IMPROVING DEPRESSION CARE IN THE RURAL WEST: SOCIAL INNOVATION FUND
Poor mental health is a major public health issue that robs millions of people of their chance to lead healthy and productive lives. Depression alone doubles overall healthcare costs, worsens other medical conditions, and results in a staggering loss of productivity at work. In underserved rural areas in the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region, a severe shortage of mental health providers compounds these problems.
Through a public-private partnership, the AIMS Center supported eight rural community primary care clinics serving low-income patients to implement collaborative care (also called collaborative care management or CoCM) in the WWAMI region, a geographic area served by the University of Washington School of Medicine and representing 27% of the land mass of the United States. These 8 clinics planned to serve 3,250 patients but ultimately enrolled 5,392 patients. This represents 16% of the total unique patients served by these clinics and is a significant increase of the patients they were able to reach before implementing CoCM.
Escalating prescription opioid use and abuse have emerged as major public health problems in Washington. Rural communities in particular have been hit hard due to their limited access to specialists. This project allows mental health specialists in urban areas to support health care providers in rural areas using videoconferencing technology. Patient evaluations and recommendations, caseload supervision, and education are all done remotely via telehealth. This project aims to establish acceptance, effectiveness, and cost-efficacy of telehealth for delivery of mental health and pain medicine care in rural primary care.
DIAMOND was a collaborative effort of 9 health plans, 25 medical groups, and over 80 primary care clinics in Minnesota to implement and study Collaborative Care for depression. The AIMS Center provided consultation and coaching for the initiative. In addition, the National Institute of Mental Health (NIMH) awarded a $3 million grant to HealthPartners Research Foundation to study the DIAMOND initiative over five years. The study evaluated all aspects of DIAMOND, including effects of the program on patient satisfaction, productivity, and program cost-effectiveness. The project used a patient registry that tracks and measures patient goals and clinical outcomes, and facilitates treatment adjustment if a patient is not improving as expected.
The New York State Collaborative Care Initiative helped primary care residents learn how to effectively practice team-based care to treat mental health conditions, a skill that has become increasingly important as integrated care becomes more widespread. Outpatient clinics associated with teaching hospitals are implementing Collaborative Care around the state, increasing the quality of mental health care for thousands of New Yorkers. By providing different intensities of technical assistance, the AIMS Center evaluated what level of support was needed to effectively help organizations implement Collaborative Care. They helped set up a technical assistance team in New York to provide on-site assistance to six clinics. Twenty other hospital organziations received web-based technical assistance, including webinars and online tools. Organizations used a patient registry to track and measure patient goals and clinical outcomes, and facilitate treatment adjustment if a patient is not improving as expected.
The COMPASS (Care Of Mental, Physical And Substance-use Syndromes) initiative, funded by the Center for Medicare & Medicaid Innovation, evaluated the large-scale implementation of the TEAMcare model treating patients with depression and comorbid diabetes and/or cardiovascular disease. The initiative was implemented in 18 medical groups and 172 clinics across eight states. Participating clinics differed significantly in size, organizational structure, patient populations, and payment systems, thus demonstrating the feasibility of implementing the TEAMcare intervention in “real world” clinical settings.
The initiative involved 3,609 Medicare and Medicaid patients in eight states and is one of the largest collaborative care implementations to date. The results of the trial were published in a 2016 issue of General Hospital Psychiatry. Among patients with uncontrolled disease at enrollment, 40% achieved depression response or remission, 23% achieved glucose control and 58% achieved blood pressure control over the 11-month treatment period. There were large variations in outcomes across the medical groups, and rigorous implementation was associated with increased effectiveness. Researchers learned best practices for treating patients in primary care settings who have multiple chronic conditions, demonstrated the model can be effective for the target population when implemented well, and identified financial models that can sustain and scale a multi-condition collaborative care program.
This project is a collaboration with the Portland Area Service Unit of the Indian Health Service (IHS) and George Fox University. George Fox University received a Health Services Resource Administration (HRSA) grant to promote integrated mental health care at two Oregon sites: the Chemawa Indian School’s Primary Care Clinic (operated by the Portland Area Service Unit) and Providence Medical Group in Newburg, OR. This project creates a learning collaborative among interested IHS and tribal clinics to implement Collaborative Care. Other clinics include the Warm Springs IHS unit and tribal clinics.
The AIMS Center is providing implementation coaching support and clinician training to support the project at the Indian Health Service and related sites.
This project was borne of a unique partnership between two federal entities, HRSA and NIMH, who contracted with the AIMS Center to train and support care teams in Nurse-led clinics to implement Collaborative Care. The project began in 2017 with11 clinics in diverse regions of the US for two years. All the sites were safety-net clinics providing care to underserved, predominantly uninsured patient populations, and were located in rural, suburban, and urban areas. Target populations included low-income, homeless, and/or LGBTQ adults facing significant financial, geographic, cultural-linguistics barriers. Patients served in these clinics suffered from chronic disease conditions (e.g. diabetes, hypertension) and untreated/undertreated mental health conditions or substance abuse.
AIMS Center practice coaches provided individualized support to each clinic as they laid the groundwork for their Collaborative Care teams, which included hiring staff, developing workflows, and financial planning. Teams had highly variable staffing models and experience with integrated care, but after several months of remote team meetings and didactic webinars with practice coaches, in-person trainings, and site visits, all 11 sites launched Collaborative Care in early 2018. Each site then received ongoing clinical training for behavioral health care managers and psychiatric consultants, as well as monthly sessions with a practice coach to refine workflows and team communications, report on and improve quality metrics, and plan for financial and clinical sustainment.
A unique aspect of this project is that site visits were conducted early in Year Two of the project, and a formalized set of evaluation tools were developed and used to assess site progress and identify areas in need of support. The site visits were conducted by the AIMS practice coach and clinical trainers and thoroughly documented for reporting back to HRSA and NIMH, as well as to the sites themselves. This was a rich method for thoroughly understanding any implementation challenges these sites faced and helping them solve these problems in real time. The project concluded in June of 2019.
This NIMH-HRSA collaboration supported Strategic Objective Four (4) of the NIMH Strategic Plan, which is to strengthen the public health impact of NIMH-supported research by providing training and health information dissemination.
The COVID-19 pandemic has caused us all to find new ways to make and maintain connections with others, especially with older adults in our own lives and communities. In response to increasing COVID-related isolation, AIMS Center members and UW faculty developed a program called Stay Connected. Delivered via telehealth, Stay Connected is a program that employs evidence-based behavioral strategies for older adults experiencing loneliness, anxiety, or depression symptoms. Case managers, community health workers, and others working in senior service settings make structured phone calls to a caseload of clients in which they ask targeted questions and provide specific tools and guidance to ward off stress, loneliness, and anxiety. Callers are trained and supported by licensed behavioral health clinicians and psychologists.
“The Stay Connected program helps older adults restructure their day and add self-care and mood boosters.” – Patrick Raue, PhD
The program was developed by AIMS Center members in partnership with organizations participating in an Archstone Foundation-funded project known as Care Partners. Stay Connected was also funded by NIMH as part of the University of Washington School of Medicine ALACRITY Center. In addition, Seattle-King County Aging and Disability Services implemented a brief pilot of the Stay Connected program in 2020.
Up to 25% of people with cancer will become clinically depressed, significantly affecting their quality of life and overall functioning. Depression has been associated with a decreased ability to tolerate and complete cancer treatment, as well as significantly increased healthcare costs. Unfortunately, about 75% of cancer patients with depression do not receive adequate treatment, and that likelihood is even greater for patients in rural settings. Although the CoCM model has been shown to be highly effective in the cancer setting, high-fidelity implementation has been slow, particularly in low-resourced and rural areas. The use of technology has the potential to enhance implementation and fidelity of CoCM in diverse cancer settings.
The research project “Using Technology to Optimize Collaborative Care Management of Depression in Urban and Rural Cancer Centers,” funded by the National Cancer Institute, will explore and build on this potential. This study is using a human-centered design approach to develop, build, and test a web and mobile platform to enhance the implementation and fidelity of CoCM of depression for patients being treated at 2 urban and 2 rural cancer centers. Patient-facing web and mobile applications and a clinician-facing website will aim to: (1) enhance treatment engagement among patients and clinicians; (2) collect timely patient-reported outcomes for measurement-based care; (3) promote patient-centered shared decision-making for better treatment adjustments; and (4) maximize adherence to evidence-based guideline-level behavioral and pharmacologic treatments. Once developed, the technology-enhanced CoCM model will be compared to usual CoCM to evaluate their ability to achieve optimal fidelity of CoCM and clinical outcomes.
Around 2.1 million Americans aged 12 years and older had an opioid use disorder (OUD) in 2016. Among adults who misused opioids in the prior year, 43% also had a mental illness. There is strong evidence for the efficacy of the Collaborative Care model (CoCM) in treating common mental health disorders, but not for the treatment of OUD. The CHAMP study (Collaborating to Heal Opioid Addiction and Mental Health in Primary Care) will investigate whether CoCM that addresses both mental health conditions and co-occurring OUD can improve patient lives.
The Department of Psychiatry & Behavioral Science’s Population Health Division and the AIMS Center will support up to 24 primary care clinics in implementing either CoCM for OUD and mental health conditions, or for mental health conditions only. Training for the intervention began in late summer 2020.
Find out more about this clinical trial by visiting the CHAMP website.
Contact
Lori Ferro Phone: (206) 685-7538
Email: ljf9@uw.edu
Webinar
Watch presenter Anna Ratzliff, MD, PhD give an introduction to the project and answer questions from attendees.
