When Matthew Press, MD, was hired to lead Penn Medicine’s primary care practices, the first thing he did was create a system to help clinicians treat patients with mental health conditions, particularly those at risk of suicide.

As many as half of Americans who die by suicide have a healthcare visit in the month prior, research has shown. About 10% of these people see a primary care clinician in the week leading up to their attempt.

“I knew how much our primary care clinicians were struggling to help these patients,” said Press, an associate professor of medicine at Penn Medicine and former physician executive of Penn Primary Care in Philadelphia. “Primary care providers have not been equipped with the tools to manage mental health conditions well; they have been sort of alone in the effort and feeling, I think, pretty overwhelmed by that.”

But health systems that embed resources into primary care practices can help patients reduce suicidal thoughts and attempts, according to a new report by the healthcare advocacy organizations Bowman Family Foundation and addiction nonprofit Shatterproof. Known as the collaborative care model, its use in reducing suicide in this setting was first published in a clinical trial in 2002.

Patients are asked questions that might indicate suicidal thoughts or planning during screenings. If the result is positive, primary care clinicians work with a care manager and psychiatrist to provide in-office mental health services, including medication when appropriate. The three programs studied in the report were launched at Kaiser Permanente, the University of Pennsylvania Health System, and Concert Health, a health system in 17 states.

“Most primary care providers are already using depression questionnaires like the [Patient Health Questionnaire-9] PHQ-9. The question is, what am I supposed to do when someone says yes?” said Greg Simon, MD, a psychiatrist and investigator at the Kaiser Permanente Washington Health Research Institute, Seattle.

A Flexible Roadmap

Collaborative care models aimed at preventing suicide were first developed by clinicians at the University of Washington Advancing Integrated Mental Health Solutions (AIMS) Center, Seattle, in the 1990s, which develops research-backed approaches to behavioral healthcare. To date, around 90 clinical trials have tested these models in primary care for additional mental health issues like depression and substance use disorder, showing mostly improved outcomes for patients.

Patients are screened with tools such as the PHQ-9. If a patient is flagged as “at-risk” for suicide, a psychiatry consultant, who may not work on site, provides guidance about what types of care or medication a patient should receive.

After a treatment plan is initiated, a care manager — who might be a nurse, social worker, or physician’s assistant — checks in with patients every week to reassess suicide risk, usually with questionnaires or interviews. Patients who need more help might have more medications added or receive a different kind of therapy modality. Care managers help patients arrange those additional appointments.

“Less than 10% of people will show up at a behavioral health visit if you say, ‘Hey here’s this number, go make yourself a behavioral health appointment,’” said Brian Ahmedani, PhD, director of the Center for Health Policy & Health Services Research and the Research in Behavioral Health Services at Henry Ford Health in Detroit. “They need help, and collaborative care is exactly that, managing insurance, finding an available appointment at a time that will work for them, and finding the right kind of provider to address those risks.”

The Concert Health and University of Pennsylvania trials enrolled primary care clinicians across 18 states with a little over 4000 patients combined. At Concert Health clinics, roughly 56% of patients in the program reported a reduction in their symptoms, while 49% no longer reported having thoughts of suicide or that they would be better off dead. Patients at the University of Pennsylvania exhibited similar results.

Kaiser Permanente, meanwhile, launched a program that used aspects of the model in 19 primary care practices over a 3-year period starting in 2015. The program used electronic medical records to keep track of patients who were flagged as high risk after screening. During the trial, clinicians at the 19 sites enrolled 228,255 patients. Compared with patients at control clinics, those who received intervention care were 25% less likely to attempt or die by suicide within 90 days of starting the program. The system expanded the model since the trial ended and now uses care managers.

Clinics without these resources can provide parts piecemeal. For instance, if a practice does not provide in-house therapy, just monitoring changes in a patient’s mental state can be beneficial, said Teresa Lovins, MD, a family physician in Columbus, Indiana, and a member of the board of directors for the American Academy of Family Physicians.

“You don’t necessarily need someone who can do therapy with those patients, as long as they can track those scores,” she said.

A psychiatric consultant might also work with multiple practices, which can be particularly helpful in rural areas where specialists are scarce and in small practices with smaller budgets, Lovins said.

“It’s not about doing anything that is impossible; it’s about doing small things that are possible and can be effective,” Simon said.

Getting Paid

For patients with insurance, clinicians can use billing codes to pay for the model, “as long as you use a screening tool that asks about suicide specifically,” said Ahmedani, who worked on the Kaiser Permanente trial.

For insurers to reimburse, clinics must also provide active treatment and care management and employ a registry to enable review of cases, according to the American Medical Association.

The new report included recommendations on how practices can bill Medicare and private insurance using the add-on code 99494. But for clinicians with large Medicaid caseloads, reimbursement may be a barrier.

“We do still have 15 or so state Medicaid agencies that are not covering the code, and that is an issue if your state isn’t covering it,” Press said.

The model can provide support to overstretched primary care clinicians. The goal, Press said, is to take tasks off physicians’ already overflowing plate, not to add to it.

“That has been our experience, having that team of experts right there, connected to your practice and in coordination with everything else that is happening with care for that patient, is really a win-win,” he said.

Kaitlin Sullivan is a freelance journalist whose work also appears in NBC News, Everyday Health, and The Guardian.