care through a treat-to-target approach in order to reach defined clinical goals (such as depression response and remission). This process often requires adjustments to care recommended by the psychiatric consultant during a weekly review of the behavioral care manager’s caseload registry. The registry provides a population management approach with data from repeatedly assessing symptoms by using validated measurement tools. With this model, patients with less severe forms of psychiatric conditions or earlier presentations of serious mental health conditions receive effective treatment, are treated earlier, and experience less stigma in obtaining care. Furthermore, because psychiatrists remain in the treatment role and have enhanced communication with the primary care provider (PCP), they can help build the PCP’s competence and capacity while triaging patients who need a higher level of specialty care. The model involves indirect uses of psychiatric expertise via curbside consultations and systematic caseload reviews (4) to improve clinical outcomes and increase PCPs’ capacity to treat patients with these conditions. As a result, this model has demonstrated the ability to shorten the waitlist for specialty psychiatric evaluation in primary care (5).

Other models, in addition to CoCM, utilize psychiatric consultants (including psychiatric advanced practice nurses and psychiatric certified physician assistants) to better leverage psychiatric expertise. Not all options have the same advantages of CoCM, however, and not all are reimbursed by insurance. Table 1 compares CoCM and additional approaches—synchronous, asynchronous, direct (in person or televideo), and indirect (not visually evaluated)—and provides key characteristics of each.

Case-Based Learning

Case-based learning is an important aspect of the consultative approaches that guide PCPs through management of patient care (compared with providing didactic education only). This practice entails applying knowledge to real-world scenarios to help PCPs’ understand how to treat psychiatric conditions and apply this learning to patients with similar conditions. We have recognized a noticeable reduction in consultation requests in the 3–6 months after implementation as the learning process takes place, and later consultation requests tend to occur for more complicated presentations. This approach aligns with practices of adult learning theory that demonstrate more effective knowledge gains when learning is applied and not just didactic, thus providing the structure for building the competence of the PCPs requesting the consultation (6).

A best practice approach for effective consultations includes the components of diagnostic clarification, treatment recommendations, contingency planning, and an educational component, done in a collegial manner. The educational component helps explain to the requesting provider why the recommendation was made and further enhances the learning opportunity (7). Encouraging PCPs to use measurement-based care (8) with validated tools to inform progress and promote treatment to defined targets is particularly important in monitoring the effectiveness of care and improves communication about patients’ progress.

Experience has shown that PCPs’ engagement and follow-through with the psychiatric consultant’s recommendations rely heavily on a foundation of trust, which develops over time. In addition, selection of a psychiatric consultant needs to be based on the individual’s ability to engage with the team. This standard includes such exhibiting traits such as flexibility, responsiveness to the team, gratification in being part of a team, and being a good and willing educator (9). Suitable psychiatrists have experienced significant job satisfaction and enjoy answering a multitude and variety of questions during consultation (10).

Increasing Access to Traditional Psychiatric Care

Treating in the primary care setting by utilizing psychiatric consultation to assist with treating less severe forms of common conditions or earlier (and more treatment-sensitive) presentations of severe mental health conditions can lead to greater availability of traditional psychiatric appointments for direct evaluation of patients. This approach can address problems with waitlists, timeliness of evaluations, cost of inpatient and emergency room admissions, and suffering that occurs with delays in care. In addition, psychiatric consultants can support PCPs who take stable patients back into their care for refills of psychotropic medications, thereby freeing up even more time for direct psychiatric care and replicating how most of medicine tends to use specialty care.

Limitations and Policy Recommendations

As noted in Table 1, funding for some forms of consultative approaches to leveraging psychiatric expertise are not covered by insurance. There are Current Procedural Terminology (CPT) codes for CoCM, and it is now reimbursed by Medicare, and by Medicaid and commercial insurers in some states, thereby providing a mechanism to pay for the work of added team members, including the psychiatric consultant. These codes provide relative value unit credit for the psychiatric consultant’s time spent on the caseload review and team functions, so there is no need for a separate funding source. Another set of codes covers interprofessional internet and telephone consultation, but these codes are used infrequently due to lack of reimbursement by some payers, low reimbursement rates, and the requirement for patient copays and consent. Value-based payment arrangements could result in less dependence on CPT codes and a greater focus on reducing costly specialty care and emergency room and inpatient visits, thus providing reimbursement for the psychiatric consultant through overall cost savings and performance incentives.

Liability concerns may lead psychiatrists to resist providing indirect consultation. In addition, obtaining licensure in the state where the patient (or the caseload registry) is located is recommended, so barriers to consultation across state lines must be addressed. To guide psychiatrists, the American Psychiatric Association has developed a resource document for cross-state consultation to guide psychiatrists (11), which is available online. Lastly, PCPs often have liability concerns about adopting a model of care where they are the prescribers of psychotropic medications and express reluctance to do so. Addressing this issue will require a skilled psychiatric consultant who understands the need to build a trusting relationship with PCPs and utilizes an educational approach to guide them through this initial resistance.

Training enough psychiatric consultants to meet demand is an important aspect because this is a different approach to patient care than is currently taught in most residency training programs. However, many newly trained psychiatrists who are expressing interest in the shift to a more consultative approach are enthusiastic about practicing a form of effective psychiatric care that keeps them connected to their colleagues in other medical specialties.