WEBB FELLOW: Improving Integration of Psychiatry in an Internal Medicine Resident Clinic: A Quality Improvement Study

Abstract: Background/Significance: Integrated care is an evidence-based model designed to provide mental health care at the population level to patients, through interdisciplinary collaboration, in the primary care setting. In this quality improvement study, we describe the approaches, challenges, and interventions in improving an integrated behavioral health (IBH) model in an internal medicine resident/trainee-based clinic—an area with relatively little literature thus far.

Methods: We conducted a quality improvement (QI) study beginning August 2023. Our interdisciplinary team included an internal medicine resident, psychiatry resident, IBH social worker, IBH psychiatrists, and two IBH medical directors (one from medicine; one from psychiatry). Our root-cause analysis focused on the limited clinic engagement with the existing IBH model despite long wait times for outbound psychiatry referrals. Our analysis elucidated an overly complex process for connecting patients with IBH resources as well as limited trainee understanding of the program. Our initial aim was to improve access to mental health care within the clinic. Our primary metrics were reducing the number of outbound psychiatry referrals by 10% and increasing inbound IBH referrals by 10% across 12 weeks; however, this project has extended beyond that timeframe given the positive response from colleagues. We conducted multiple PDSA cycles including implementation of connecting patients face-to-face with the IBH social worker on the day of their visit; weekly psychoeducation sessions with medical residents/attendings regarding IBH; creation of IBH resource space inside clinic; and direct workflow changes related to provision of recommendations from case review between the psychiatric and social worker.

Results: This quality improvement project is ongoing with full results expected by presentation at ACLP in November of 2024. Provisionally, our inbound IBH enrollment/consults have quadrupled. Our outbound psychiatry referrals have fluctuated but trended downward. Lastly, the number of in clinic consultations performed by our IBH psychiatrists has increased due to better awareness/improved perception of our IBH program.

Discussion: The implementation of an integrated behavioral health program in a training environment presents with unique challenges. Our study elucidated the lack of awareness and training in integrated care by primary care physicians and the impact this gap in knowledge has in connecting patients with effective, evidence-based mental health care. Through directed education and workflow optimization we were able to increase engagement in our IBH program and therefore improve access to mental health care for our patient population.

Conclusion/Implications: Training residents, both psychiatry and primary care, is crucial to implementing effective IBH programs. Our QI study identified gaps in knowledge as well as effective workflow optimizations that can help improve IBH program quality and effectiveness while also educating resident physicians.