p-ISSN: 1454-7848
e-ISSN: 2068-7176



Stimați colegi, Îmi face o deosebită plăcere de a vă împărtăși două din rezultatele colaborării noastre fructuoase între Asociația Română de Psihiatrie și Psihoterapie, Organizația Mondială de Psihiatrie,Asociația Mondială a Medicilor de Familie (WONCA) și Asociația Americană de Psihiatrie dezvoltată între anii 2011 și 2016. Mă refer la două documente inovative, WPA Bucharest Statement on Collaborative and Integrated Care ratificat la Palatul Parlamentului în Bucuresti pe 27 Iunie, 2015 și Integrated Care ratificat de către Consiliul Director al Asociației Psihiatrilor Americani pe 10 Iulie, a,c. pe care le publicăm în revista dumneavoastră în această ediție. Mulțumim mult Profesorilor Dan Prelipceanu, Aurel Nireștean și Cătălina Tudose cât și partenerilor noștri de la Universitatea Carol Davila, Universitatea Politehnică București, Societatea Națională a Medicilor de Familie și al Asociației Române de Sănătate Publică și Health Management pentru rolul lor catalitic în această colaborare istorică și fără precedent încununată cu succes. Cu stimă, Prof. Dr. Eliot SOREL Universitatea George Washington Washington, D.C.

The WPA Bucharest Statement on Collaborative and Integrated Care The World Psychiatric Association, 2015
Bucharest International Congress Palace of
Parliament Bucharest, ROMANIA, 24-27
June 2015

WHEREAS, cardiovascular and mental disorders lead in the global burden of non-communicable diseases; WHEREAS, most mental disorders are attended to in primary care;
WHEREAS, mental disorders account for 30-45% of the global burden of disability;
WHEREAS, 50% of mental disorders exist by age 14, and
75% by age 24;
WHEREAS, these disorders result in billions of dollars of negative economic consequences across low-, middle-, and high-income nations;
WHEREAS, significant global health systems fragmentation diminishes access to care and its effectiveness;
WHEREAS, more research into the brain and into the determinants of health is needed;
WHEREAS, effective treatments for mental disorders exist for most cases; and
WHEREAS, the collaboration and integration of primary care, mental health, and public health is proven to enhance access, quality, and sustainability;


United Nations member states adopt collaborative and integrated care as a means toward
achieving total health for all in the 21st Century; and be it further resolved that

This goal be included in the updated United Nations
Sustainable Development Goals; and be it further resolved that,
United Nations member states allocate the necessary human, financial, and technological resources for training, education, and implementation of this resolution.

Prof. Dinesh Bhugra WPA President & Congress President

Prof. Helen Herrman
WPA President Elect
Co-Chair, Scientific Committee

Prof. Roy Kallivayalil
WPA Secretary General

Prof. Eliot Sorel
Co-Chair Scientific Committee

Prof. Aurel Nireștean
President Romanian Psychiatric & Psychotherapy
Position Statement on Integrated Care

Approved by the Board of Trustees, July 2016
Approved by the Assembly, May 2016

“Policy documents are approved by the APA Assembly and Board of Trustees. . . These are . . . position statements that define APA official policy on specific subjects. . .” – APA Operations Manual

Issue: The American Psychiatric Association (APA) recognizes the well documented impact of untreated behavioral health conditions on outcomes, total healthcare expenditures and the patient care experience. Enhancing health care quality, access and value, including psychiatric services, requires employing new models of care with organized, proactive approaches to individuals’ and populations’ health. Patients with behavioral health conditions present in all sectors of the health care system and the APA can provide vital input in designing evidence- based approaches that provide comprehensive, high quality health care to the populations they serve while judiciously allocating precious healthcare resources.

It is the position of the APA that:
ź Five Core Principles of Effective Integrated Care1 are founded in the Wagner Chronic Care Model2 and should serve as a guide for implementing and designing programs:

1. Team-Based: Care is patient-centered and provided by teams using shared care plans. Effective teams in the primary care setting include at a minimum primary care providers, behavioral care managers and psychiatric consultants. Careful attention to cultural differences and change management are crucial to success.
2. Population-Based: Patient populations are defined in advance, screened and triaged for targeted illnesses and/or health complexity, tracked in databases (referred to as registries), and followed for adherence and response to treatment. Caseloads are regularly reviewed for patients who have not followed-up and those who continue to have significant symptoms.
3. Measurement-Based treatment to target: Outcomes are regularly measured using patient and illness- specific assessment tools (standardized when possible) and treatment adjustments made when improvement is not occurring. This is an iterative process until health stabilizes at a desired level (treatment to target).
4. Evidence-Based: Treatments with evidence of effectiveness are used first, including evidence-based brief psychosocial interventions and/or pharmacotherapy proven to work in the primary care setting, followed by secondary and tertiary interventions if the initial treatment is ineffective.
5. Accountability and Quality Improvement: Systems adopting the above elements track quality of care and outcome measures that allow for quality improvement and accountability during implementation and ongoing practice.

ź In the Primary Care setting, the APA recognizes a model of integrated care known as the Collaborative Care Model (CoCM) as the most effective approach with d e m o n s t r a t e d p o s i t i v e o u t c o m e s a n d c o s t containmentacross different mental health diagnoses and treatment locations3. This model enables enhanced access to the available psychiatric workforce to provide more optimal care outside of traditional psychiatric settings. There are other practice tested approaches that have merit but currently have a more limited research base. Utilization of blended models with adaptation to local practice conditions is common and mayeventually merge with the CoCM model.

ź In Critical Care/Medical/Surgical settings, the APA supports the use of evidence-based models of care to improve total health outcomes, reduce admissions, readmissions, and lengths of medical/surgical hospitalization, and to promote health stabilization in inpatients with medical complexity.

ź In the Public Mental Health sector, the APA will advocate aggressively for efforts to develop effective models to address the physical health disease burden and subsequent 20-30 year mortality gap experienced by psychiatric patients with serious mental illnesses (“reverse integration”). Successful models are emerging that include nurse care managers and an emphasis on health behavior change in a behavioral health home setting. There is a responsibility to monitor and address chronic medical conditions associated with mental illness and psychotropic medications. The APA will support the efforts of psychiatrists to utilize their full range of medical training to oversee the total health needs of patients.
ź The APA must be at the forefront of supporting the development of best practices in integrated care. Psychiatrists utilize unique skills among behavioral health professionals, including knowledge about the interaction of medical and behavioral conditions. This approach supports effective patient-centered care and the ability to successfully treat psychiatric symptoms in the face of comorbid medical/surgical conditions. As a result, the APA will marshal its resources in education, research and advocacy to prepare psychiatrists for new roles in providing patient-centered outcome changing integrated health care.

ź The APA will work with relevant payer, stakeholder and health systems to find sustainable reimbursement strategies, consistent with the requirements of Mental
Health Parity and Addiction Equity Act (MHPAEA), for the essential processes and functions of evidence-based models of integrated care services including quality outcomes, timely access, and related performance measures.

Author(s): Lori Raney, MD and Eliot Sorel, MD (primary); APA Workgroup on Integrated Care and Council on Healthcare Systems and Financing

Adoption Date: