Split Treatment

Abstract

The objective of this study was to examine the adherence rates of psychiatrists with APA standards for coordination of care in split treatment. Coordination of care in split treatment is monitored from claims paid data in an academic MBHO as an ongoing quality improvement activity. For an 18-month period, 93 psychiatrists were identified with 559 patients in split treatment and were mailed a survey. Surveys were controlled for change of providers. Self-report survey results were obtained from 69 psychiatrists for 295 patients in split treatment. The average rate of coordination was 66 percent; however, the distribution was bimodal with 36 percent of psychiatrists always coordinating and 26 percent never coordinating. Not obtaining a release accounted for 87 percent of non-coordination. In conclusion, while coordination of care in split treatment is an APA standard of practice, only 36 percent of psychiatrists fully complied. That one third of patients in split treatment did not receive coordinated care suggests a need for improvement to meet the APA standards of practice and avoid legal exposure.

INTRODUCTION

Split treatment, also called collaborative treatment, “…refers to an arrangement whereby a psychiatrist is responsible for medication management while psychotherapy is provided by another mental health professional, such as a psychologist, social worker, nurse specialist, or counselor.”¹ In 1980, the American Psychiatric Association (APA) issued guidelines for psychiatrists in consultative, supervisory, and collaborative relationships with non-medical therapists. Regarding split treatment or collaborative relationships, the guidelines indicate psychiatrists “…should undertake such relationships with a therapist only if they are able to keep themselves appropriately informed…and can assure themselves that the treatment is being carried out competently and adequately.”² In 1997, the APA confirmed coordination of care as a standard of practice. “When the psychiatrist assumes a collaborative or supervisory role with another mental health worker, he/she must expend sufficient time to assure that proper care is given.”³ Macbeth,⁴ in recommending strategies to psychiatrists for controlling the risks of split treatment, indicates that coordination with nonphysician clinicians is critical. Macbeth points out that psychiatrists are traditionally considered the “captain of the ship” with “deep pockets” and, therefore, may have the legal exposure of a supervisor even in a collaborative relationship. Balon recommends that psychiatrists “carefully design and monitor their collaboration with nonmedical health professionals.”⁵ Meyer and Simon indicate that at times split treatment appears as a “clinical shotgun wedding” where lack of communication results in fragmented treatment.⁶ Meyer and Simon offer a model letter for psychiatrists to use with psychotherapists to assist in addressing core clinical issues and reaching agreement regarding roles and responsibilities in split treatment.⁷ Riba indicates split treatment is more complex to manage than integrated treatment and requires better psychotherapy skills to avoid disruptions in care.⁸ In describing the negative interdisciplinary aspects of split treatment, Riba and Balon note that clinicians may not know each other or each other's skills, strengths and weaknesses, or styles, which may result in unclear or incompatible treatment goals. They report that the relationship between clinicians may be competitive rather than collaborative, which may result in displacement from the clinicians onto the patient.⁹ To further complicate the picture, J.M. Smith, in describing transference issues in split treatment, indicates, “…in contemporary treatment situations that include a patient, a therapist, a pharmacotherapist, and a pill, the transference issues can become more complex than landing patterns of airplanes at an overcrowded airport.”¹⁰ While behavioral healthcare practitioners generally understand that coordination of care is an accepted standard of practice and necessary for good risk management, the literature provides little information about adherence to this standard of practice. A 1995 study of split treatment coordination between 13 psychiatric residents and psychotherapists in a university outpatient clinic found a 53-percent coordination rate (44 of 83 cases).¹¹

Method

University of Miami Behavioral Health (UMBH), an academic MBHO in the Medical School of the University of Miami, manages approximately 210,000 covered lives in South Florida with an average of 2,848 active out patients/month. Split treatment accounts for an average of 35 active patients per month. To track clinician practices, a report is generated quarterly from claims data to identify all patients seen by multiple behavioral healthcare practitioners during the previous quarter. The data are controlled to eliminate change of practitioner requests. Survey letters are sent from the Medical Director to each practitioner with the patient's name, other practitioner's name, dates of service, phone, and fax. Practitioners report for each patient if they obtained consent for coordination of treatment, and if so, whether or not they exchanged information with the other practitioner. The survey letter is returned by fax and compiled and summarized for each practitioner by practitioner license level.

Results

For an 18-month time period (January 2001–June 2002) UMBH identified 93 psychiatrists involved in split treatment with 559 patients. The psychiatrists' survey return rate for split treatment was 74 percent (69 of 93) accounting for 295 of the 559 patients (53%). Of those responding, psychiatrists obtained signed releases for 70 percent (207 of 295) of their patients in split treatment. Coordination rates for psychiatrists to non-medical psychotherapists were 66 percent (194 of 295). Not obtaining a release accounted for 87 percent (88 of 101) of non-coordination. Based on 56 survey comments related to non-coordination, psychiatrists indicated that only two patients refused to sign a release. While the split treatment coordination rate for psychiatrists averages 66 percent, the bimodal distribution of coordination averages of individual psychiatrists ranges from 0 to 100 percent with rates of 0 and 100 percent accounting for 62 percent of the variance. Figure 1 provides details of psychiatrists' averages in coordination of split treatment. Psychiatrists who always or routinely coordinate average 8.7 cases in split treatment while those who never or rarely coordinate average 3.3 cases in split treatment. Of the psychiatrists who always or routinely coordinate, 41.2 percent are in group practices with non-medical therapists and average 15.3 cases in split treatment, accounting for 72.1 percent of total cases in split treatment while only 20.0 percent of psychiatrists who never or rarely coordinate are in group practices. Psychiatrists who did not respond to the survey average only 1.7 cases in split treatment; 20.8 percent of non-responders are in group practices.

Figure 1.

Split treatment coordination percent psychiatrists (n=69)

Table 1.

Split treatment coordination

Rate	# MDs	% MDs	# PATIENTS	% PATIENTS
0%	18	26%	31	10.5
1–9%	0	0%	0	0
10–19%	2	3%	14	4.7
20–29%	0	0%	0	0
30–39%	3	4%	9	3.1
40–49%	2	3%	26	8.8
50–59%	7	10%	18	6.1
60–69%	2	3%	34	11.5
70–79%	5	7%	50	16.9
80–89%	3	4%	18	6.1
90–99%	2	3%	26	8.8
100%	25	36%	69	23.4
TOTAL	69	99%	295	100.0

Discussion

Patient refusal to sign consent is the reason most frequently offered for lack of coordination; however, the wide variation of success in obtaining signed releases by individual practitioners ranging from 0 to 100 percent may be attributed to effort expended or some resistance on the part of some practitioners. In a review of the literature to identify barriers to adherence to clinical practice guidelines, Cabana, Rand, Powe, et al.,¹² described seven categories: 1) lack of awareness; 2) lack of familiarity; 3) lack of agreement; 4) lack of self-efficacy; 5) lack of outcome expectancy; 6) inertia of previous practice; and 7) external barriers, including those related to the guidelines, patients, and environment.

Lack of awareness and lack of familiarity are considered to be minimal barriers as a result, in part, of UMBH's quarterly surveys emphasis on improved coordination. Since many psychiatrists surveyed are involved in limited split treatment, the lack of agreement with both the practice of split treatment and the need for collaboration may be considered major barriers to adherence to the guidelines. Lack of outcome expectancy may apply as some psychiatrists appear to minimize both the risks of non-coordination and the value of collaboration. Inertia of previous practice is suggested to be a major barrier due to the minimal improvement in coordination rates as measured by quarterly surveys. Of the external barriers only time constraints likely apply as few patients refused to sign a release; in addition, the guidelines were not difficult to implement. The average split treatment coordination rate for psychiatrists responding to the survey is 66 percent; however, the variation ranges from 0 to 100 percent. Psychiatrists in group practices account for the majority of cases in split treatment and are more likely to coordinate. Psychiatrists in group practice may be more comfortable with the arrangement of split treatment and their group practice colleagues. Coordination is likely easier for group practice providers as they share the medical record and have frequent opportunities to meet. The psychiatrists who did not respond to the survey have few cases in split treatment and few are in group practices so it is suggested their rates of coordination are similar to the psychiatrist who never or rarely coordinates. The clinical and legal dangers of lack of coordination in split treatment have been previously described; however, the magnitude of non-coordination was not. The results of the UMBH quarterly surveys, while specific to South Florida psychiatrists in an academic MBHO network, suggest that on average one of every three patients in split treatment does not receive coordinated care. With only 36 percent of psychiatrists always coordinating in split treatment, there is a significant opportunity for improvement. Many of the negative aspects of split treatment are related to the lack of coordination and collaboration between clinicians. Split treatment may result in sub-optimal patient care particularly when clinicians are in a competitive rather than collaborative relationship. There is an ongoing need to educate and encourage improved coordination between practitioners providing split treatment to decrease the risks to patients and clinicians that may occur with fragmented treatment.

Conclusions

Based on self-report, psychiatrists in a South Florida MBHO network are coordinating care with only 2 of 3 patients in split treatment. That one third of patients in split treatment do not receive coordinated care suggests a need for improvement to comply with the standard of care regarding collaborative relationships and to avoid legal exposure. Psychiatrists are particularly vulnerable as the legal system may confer super-visory status if a split treatment case results in an adverse occurrence. Psychiatrists need to evaluate their involvement in split treatment and conduct a self-assessment of their adherence to the standard of care in collaborative relationships.

IRB Approval

University of Miami IRB.

Approval: February 19, 2004

Protocol Number: 2004-0904

Acknowledgments/Sources of Financial Support

None. Activity conducted as part of quality improvement initiative.

Results Presented

Poster session: APA Annual Meeting, New York, New York, May 4, 2004; Poster session: APA Institute on Psychiatric Services, Atlanta, Georgia, October 8, 2004.