What is Collaborative Care?
Behavioral health problems such as depression, anxiety, alcohol or substance abuse are among the most common and disabling health conditions worldwide, collectively robbing millions of their chance to lead healthy and productive lives. The good news is that there are effective treatments for most mental health conditions. The bad news is that most people in need don’t receive effective care due to stigma, a shortage of mental health specialists, and lack of follow through.
Integrated care programs try to address this problem by providing both medical and mental health care in primary care and other clinical settings. Offering mental health treatments in primary care is convenient for patients, can reduce the stigma associated with treatment for mental disorders, builds on existing provider-patient relationships, and can help improve care for the millions of patients who have both medical and mental disorders. There is a wide range of integrated programs, some of which are based on evidence and some of which are not.
Collaborative Care is a specific type of integrated care developed at the University of Washington that treats common mental health conditions such as depression and anxiety that require systematic follow-up due to their persistent nature. Based on principles of effective chronic illness care, Collaborative Care focuses on defined patient populations tracked in a registry, measurement-based practice and treatment to target. Trained primary care providers and embedded behavioral health professionals provide evidence-based medication or psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for patients who are not improving as expected.
Collaborative Care originated in a research culture and has now been tested in more than 80 randomized controlled trials in the US and abroad. Several recent meta-analyses make it clear that Collaborative Care consistently improves on care as usual. It leads to better patient outcomes, better patient and provider satisfaction, improved functioning, and reductions in health care costs, achieving the Triple Aim of health care reform. Collaborative Care necessitates a practice change on multiple levels and is nothing short of a new way to practice medicine, but it works. The bottom line is that patients get better.
Use our Resource Library to find materials about Collaborative Care.
Co-location is Not Enough
There are big differences between Collaborative Care and co-located care. The most important among these is that true Collaborative Care has been shown across dozens of research studies to be significantly more effective in treating conditions like depression and anxiety. The same cannot be said for co-located care, in which primary care and behavioral health clinicians provide services in the same location but practice independently using a traditional referral model.
The figure to the right shows the eight health care organizations that participated in the IMPACT study, which was a national study of Collaborative Care for depression and one of the largest depression treatment studies ever conducted in the United States. The organization circled had Masters-level co-located behavioral health clinicians in each participating primary care office. These providers practiced within the primary care clinic using a referral model in patients participating in the IMPACT study at this clinic who were randomly assigned to the usual care group could be referred by their primary care provider to these co-located therapists for treatment, and many were. The graph shows that patients in this clinic who were randomly assigned to receive IMPACT care were almost twice as likely to have significant improvement in their depression as compared to patients receiving usual care (including referral to the co-located therapists) which the primary care providers referred patients to them and they provided care to these patients independently using a traditional approach (50 minute psychotherapy sessions). These clinicians did not collaborate closely with the primary care providers using a team approach and did not use the principles of measurement-based, stepped care treatment.
Elizabeth is a 66 year old woman who was a patient in the original IMPACT Trial. She had been suffering from depression for 20 years.
"Twenty-seven years ago, the son of my housekeeper killed my daughter. She was fifteen. Everything changed in my life—completely. Before that I had happiness, a good family, everything was nice—but it turned into nothing. I was in shock.
For years and years I accumulated all the pain for myself. I tried to be strong for my son and my other daughter. My husband died six months later of a heart attack. So I found work to support my family. I thought I was strong and people told me I was strong. But it’s not true. I suffered. I cried. I was bleeding inside. I don’t know if people understand about depression. It puts your soul far away from you.
The years passed and I stayed in the same home. My children grew up and moved away. A year ago I lost my property. Before that I thought I could control everything. After that everything came on top of me and destroyed me. I tried to sleep and I could not. I felt like I was in a big bucket of oil trying to get out. I tried but I couldn’t. Life was terrible. I didn’t want to live anymore.
I went to Kaiser and said to my doctor, I’m depressed. She gave me pills, but they didn’t help. Then my doctor sent me to see Rita."