Article

The International Journal of

Psychiatry in Medicine
A review of the 0(0) 1–12
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care-embedded
psychiatric consultation
service in a medically
underserved setting

Dennis J Butler1,2,
Dominique Fons3,4, Travis Fisher5,6,
James Sanders1,2 ,
Sara Bodenhamer7, Julie R Owen8,
and Marc Gunderson9

Abstract
A significant percentage of patients with psychiatric disorders are exclusively seen
for health-care services by primary care physicians. To address the mental health
needs of such patients, collaborative models of care were developed including the
embedded psychiatry consult model which places a consultant psychiatrist on-site

1
Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
2
Columbia St. Mary’s Family Medicine Program, Medical College of Wisconsin, Milwaukee, WI, USA
3
Department of Family and Community Medicine, University of Illinois Medical School, Urbana, IL, USA
4
Family Medicine Residency Program, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
5
Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
6
Community Division Psychiatry, Froedtert Hospital, Milwaukee, WI, USA
7
Ascension Health, Milwaukee, WI, USA
8
Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin Affiliated Hospitals,
Milwaukee, WI, USA
9
Saint Louis Behavioral Medicine Institute, Saint Louis, MO, USA
Corresponding Author:
Dennis J Butler, Columbia St. Mary’s Family Medicine Program, Medical College of Wisconsin, 1121 E.
North Avenue, Milwaukee, WI 53212, USA.
Email: dbutler@mcw.edu
2 The International Journal of Psychiatry in Medicine 0(0)

to assist the primary care physician to recognize psychiatric disorders, prescribe

psychiatric medication, and develop management strategies. Outcome studies
have produced ambiguous and inconsistent findings regarding the impact of this
model. This review examines a primary care-embedded psychiatric consultation
service in place for nine years in a family medicine residency program. Psychiatric
consultants, family physicians, and residents actively involved in the service par-
ticipated in structured interviews designed to identify the clinical and educational
value of the service. The benefits and limitations identified were then categorized
into physician, consultant, patient, and systems factors. Among the challenges
identified were inconsistent patient appointment-keeping, ambiguity about appro-
priate referrals, consultant scope-of-practice parameters, and delayed follow-up
with consultation recommendations. Improved psychiatric education for primary
care physicians also appeared to shift referrals toward more complex patients.
The benefits identified included the availability of psychiatric services to under-
served and disenfranchised patients, increased primary care physician comfort
with medication management, and improved interprofessional communication
and education. The integration of the service into the clinic fostered the devel-
opment of a more psychologically minded practice. While highly valued by
respondents, potential benefits of the service were limited by residency-specific
factors including consultant availability and the high ratio of primary care physi-
cians to consultants.

Keywords
primary care, psychiatry, consultation, psychiatric disorders, collaboration

Introduction
Up to 60% of patients with a psychiatric disorder are only seen by primary
care physicians.1,2 Early studies examining the care provided to such
patients found that primary care physicians frequently failed to recognize psy-
chiatric disorders, over- or underprescribed psychotropic medications, rarely
provided structured counseling, and infrequently referred patients for mental
health services.3,4 As noted by Regier, there was “a need both for further inte-
gration of the general health and mental health care sectors . . . that will max-
imize the availability and appropriateness of services for persons with mental
disorders.”1 Primary care physicians identified multiple barriers to mental health
referral including patient resistance, stigma, inadequate insurance coverage,
poor communication with mental health providers, difficulty recognizing psy-
chiatric disorders, and a tendency to focus on patients’ multiple medical com-
plaints.3–5
Butler et al. 3

Pincus identified multiple strategies designed to bring mental health services

into primary care settings to assist in treating patients with psychiatric disor-
ders.6 In the consultation model, a psychiatrist is embedded in the ambulatory
care clinic and available to see patients for consultation visits or to offer rec-
ommendations through “curbside consults” to physicians (Table 1). In this
model, the consultant psychiatrist has three functions: (1) to assist the primary
care physician through diagnostic evaluations, (2) to provide medication recom-
mendations, and (3) to offer patient management strategies. Responsibility for
the care of the patient remains with the primary care physician. This model is
intended to support the primary care physician to care for patients with mild-to-
moderate depression, common anxiety disorders, adjustment reactions, or
somatoform tendencies or disorders.7–9
Existing studies of outpatient embedded consult services examined clinical
outcomes using short time frames or relied on consultants’ impressions or anec-
dotal reports about embedded services. Outcome research on the model pro-
duced inconsistent results in part because there is no consensus on the outcomes
to be evaluated.10 In a meta-analysis, an embedded service was found effective
for patients with somatoform and depressive disorders with the largest effects
seen in the reduction of health service utilization.11 Another meta-analysis found
no significant effect on patient antidepressant use, and the authors concluded
that consultation services were no more effective than usual care but might be
effective if combined with integrated care models.12 Katon and Gonzales con-
cluded that consultation trials in primary care were more successful in improv-
ing detection of mental illness and increasing psychiatric treatment by primary
care physicians than in changing patient outcomes.13 Psychiatric consultants
working in primary care settings report that embedded services increase patient
accessibility to psychiatric care, improve continuity of care, support family
physicians, improve communication between medical professionals, and
improve psychiatrists’ recognition of nonpsychiatric medical problems.14,15
The following report provides an expanded view of an embedded consult
service from a longitudinal perspective. In addition, the review is unique in
that it provides insights from a consult service staffed by psychiatry residents
embedded in a primary care residency program. The purpose of the review was
to examine the value of a psychiatric consultation service embedded in a family
medicine residency clinic for nine years based on the perspective of multiple
clinical providers. Although the consultation service remains active at the
clinic, the review was undertaken prior to the introduction of an integrated
care health consultant whose clinical interventions might alter how the psychi-
atric consultation service is utilized. The review was conducted using individual
interviews of consultants and referring physicians and designed to identify
strengths, limitations, barriers, challenges, and the perceived value of the con-
sultation service. Responses were organized into predetermined categories of
four fundamental factors which directly affect the outcome of mental health

Table 1. Comparison of the embedded consultation model core components and the model implemented.
Core components of a primary care-embedded consulta-
tion model
 Adult ambulatory care patients are seen in consultation by a
psychiatrist
 In most health-care systems with a consultation service, any
patient can be seen
 An ideal ratio of PCPs to consultant is unspecified but fre-
quently low (e.g., 5:1)
 The purpose of the consultation visit is for diagnostic clarity/
global assessment, medication assessment, and/or patient
management advice
 The consultant can see patients for reevaluation if symptoms
worsen or to recheck medication recommendations
 The psychiatrist is regularly scheduled to see patients with or
without the PCP present and to provide curbside
consultations
 The consultant will see patients with urgent problems
 The PCP remains responsible for the care of the patient,
prescribing psychiatric medication and referring patients for
mental health services when indicated
 The consultant and PCP chart in a common electronic medi-
cal record
 Consultation services are financially supported by fee-for-ser-
vice or by the health-care system
PCPs: primary care physicians.
4
The embedded consultation model at Columbia St. Mary’s Family
Health Center
 Adult family medicine patients are seen for consultation by a
postgraduate fourth-year psychiatry resident
 Patients receiving care from a community psychiatrist are not
scheduled for consultation
 The ratio of family physicians to consultant is high due to the
size of the training program
 The purpose of the consultation visit is for diagnostic clarity/
global assessment, medication assessment, and/or patient
management advice
 Opportunities to reevaluate patients are limited as each psy-
chiatry resident is placed for 6 to 12 months
 The consult resident is scheduled half day per week and sees
patients without the family physician present or provides
curbside consultations
 The consult resident does not routinely see patients on an
urgent basis
 Family medicine faculty and residents remain responsible for
the care of the patient, prescribing psychiatric medication and
referring patients for mental health service when indicated
 The consultant and family medicine physician chart in a
common electronic medical record
 Consultation services are provided at no cost to the patient by
psychiatry residents
The International Journal of Psychiatry in Medicine 0(0)
Butler et al. 5

referrals: patient, primary care physician, consultant, and health-care system

factors. No patients were interviewed, and the review did not directly examine
clinical outcomes.

Description of the consultation service

The psychiatric consultation service described in this review is located at the
Columbia St. Mary’s Family Medicine Residency Program. It was established in
2007 and closely adheres to an embedded consultation model (Table 1).
Consultation services are provided by psychiatry residents who are licensed
and in their final year of training. Residents rotate on the consultation service
for 6 or 12 months. The Columbia St. Mary’s Family Health Center is located in
a Midwestern U.S. city and is a fee-for-service, full-spectrum family medicine
clinic that serves as the primary outpatient training site for 26 family medicine
residents and 12 family medicine faculty. The clinic currently provides health
care for 22,000 patients in an urban, medically underserved area. It is recognized
as a National Committee for Quality Assurance level 3 patient-centered medical
home with a special emphasis on high-risk obstetrical care. The psychiatric
consultants, family medicine faculty, and residents are affiliated with the
Medical College of Wisconsin.
An early overview of consultation service activity is contained in an audit
completed after the first four years of the service.16 Based on a chart audit of
22 consecutive patients, the majority of referred patients presented with a diag-
nosable psychiatric disorder. The consultants diagnosed 85% of the patients
with depression, an anxiety disorder, or an adjustment reaction. The average
Global Assessment of Functioning for consult patients was 52 while 50%
reported a remote history of suicidal ideation, suicide attempts, or psychiatric
hospitalization. Referred patients were predominantly female (80%). Almost
80% of consultations resulted in recommendations for medication management
and 50% included a recommendation for psychotherapy.
Subsequent monitoring of diagnostic categories in the next five years of the
service revealed an increase in referral of patients with more severe and per-
sistent psychiatric disorders and a broadening of diagnostic categories includ-
ing cognitive dysfunction, adult attention deficit disorder, and comorbid
substance abuse problems. In line with the trend toward more significant
impairment, there was also a notable increase in referral recommendations
for services beyond primary care such as intensive outpatient or partial hos-
pitalization programs. Presently, over 90% of available appointments are
scheduled, but patient appointment-keeping varies from 50% to 100% in a
given month.
6 The International Journal of Psychiatry in Medicine 0(0)

Review process
The consultation service coordinator (author DJB) conducted a review of the
consultation service prior to the implementation of an integrated care behavior-
al health service at the clinic. Prior to that time, the consultation service func-
tioned as the only psychiatric service available at the clinic for nine years. The
purpose of the review was to examine the value and limitations of the service to
the clinic and residency program from the perspective of clinic providers.
Six physicians who were actively involved in the service were invited to par-
ticipate in the review. All participants are currently in practice or pursuing
advanced training. The family physicians chosen included two who completed
residency at the program and completed advanced training in the residency’s
behavioral medicine track17 as well as the clinic’s medical director whose clinical
practice coincided with the duration of the consultation service. The three con-
sultant psychiatrists interviewed were fourth-year residents when they provided
consultations. All are currently engaged in clinical practice and continue to be
involved with psychiatric consultation services or integrated care programs.
To minimize interpretation bias by the interviewer and to establish a method
for organizing interview content, a predetermined framework was used to guide
all interviews. The framework was originally proposed as a guide for teaching
family medicine residents about key factors in the mental health referral pro-
cess.18 The framework is based on the position that the success of mental health
referral in primary care settings is determined by multiple factors which can be
organized into four core areas: patient factors, physician factors, provider (con-
sultant) factors, and health system factors.
All six physicians agreed to participate and are coauthors. Prior to each
interview, participants were asked to respond in writing to four questions
about the value and limitations of the service based on the four factors. Once
written responses were returned, interviews were conducted in person or by
telephone. Each respondent was interviewed twice, first to discuss the value of
the service and then to discuss limitations and challenges. The results of the
interviews are summarized in Tables 2 to 5.

Review themes
The strong consensus among all interviewees was that the service is invaluable to
the clinic’s medically underserved patient population which has limited access to
mental health services. Access to the consultation service was timely as most
patients could be seen within one to three weeks, although referring physicians
noted that on some occasions it could be up to six weeks to be scheduled for an
appointment. Patients were familiar with the clinic and staff and could have an
appointment scheduled directly from their visit with the family physician. As
consultants and family physicians noted, a sizable portion of referred patients
Butler et al. 7

Table 2. Value and limitations of a primary care embedded consultation service:

Patient factors.
Consultation service value to patients
 Timely access to psychiatric services
 Service provided to patients with access barriers to mental health care
 Stigma is reduced due to embedded nature of services
 Patient are familiar with clinic policies, procedures, and personnel
 No copay, deductible, or facility fee
 One visit and return to PCP lowers anxiety about mental health contact
Limitations and barriers of consult service—patient factors
 No process exists for identifying how many referred patients fail to schedule consultation
 Variable no show rate which can be as high as 50%
 A few patients are confused about the purpose of consultation
 Patients fail to return to PCP, cannot obtain timely visit, or see a different provider
 Some patients feel the PCP is minimizing their symptoms by referring for consultation
 For some patients, a 60-min evaluation is insufficient
 Consultants’ availability did not match patients’ schedules
PCPs: primary care physicians.

Table 3. Value and limitations of a primary care embedded consultation service: Family
physician factors.
Consultation value to family physicians
 Timely evaluation fosters timely initiation of medication or referral
 Thorough evaluation provides a broader understanding of patient context
 Consult reports improve PCPs’ knowledge of and ability to treat psychiatric disorders
 Availability of consultant for curbside consults contributes to effective care
 Reassurance (backup) for managing distressed patients
 Distinguishes less complex patients from those needing more specialized care
Limitations and barriers of a consult service-family physician factors
 Volume of referrals was lower than patient panel would predict
 Some PCPs do not specify reason for referral on the consultation referral form
 Some consults are for more complex disorders (e.g., bipolar disorder, schizophrenia)
 PCPs did not always explain reason for consultation to patients
 Majority of referrals were increasingly for newly registered patients
 No consistent mechanism or guidelines for accessing psychiatrist when not on site
 Consults are a “snapshot in time” of the patient but patient functioning varies over time
 Patients’ preexisting psychiatric diagnoses don’t always reconcile with consul-
tant’s diagnosis
 The process of scheduling consultations was occasionally confusing for office staff
 Limited face-to-face contact between PCP and consultant lessened camaraderie
PCPs: primary care physicians.
8 The International Journal of Psychiatry in Medicine 0(0)

Table 4. Value and limitations of a primary care embedded consultation service: Consult
psychiatrist factors.
Consultation value to consult psychiatrists
 Develop and hone collaborative skills
 Consultants learn to write primary care-oriented reports
 Exposure to moderate disorders and PCP management patterns
 Consultants addressed two (of three) consultation goals: psychiatric diagnosis and med-
ication management
 Immediate access to medical labs, tests, and workups
 Early recognition and referral of patients with severe impairment
 Consulting on patients who are not severely mentally ill or in psychiatric crisis
Limitations and barriers of a consult service-consultant factors
 Practice scope doesn’t match breadth of family medicine: limited expertise with dementia,
AODA, and ADHD or with some high need populations (e.g., adolescents, children)
 Ambiguity and ambivalence about PCPs’ ability to treat complex patients
 Few consultation requests for patient management advice (the third consultation goal)
 Overvalue specialty mental health referrals
 Inadequate feedback from PCPs on appropriateness or impact of recommendations
 Crafting consult reports affected by concern about liability for clinical advice
 Some consult residents could not complete evaluation in an hour
 Necessary or common psychiatric laboratory tests unavailable at clinic
ADHD: Attention Deficit Hyperactivity Disorder; AODA: Alcohol and Other Drug Abuse; PCPs: primary
care physicians.

Table 5. Value and limitations of a primary care embedded consultation service:

System factors.
Value of consultation service to health-care system
 Reduces burden on overloaded mental health-care system
 Integrates medical and psychiatric care into one electronic medical record
 Utilizes a unified scheduling system which prevents patients “getting lost”
 Increases likelihood patients will make it to appointment
 Contributes to a “psychologically minded” environment in the primary care clinic
Limitation and barriers of a consult service-health-care system factors
 No mechanism for closing consult loop (i.e., PCP back to psychiatrist)
 High ratio of PCPs to consultants interferes with tailoring recommendations to the
practice philosophy of individual PCPs
 Delays in patient follow-up appointments with PCP delays initiation of treatment
 Patients are sometimes assigned to a different provider for follow-up
 Service produces no revenue
 Scheduling process was sometimes confusing or difficult
 No efficient method for tracking if consultant recommendations were implemented
 No efficient method for tracking outcomes of implemented recommendations
PCPs: primary care physicians.
Butler et al. 9

had a history of psychiatric care which had been discontinuous or inconsistent.

Such patients were willing to reconsider psychiatric care provided by the prima-
ry care physician supported by a consultant. Many clinic patients reported being
unable to gain timely access to community-based mental health services which
were overburdened with long wait times for appointments.
The respondents also clearly endorsed the value of the service for advancing
interprofessional collaboration, communication, and education. Consultants
learned to incorporate the patient’s medical history into their evaluations
which had to be written in a manner that was primary care-friendly. Family
physicians had to hone their psychiatric referral skills and had to learn how to
formulate a clear consultation request. The use of a unified electronic record
facilitated communication through the consultation referral, consult report, and
workflow communication. The presence of consultants contributed to building
“psychological mindedness” among physicians and staff at the clinic.
The family physician respondents all noted that their interactions with con-
sultants contributed to an increased confidence in their ability to recognize and
diagnose patients with psychiatric disorders and to build their comfort in using
multiple psychopharmacologic agents. They noted that consultants provided
valuable reassurance through their more extensive evaluations and risk
assessments.
A number of factors limited the quality of clinical communication and the
nature of the relationship between consultants and providers. The high ratio of
providers to consultants diminished opportunities for face-to-face consultations,
and the limited availability of consultants may have reduced the number of
patients referred for evaluation. Patient delays in scheduling follow-up appoint-
ments with their physicians delayed the implementation of recommendations or
resulted in disjointed care. Very few consultations included the primary care
physician in the sessions. Due to the limited number of days consultants were
available, they could not build collaborative relationships with many providers
and consequently could not tailor recommendations to the practice style or
training level of an individual physician. The consultation system lacked a feed-
back loop from the physician back to the psychiatrist to indicate if their recom-
mendations were helpful or if the physician was willing to proceed with
recommendations.
Some structural components of the model also prevented the optimal use of
the service. While family medicine cares for patients of all ages, the consultants’
scope of practice was limited to adult patients. Children, adolescents, and preg-
nant adolescents with psychiatric difficulties present unique challenges to family
physicians especially because psychiatric services for such patients are sparse
and difficult to access.
Patient appointment-keeping rates varied and resulted in lost consultation
opportunities. Multiple strategies were applied in an attempt to improve
appointment-keeping including reminder calls, scripting physician referral
10 The International Journal of Psychiatry in Medicine 0(0)

interactions, and not rescheduling patients who canceled or no-showed for

appointments. While such interventions were effective in increasing
appointment-keeping, no-shows and cancelation rates continue to vary.
The review also identified areas for further discussion. Little attention is
devoted in the literature to questions about liability associated with embedded
consultation services. What is the liability exposure for the primary care physi-
cian in the event of an adverse event (suicide, medication reaction) when the
physician did or did not choose to proceed with a consultant’s recommendation?
Similar concerns would exist for the consultant. A second significant area for
discussion is addressing the financial underpinnings of an embedded consulta-
tion service. The consultants in this review were residents whose salaries are paid
through affiliated hospital funds and patients were not billed for consultation
services. Sustaining an embedded consult service in a nontraining practice envi-
ronment requires that funding sources are available and that financial goals
are clear.
By design, this review is based on the observations and experiences of clini-
cians who were active utilizers or providers for the service. There is a glaring
absence in the literature of any research with patients who have been seen for
embedded consultation services. Findings of the present review suggest that for
some patients, the purpose of the consultation was not clear or the clinical
follow-up was insufficient (Table 2).
Finally, there are some indications in this review that the compelling reason
for developing embedded psychiatric services has evolved. When originally pro-
posed, it was clear that such services were needed to educate and assist the
primary care physician to manage common psychiatric disorders, but in the
intervening decades, family physicians and family medicine residents have
received more extensive training in the diagnosis of psychiatric disorders and
psychopharmacologic interventions. As the family physician participants noted,
they gained confidence from consultations in their ability to manage common
psychiatric disorders and increasingly felt competent to manage patients with
mild-to-moderate depression and anxiety. This may, in part, account for a shift
in referrals toward patients with more severe forms of depression and to patients
with more severe or diverse psychiatric disorders.

Summary
This is the first published review to examine a long-term embedded consultation
service in place continuously at a family medicine clinic. This review is also
unique because it reports on the use of psychiatric residents as consultants in
a family medicine residency clinic and because the review incorporates family
physicians’ views on the value and limitations of an embedded service. The
findings of this review are consistent with previous reports which suggest that
such services build the confidence of primary care physicians in their ability to
Butler et al. 11

recognize and treat common psychiatric disorders in primary care. All of the
clinician respondents held the strong opinion that the service was of high value
for patients referred to the service, and they endorsed the service as an effective
way to advance interprofessional collaboration, communication, and education.
The review also acknowledges that embedded consult services cannot meet the
needs of all primary care patients with psychiatric disorders, but that the avail-
ability of the service helped clinic patients overcome significant barriers to psy-
chiatric help-seeking.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iD
James Sanders http://orcid.org/0000-0003-0339-5370

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