From Theory to Practice: A PCP Perspective on Collaborative Care
On the heels of a feature in Boston Globe, we grabbed some time with Wayne Altman, MD, who is the co-owner of the Massachusetts-based family medicine practice, Family Practice Group.
A small group of 12 primary care physicians, Family Practice Group is grappling with a capacity problem. Like many primary care practices across the country, the healthcare demand surpasses the supply of physicians able to provide it, leaving them unable to accept any new patients. On top of that, many of their existing patients have mental health concerns and treating these adequately adds significant strain on primary care provider capacity.
To address this burden, Family Practice Group launched their very own collaborative care model (CoCM) program alongside nonprofit behavioral health center Brookline Center. The program, which launched in January of 2024, was built with Mirah technology and implementation support.
While Family Practice Group’s CoCM program is still relatively new, Mirah’s Jessica Lyons sat down for a Q&A with Dr. Altman to hear his initial impressions as a PCP around collaborative care, building a program from scratch, and his experience with Mirah.
Check out the transcript below to learn more or watch the full interview.
This interview was conducted in May 2024 and has been edited for length and clarity.
Can you start off by just giving us a brief introduction and information about your background?
Wayne Altman, MD: I am professor and chair of family medicine at Tufts Medical School in Boston, and I am the co-owner of a medium sized family medicine practice just outside of Boston in Arlington, Massachusetts called Family Practice Group.
Could you please describe collaborative care from your unique perspective as a PCP and family medicine doctor?
Wayne Altman, MD: Well, I used to think I knew what collaborative care was because in my office for about 10 years, we had something called integrated behavioral health and many family physicians and primary care clinicians know what integrated behavioral health is - having a psychologist or a therapist in your office that you have an opportunity to collaborate with at times.
The difference being that [in the collaborative care model] in addition to having a therapist embedded in your office there's a care manager as part of the team. And that care manager is the quarterback. That care manager is calling the patient, is organizing things, is setting them up with the therapist, is finding resources.
And that role is of critical importance for the patient and the primary care clinician and the third member of the team, which is a psychiatrist who does not meet directly with the patients, but is available one hour a week for a zoom call. So, each week I spend five or ten minutes on a zoom call, briefly checking in with my patients, and getting any advice, if necessary, from the psychiatrist about psychopharm.
As a primary care clinician, I take care of a lot of mental health needs of my patients and I'm reasonably comfortable prescribing medications for mental illness, but when things get a little complicated or don't work as well as I had hoped, it is incredibly luxurious to once a week have a psychiatrist available to you to ask questions, and help guide pharmacological management of mental illness of my patients.
One of the things we often hear about is that systems change is hard and PCPs are already burdened with more and more of that one more thing to do. So we often hear things like, “I'm so busy, I don't have time to figure this out and implement a new workflow in my practice.” What would you say to those providers? Why were you willing to introduce a new program into your very busy practice?
Wayne Altman, MD: Well, what I would say to those folks is they're right. They are so busy. And they don't have time to do new things. That's all correct.
So I would start by validating that. And then the second thing I would say is if you want something different, you have to do something different. Something fundamentally different. And it turns out that navigating mental health crises of patients on a day-to-day basis [necessitates that].
We're not talking about the occasional patient. We're talking about multiple patients a day in a primary care family medicine setting. Navigating the challenging mental health needs of patients and mental health crises takes an enormous amount of time and bandwidth. And it often results in banging your head against the wall because you can't find the people or resources that you need for your patients who are struggling.
When you are doing collaborative care management, you have a care manager – and that is a complete game changer when it comes time to navigate your patient's mental health care needs and crises because it gives an impressive amount of bandwidth back to the primary care clinician.
So, in a sense, it's not that I don't have enough time for collaborative care, it is that I don't have enough time to not do collaborative care.
What problems has this solved for you at your practice?
Wayne Altman, MD: Well, it's kind of simple. I'm sitting in an exam room and I'm talking to a patient and the patient shares some challenges or issues that they're having related to their mental health and they express a need for help. You know they need help. You want to give them the help that they need. And you're thinking, “where am I going to find these resources? How am I going to help this patient? I can find something for them, but it might be a 3 to 6 month wait to get them in. I don't know if I can find someone that their insurance will accept and they can afford it.”
All of these barriers are immediately placed in your way. And so what collaborative care does for me is it brings me a care manager to navigate these. I now have a person on my team that will help me and the patient overcome access, cost, and resource barriers.
And, it feels like weight is being lifted off your shoulders. It is really quite magical.
You are mentioning access and we know that is a huge issue in general with behavioral health in our country. So, for patients participating in collaborative care in your practice, how have the patients responded to the program and what do you think they think about it?
Wayne Altman, MD: I think it feels a little too good to be true for them. They're a little bit skeptical that they're actually going to have someone reach out to them within a few days and help them take their first steps into accessing mental health healthcare in a pretty expedited fashion. But they quickly understand that, no, this is real – because then it happens.
And so, you know, they trust me. And so they're like, “okay, I'll try this. This sounds too good to be true, but I'm in.” And everything tends to go really smoothly because when you have a care manager whose primary job it is to organize everything and make sure things go smoothly, then things go smoothly, and quickly your patients go from suspicious that this was too good to be true to delighted that this is so fantastic.
What types of patient outcomes are you seeing so far?
Wayne Altman, MD: Well, it's four months in and so it's a bit early, but I can think of many patients who have come back to me and said that this was fantastic and helpful and thank you. No patients have come back to me with concerns or complaints. None.
That's wonderful. So, we have to talk about financial sustainability. That seems to be one of the biggest barriers to amazing integrated behavioral health programs as you were referencing earlier on. Curious to know again, it’s early days [for your program], but what are you seeing in terms of the financial return here billing under these unique collaborative care codes?
Wayne Altman, MD: Well, there's some early good news. What we're seeing per my office manager is the codes are generating the high amounts of revenue per code that we were hoping for, anticipating, and counting on. In terms of big picture, adding it up and seeing how much revenue is being generated by the entire program compared to how much it's costing and so on, it's really too early to say. We are very optimistic that they're going to look good.
We also were hoping you could chat with us a little bit just about your experience with Mirah in general. Mirah provides not only the software platform to hold up the model - so the registry product that the care manager relies on so heavily to document tasks and track time. But, there also is a dedicated team at Mirah that supports implementation. So works shoulder-to-shoulder with healthcare practices as they're readying to launch this program and also helping to identify the unique workflows that will support collaborative care in your office. So curious to hear a little bit more about your experience working with the Mirah team.
Wayne Altman, MD: Regarding the implementation support of the program, most people who come into a primary care office to try and help primary care clinicians don't really understand how crazy our lives are. And, because they're not really getting what reality looks like for us, they sometimes impose burdens or challenges for us that are not doable.
What I've enjoyed about Mirah is they do understand how crazy our professional lives are and are really dedicated to creating the minimum amount of burden for primary care clinicians.
And, helping us navigate things in a way that really involves as little time and effort from us as possible. It's really a program there to serve the primary care clinicians and their patients. The burden is virtually negligible.
