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Comparison of Teleintegrated Care and Telereferral Care for Treating Complex Psychiatric Disorders in Primary CareA Pragmatic Randomized Comparative Effectiveness Trial

Educational Objective
To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics.
1 Credit CME
Key Points

Question  Which is more effective, an integrated or referral approach to using clinic-to-clinic interactive video to deliver evidence-based mental health treatments to patients with complex psychiatric disorders in primary care clinics?

Findings  In this pragmatic randomized comparative effectiveness trial including 1004 adult participants, both approaches significantly and substantially improved clinical outcomes. The referral approach used substantially more mental health specialist time than the integrated approach.

Meaning  Based on findings from this trial, from a health care system perspective, clinical leadership should implement whichever approach is most sustainable; from a societal perspective, policy makers should incentivize the integrated approach because it required less scarce mental health specialist time.


Importance  Only one-third of patients with complex psychiatric disorders engage in specialty mental health care, and only one-tenth receive adequate treatment in primary care. Scalable approaches are critically needed to improve access to effective mental health treatments in underserved primary care settings.

Objective  To compare 2 clinic-to-clinic interactive video approaches to delivering evidence-based mental health treatments to patients in primary care clinics.

Design, Setting, and Participants  This pragmatic comparative effectiveness trial used a sequential, multiple-assignment, randomized trial (SMART) design with patient-level randomization. Adult patients treated at 24 primary care clinics without on-site psychiatrists or psychologists from 12 federally qualified health centers in 3 states who screened positive for posttraumatic stress disorder and/or bipolar disorder and who were not already receiving pharmacotherapy from a mental health specialist were recruited from November 16, 2016, to June 30, 2019, and observed for 12 months.

Interventions  Two approaches were compared: (1) telepsychiatry/telepsychology–enhanced referral (TER), where telepsychiatrists and telepsychologists assumed responsibility for treatment, and (2) telepsychiatry collaborative care (TCC), where telepsychiatrists provided consultation to the primary care team. TER included an adaptive intervention (phone-enhanced referral [PER]) for patients not engaging in treatment, which involved telephone outreach and motivational interviewing.

Main Outcomes and Measures  Survey questions assessed patient-reported outcomes. The Veterans RAND 12-item Health Survey Mental Component Summary (MCS) score was the primary outcome (range, 0-100). Secondary outcomes included posttraumatic stress disorder symptoms, manic symptoms, depressive symptoms, anxiety symptoms, recovery, and adverse effects.

Results  Of 1004 included participants, 701 of 1000 (70.1%) were female, 660 of 994 (66.4%) were White, and the mean (SD) age was 39.4 (12.9) years. Baseline MCS scores were 2 SDs below the US mean; the mean (SD) MCS scores were 39.7 (14.1) and 41.2 (14.2) in the TCC and TER groups, respectively. There was no significant difference in 12-month MCS score between those receiving TCC and TER (β = 1.0; 95% CI, −0.8 to 2.8; P = .28). Patients in both groups experienced large and clinically meaningful improvements from baseline to 12 months (TCC: Cohen d = 0.81; 95% CI, 0.67 to 0.95; TER: Cohen d = 0.90; 95% CI, 0.76 to 1.04). For patients not engaging in TER at 6 months, there was no significant difference in 12-month MCS score between those receiving PER and TER (β = 2.0; 95% CI, −1.7 to 5.7; P = .29).

Conclusions and Relevance  In this comparative effectiveness trial of patients with complex psychiatric disorders randomized to receive TCC or TER, significantly and substantially improved outcomes were observed in both groups. From a health care system perspective, clinical leadership should implement whichever approach is most sustainable.

Trial Registration  ClinicalTrials.gov Identifier: NCT02738944

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Article Information

Accepted for Publication: June 29, 2021.

Published Online: August 25, 2021. doi:10.1001/jamapsychiatry.2021.2318

Corresponding Author: John C. Fortney, PhD, Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, 1959 NE Pacific St, Box 356560, Seattle, WA 98195 (fortneyj@uw.edu).

Author Contributions: Drs Fortney and Hawrilenko had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Fortney, Bauer, Cerimele, Pyne, Heagerty, Kaysen, Bowen, Moore, Metzger, Hafer, Unützer.

Acquisition, analysis, or interpretation of data: Fortney, Bauer, Cerimele, Pyne, Pfeiffer, Heagerty, Hawrilenko, Zielinski, Kaysen, Bowen, Moore, Ferro, Shushan, Nolan, Dalack, Unützer.

Drafting of the manuscript: Fortney, Hawrilenko, Bowen, Moore, Metzger, Hafer.

Critical revision of the manuscript for important intellectual content: Bauer, Cerimele, Pyne, Pfeiffer, Heagerty, Hawrilenko, Zielinski, Kaysen, Moore, Ferro, Shushan, Nolan, Dalack, Unützer.

Statistical analysis: Fortney, Heagerty, Hawrilenko.

Obtained funding: Fortney, Kaysen, Hafer.

Administrative, technical, or material support: Fortney, Bauer, Pfeiffer, Zielinski, Kaysen, Bowen, Moore, Ferro, Metzger, Shushan, Hafer, Nolan, Dalack, Unützer.

Study supervision: Fortney, Pyne, Kaysen, Unützer.

Conflict of Interest Disclosures: Drs Fortney, Bauer, Cerimele, Heagerty, Kaysen, Shushan, and Dalack have received grants from the Patient-Centered Outcomes Research Institute during the conduct of the study. Dr Bauer has received grants from the National Institutes of Health, Washington State Legislature Integrated Care Training Program, and Premera Blue Cross Rural Mental Health Integration Initiative outside the submitted work. Dr Pyne has received grants from the University of Arkansas for Medical Sciences during the conduct of the study. Dr Kaysen has received personal fees from Elsevier Publishing and honorarium for conducting trainings or workshops in cognitive processing therapy outside the submitted work. Dr Moore has received support from the University of Washington during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was supported by a grant PCS-1406-19295 from the Patient-Centered Outcomes Research Institute to Drs Fortney and Unützer.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The statements in this article are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its board of governors, or methodology committee.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank the patients and staff of Family Health Centers, Omak, Washington; Moses Lake Community Health Center, Moses Lake, Washington; Sea Mar Community Health Centers, Seattle, Washington; Yakima Neighborhood Health Services, Yakima, Washington; Boston Mountain Rural Health Centers, Marshal, Arkansas; East Arkansas Family Health Center, West Memphis; Lee County Cooperative Clinic, Marianna, Arkansas; Cherry Health, Grand Rapids, Michigan; Family Medical Center, Temperance, Michigan; Great Lakes Bay Health Centers, Saginaw, Michigan; InterCare Community Health Network, Bangor, Michigan; and Upper Great Lakes Family Health Center, Calumet, Michigan. We thank the staff of the Community Health Plan of Washington, the Community Health Centers of Arkansas, and the Michigan Primary Care Association. We thank our policy advisory board: Donald Weaver, MD (National Association of Community Health Centers, Bethesda, Maryland); Ed Larkins, MHA (Family Medical Center); Jay Shore, MD (University of Colorado at Denver); LaShannon Spencer, MPA, MHSA (Community Health Centers of Arkansas, Little Rock); Nancy Speck, PhD (National Association for Rural Mental Health, Houston, Texas); Sara Coates, MA, MPH, and Dawne Velianoff, LMSW (Michigan Primary Care Association, Lansing); and Susan Ward-Jones, MD (East Arkansas Family Health Center). We thank our consumer advisor board: Bernadette McDonald, BS; Florence Fee, JD (No Health Without Mental Health, Arlington, Virginia); Ingrid Deetz, BS, Kevin Einbinder, BS, and Betsy O’Brien, BS (Depression and Bipolar Support Alliance, Chicago, Illinois); Kim Arnold, BS, Marquitta Magnini, BS, and Shawn McCown, BS (National Alliance on Mental Illness, Little Rock, Arkansas); Jode Freyholtz-London, AAS (Wellness in the Woods, Eagle Bend, Minnesota); and Tammy Heral and Jeremy Mullins. We thank the members of our external data safety monitoring board: Thomas Belin, PhD (University of California, Los Angeles); John Williams, MD (Duke University, Durham, North Carolina); and Mark Williams, MD (Mayo Clinic, Rochester, Minnesota). Also, thanks to our research staff Suzanne Hunter, BS, Jared Bechtel, BS, Diane Powers, MA, MBA, Shiyu Chen, MS, and Morgan Johnson, MS (Department of Psychiatry, University of Washington, Seattle); and Nick Ponomarev, PhD, and Dan Vakoch, MS (Social and Economic Sciences Research Center, Washington State University, Pullman). We thank the following electronic health record vendors for giving us substantial discounts on the user licenses for the telepsychiatrists and telepsychologists: NextGen Healthcare, eClinicalWorks, Centricity (GE Healthcare), Allscripts, and SuccessEHS, Inc. Members of the policy advisory board and consumer advisory board as well as our research staff were compensated for their work.

Wang  PS , Lane  M , Olfson  M , Pincus  HA , Wells  KB , Kessler  RC .  Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication.   Arch Gen Psychiatry. 2005;62(6):629-640. doi:10.1001/archpsyc.62.6.629PubMedGoogle ScholarCrossref
Health Resources and Services Administration. Health center program: impact and growth. Accessed April 4, 2021. https://bphc.hrsa.gov/about/healthcenterprogram/index.html
National Association of Community Health Centers. America's health centers. November, 2017. Accessed August 1, 2021. https://www.nachc.org/wp-content/uploads/2017/11/Americas_Health_Centers_Nov_2017.pdf
National Association of Community Health Centers. Community health center chartbook: 2021. Accessed April 14, 2021. https://www.nachc.org/wp-content/uploads/2021/04/Chartbook-Final-2021.pdf
Thomas  KC , Ellis  AR , Konrad  TR , Holzer  CE , Morrissey  JP .  County-level estimates of mental health professional shortage in the United States.   Psychiatr Serv. 2009;60(10):1323-1328. doi:10.1176/ps.2009.60.10.1323PubMedGoogle ScholarCrossref
Fortney  JC , Heagerty  PJ , Bauer  AM ,  et al.  Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT): rationale and design of a randomized comparative effectiveness trial of managing complex psychiatric disorders in rural primary care clinics.   Contemp Clin Trials. 2020;90:105873. doi:10.1016/j.cct.2019.105873PubMedGoogle Scholar
Fortney  JC , Pyne  JM , Edlund  MJ ,  et al.  A randomized trial of telemedicine-based collaborative care for depression.   J Gen Intern Med. 2007;22(8):1086-1093. doi:10.1007/s11606-007-0201-9PubMedGoogle ScholarCrossref
Fortney  JC , Pyne  JM , Mouden  SB ,  et al.  Practice-based versus telemedicine-based collaborative care for depression in rural federally qualified health centers: a pragmatic randomized comparative effectiveness trial.   Am J Psychiatry. 2013;170(4):414-425. doi:10.1176/appi.ajp.2012.12050696PubMedGoogle ScholarCrossref
Fortney  JC , Pyne  JM , Kimbrell  TA ,  et al.  Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial.   JAMA Psychiatry. 2015;72(1):58-67. doi:10.1001/jamapsychiatry.2014.1575PubMedGoogle ScholarCrossref
Fortney  JC , Veith  RC , Bauer  AM ,  et al.  Developing telemental health partnerships between state medical schools and federally qualified health centers: navigating the regulatory landscape and policy recommendations.   J Rural Health. 2019;35(3):287-297. doi:10.1111/jrh.12323PubMedGoogle ScholarCrossref
Kessler  RC , Akiskal  HS , Angst  J ,  et al.  Validity of the assessment of bipolar spectrum disorders in the WHO CIDI 3.0.   J Affect Disord. 2006;96(3):259-269. doi:10.1016/j.jad.2006.08.018PubMedGoogle ScholarCrossref
Lang  AJ , Stein  MB .  An abbreviated PTSD checklist for use as a screening instrument in primary care.   Behav Res Ther. 2005;43(5):585-594. doi:10.1016/j.brat.2004.04.005PubMedGoogle ScholarCrossref
Fortney  JC , Pyne  JM , Ward-Jones  S ,  et al.  Implementation of evidence-based practices for complex mood disorders in primary care safety net clinics.   Fam Syst Health. 2018;36(3):267-280. doi:10.1037/fsh0000357PubMedGoogle ScholarCrossref
Almirall  D , Nahum-Shani  I , Sherwood  NE , Murphy  SA .  Introduction to SMART designs for the development of adaptive interventions: with application to weight loss research.   Transl Behav Med. 2014;4(3):260-274. doi:10.1007/s13142-014-0265-0PubMedGoogle ScholarCrossref
Jakupcak  M , Wagner  A , Paulson  A , Varra  A , McFall  M .  Behavioral activation as a primary care-based treatment for PTSD and depression among returning veterans.   J Trauma Stress. 2010;23(4):491-495. doi:10.1002/jts.20543PubMedGoogle ScholarCrossref
Unützer  J , Choi  Y , Cook  IA , Oishi  S .  A web-based data management system to improve care for depression in a multicenter clinical trial.   Psychiatr Serv. 2002;53(6):671-673, 678. doi:10.1176/ps.53.6.671PubMedGoogle ScholarCrossref
Fortney  JC , Unützer  J , Wrenn  G ,  et al.  A tipping point for measurement-based care.   Psychiatr Serv. 2017;68(2):179-188. doi:10.1176/appi.ps.201500439PubMedGoogle ScholarCrossref
Monson  CM , Schnurr  PP , Resick  PA , Friedman  MJ , Young-Xu  Y , Stevens  SP .  Cognitive processing therapy for veterans with military-related posttraumatic stress disorder.   J Consult Clin Psychol. 2006;74(5):898-907. doi:10.1037/0022-006X.74.5.898PubMedGoogle ScholarCrossref
Otto  MW , Reilly-Harrington  NA , Knauz  RO , Henin  A , Kogan  JN , Sachs  GS .  Managing Bipolar Disorder: A Cognitive Behavior Treatment Program. Oxford University Press; 2008.
Jones  D , Kazis  L , Lee  A ,  et al.  Health status assessments using the Veterans SF-12 and SF-36: methods for evaluating outcomes in the Veterans Health Administration.   J Ambul Care Manage. 2001;24(3):68-86. doi:10.1097/00004479-200107000-00011PubMedGoogle ScholarCrossref
Blevins  CA , Weathers  FW , Davis  MT , Witte  TK , Domino  JL .  The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation.   J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059PubMedGoogle ScholarCrossref
Derogatis  LR . Symptom Checklist-90–Revised (SCL-90-R). In: American Psychiatric Association; Rush AJ, ed.  Handbook of Psychiatric Measures. American Psychiatric Association; 2000:81-84.
Altman  EG , Hedeker  D , Peterson  JL , Davis  JM .  The Altman Self-Rating Mania scale.   Biol Psychiatry. 1997;42(10):948-955. doi:10.1016/S0006-3223(96)00548-3PubMedGoogle ScholarCrossref
Bauer  MS , Vojta  C , Kinosian  B , Altshuler  L , Glick  H .  The Internal State Scale: replication of its discriminating abilities in a multisite, public sector sample.   Bipolar Disord. 2000;2(4):340-346. doi:10.1034/j.1399-5618.2000.020409.xPubMedGoogle ScholarCrossref
Spitzer  RL , Kroenke  K , Williams  JB , Löwe  B .  A brief measure for assessing generalized anxiety disorder: the GAD-7.   Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092PubMedGoogle ScholarCrossref
Corrigan  PW , Salzer  M , Ralph  RO , Sangster  Y , Keck  L .  Examining the factor structure of the Recovery Assessment Scale.   Schizophr Bull. 2004;30(4):1035-1041. doi:10.1093/oxfordjournals.schbul.a007118PubMedGoogle ScholarCrossref
Fortney  JC , Pyne  JM , Hawrilenko  M ,  et al.  Psychometric properties of the Assessment of Perceived Access to Care (APAC) instrument.   J Ambul Care Manage. 2021;44(1):31-45. doi:10.1097/JAC.0000000000000358PubMedGoogle ScholarCrossref
McNeish  D , Stapleton  LM .  Modeling clustered data with very few clusters.   Multivariate Behav Res. 2016;51(4):495-518. doi:10.1080/00273171.2016.1167008PubMedGoogle ScholarCrossref
VanderWeele  TJ .  A unification of mediation and interaction: a 4-way decomposition.   Epidemiology. 2014;25(5):749-761. doi:10.1097/EDE.0000000000000121PubMedGoogle ScholarCrossref
Muthén  B , Asparouhov  T .  Causal effects in mediation modeling: an introduction with applications to latent variables.   Struct Equation Modeling. 2015;22(1):12-23. doi:10.1080/10705511.2014.935843Google ScholarCrossref
Graham  JW , Olchowski  AE , Gilreath  TD .  How many imputations are really needed? some practical clarifications of multiple imputation theory.   Prev Sci. 2007;8(3):206-213. doi:10.1007/s11121-007-0070-9PubMedGoogle ScholarCrossref
Tang  F , Ishwaran  H .  Random forest missing data algorithms.   Stat Anal Data Min. 2017;10(6):363-377. doi:10.1002/sam.11348PubMedGoogle ScholarCrossref
Stekhoven  DJ , Bühlmann  P .  MissForest—non-parametric missing value imputation for mixed-type data.   Bioinformatics. 2012;28(1):112-118. doi:10.1093/bioinformatics/btr597PubMedGoogle ScholarCrossref
Shah  AD , Bartlett  JW , Carpenter  J , Nicholas  O , Hemingway  H .  Comparison of random forest and parametric imputation models for imputing missing data using MICE: a CALIBER study.   Am J Epidemiol. 2014;179(6):764-774. doi:10.1093/aje/kwt312PubMedGoogle ScholarCrossref
Enders  CK .  Multiple imputation as a flexible tool for missing data handling in clinical research.   Behav Res Ther. 2017;98:4-18. doi:10.1016/j.brat.2016.11.008PubMedGoogle ScholarCrossref
Cerimele  JM , LePoire  E , Fortney  JC , Hawrilenko  M , Unützer  J , Bauer  AM .  Bipolar disorder and PTSD screening and telepsychiatry diagnoses in primary care.   Gen Hosp Psychiatry. 2020;65:28-32. doi:10.1016/j.genhosppsych.2020.05.006PubMedGoogle ScholarCrossref
Bauer  MS , McBride  L , Williford  WO ,  et al; Cooperative Studies Program 430 Study Team.  Collaborative care for bipolar disorder: part II. impact on clinical outcome, function, and costs.   Psychiatr Serv. 2006;57(7):937-945. doi:10.1176/ps.2006.57.7.937PubMedGoogle ScholarCrossref
Salyers  MP , Bosworth  HB , Swanson  JW , Lamb-Pagone  J , Osher  FC .  Reliability and validity of the SF-12 health survey among people with severe mental illness.   Med Care. 2000;38(11):1141-1150. doi:10.1097/00005650-200011000-00008PubMedGoogle ScholarCrossref
Kudla  D , Lambert  M , Domin  S , Kasper  S , Naber  D .  Effectiveness, tolerability, and safety of ziprasidone in patients with schizophrenia or schizoaffective disorder: results of a multi-centre observational trial.   Eur Psychiatry. 2007;22(3):195-202. doi:10.1016/j.eurpsy.2006.06.004PubMedGoogle ScholarCrossref
Kilbourne  AM , Post  EP , Nossek  A , Drill  L , Cooley  S , Bauer  MS .  Improving medical and psychiatric outcomes among individuals with bipolar disorder: a randomized controlled trial.   Psychiatr Serv. 2008;59(7):760-768. doi:10.1176/ps.2008.59.7.760PubMedGoogle ScholarCrossref
Kilbourne  AM , Goodrich  D , Miklowitz  DJ , Austin  K , Post  EP , Bauer  MS .  Characteristics of patients with bipolar disorder managed in VA primary care or specialty mental health care settings.   Psychiatr Serv. 2010;61(5):500-507. doi:10.1176/ps.2010.61.5.500PubMedGoogle ScholarCrossref
Bartels  SJ , Coakley  EH , Zubritsky  C ,  et al; PRISM-E Investigators.  Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use.   Am J Psychiatry. 2004;161(8):1455-1462. doi:10.1176/appi.ajp.161.8.1455PubMedGoogle ScholarCrossref
Areán  PA , Ayalon  L , Jin  C ,  et al.  Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study.   Int J Geriatr Psychiatry. 2008;23(10):1086-1092. doi:10.1002/gps.2100PubMedGoogle ScholarCrossref
Hays  RD , Morales  LS .  The RAND-36 measure of health-related quality of life.   Ann Med. 2001;33(5):350-357. doi:10.3109/07853890109002089PubMedGoogle ScholarCrossref
Engel  CC , Jaycox  LH , Freed  MC ,  et al.  Centrally assisted collaborative telecare for posttraumatic stress disorder and depression among military personnel attending primary care: a randomized clinical trial.   JAMA Intern Med. 2016;176(7):948-956. doi:10.1001/jamainternmed.2016.2402PubMedGoogle ScholarCrossref
Mueser  KT , Rosenberg  SD , Xie  H ,  et al.  A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness.   J Consult Clin Psychol. 2008;76(2):259-271. doi:10.1037/0022-006X.76.2.259PubMedGoogle ScholarCrossref
Meredith  LS , Eisenman  DP , Han  B ,  et al.  Impact of collaborative care for underserved patients with PTSD in primary care: a randomized controlled trial.   J Gen Intern Med. 2016;31(5):509-517. doi:10.1007/s11606-016-3588-3PubMedGoogle ScholarCrossref
van der Voort  TY , van Meijel  B , Goossens  PJ ,  et al.  Collaborative care for patients with bipolar disorder: randomised controlled trial.   Br J Psychiatry. 2015;206(5):393-400. doi:10.1192/bjp.bp.114.152520PubMedGoogle ScholarCrossref
Suppes  T , Rush  AJ , Dennehy  EB ,  et al; Texas Medication Algorithm Project.  Texas Medication Algorithm Project, phase 3 (TMAP-3): clinical results for patients with a history of mania.   J Clin Psychiatry. 2003;64(4):370-382. doi:10.4088/JCP.v64n0403PubMedGoogle ScholarCrossref
Craske  MG , Stein  MB , Sullivan  G ,  et al.  Disorder-specific impact of coordinated anxiety learning and management treatment for anxiety disorders in primary care.   Arch Gen Psychiatry. 2011;68(4):378-388. doi:10.1001/archgenpsychiatry.2011.25PubMedGoogle ScholarCrossref
Schnurr  PP , Friedman  MJ , Oxman  TE ,  et al.  RESPECT-PTSD: re-engineering systems for the primary care treatment of PTSD, a randomized controlled trial.   J Gen Intern Med. 2013;28(1):32-40. doi:10.1007/s11606-012-2166-6PubMedGoogle ScholarCrossref
Watts  BV , Schnurr  PP , Mayo  L , Young-Xu  Y , Weeks  WB , Friedman  MJ .  Meta-analysis of the efficacy of treatments for posttraumatic stress disorder.   J Clin Psychiatry. 2013;74(6):e541-e550. doi:10.4088/JCP.12r08225PubMedGoogle ScholarCrossref
Carlo  AD , Drake  L , Ratzliff  ADH , Chang  D , Unützer  J .  Sustaining the collaborative care model (CoCM): billing newly available CoCM CPT codes in an academic primary care system.   Psychiatr Serv. 2020;71(9):972-974. doi:10.1176/appi.ps.201900581PubMedGoogle ScholarCrossref
Fortney  JC , Pyne  JM , Turner  EE ,  et al.  Telepsychiatry integration of mental health services into rural primary care settings.   Int Rev Psychiatry. 2015;27(6):525-539. doi:10.3109/09540261.2015.1085838PubMedGoogle ScholarCrossref
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