Fidelity to Collaborative Care can Further Help Low-income Mothers

The mission of the AIMS Center is to improve the health of populations by advancing effective, integrated behavioral healthcare. Since our inception, our projects have helped a wide range of populations access and receive effective mental health care. In a recent project, we worked with a group of high risk mothers in partnership with Public Health – Seattle & King County (PHSKC). Through this Mental Health Integration Project (MHIP) for High-Risk Moms, we learned that Collaborative Care, when implemented properly, can significantly improve depression symptoms in new and expecting mothers receiving care in a primary care clinic.  

MHIP for High-Risk Moms used data from low-income, new and expecting moms with depression and other mental disorders being treated in 14 community health clinics that are part of the Mental Health Integration Program (MHIP) also supported by PHSKC. In evaluating this project, we examined rates of improvement for depression across different groups of moms and participating clinics in an attempt to investigate if differences in program implementation and organizational cultures and climate are associated with such differences. 

As part of this effort, we developed and tested a number of fidelity measures that indicate how closely clinics are following core components of evidence-based Collaborative Care for depression. Specifically, we examined to what extent participating clinics completed six key processes of effective Collaborative Care implementation such as treatment to target, using a patient registry, and monitoring treatment and outcomes. The fidelity measures were created in partnership with Ian Bennett, MD, PhD, an implementation researcher from the University of Pennsylvania. Our initial research suggests that the likelihood of a patient’s improvement in depression can be improved seven-fold if clinics fully implement all core components of collaborative care for all of their patients served compared to clinics that do not implement such components. 

“This evaluation by the AIMS Center provides compelling data linking fidelity in implementation to better outcomes for mothers,” said Anne Meegan, the PHSKC Community Health Partnerships Manager. “The results underscore the importance of using measures of fidelity in ongoing performance assessment.”

In a previous study by AIMS Center researchers looking at the effects Collaborative Care on high-risk moms, researchers interviewed care managers who participated in the program to better understand their experiences in caring for depressed mothers. The care managers identified factors that may affect their depression care and outcomes, such as levels of engagement, motivational interviewing, and increased psychiatric support. These factors have provided a qualitative way for the researchers to identify potential reasons for the variance of depression outcomes among the clinics.

AIMS Center researchers analyzed data from 2,500 mothers enrolled in the MHIP program from 2009 – 2014 and presented the results to a group of over ten local, state, and national partners in December 2014. The findings showed that most of the moms who received Collaborative Care at one of the participating clinics had significant improvements in their depression. However, significant variations were discovered across different patient ethnicities and clinics. On average, over half (approx. 59%) of patients in all participating clinics responded with significant improvement in their depression, but this rate of improvement varied from 35% to 78% across participating clinics. This variation provides an opportunity to more fully explore why some clinics perform better than others, a question AIMS Center researchers are currently exploring. 

The impact of maternal depression is huge. When moms have depression during pregnancy or in the first few months after giving birth, their children are at an increased risk for depression in adulthood. If maternal depression is left untreated, it could have serious consequences. A clinically depressed mother can lose interest in daily activities – including her child – for weeks at a time. This loss of interest has potentially harmful effects on their families, their children, and society. Maternal depression can also affect a child’s brain development, hormones, sociability, behavior, and ability to feel empathy. Despite research findings showing the far-reaching, serious implications of maternal depression, only one in three mothers receive effective depression treatment. 

“Time and again, the mothers we work with comment on the moment of realization they have that they needed outside help because of the mental health symptoms they were experiencing, but they didn’t know how they could ever afford treatment,” says Sarah Doty, the Health Education Program Coordinator & Mental Health Therapist at Sea Mar Community Health Centers, one of the clinics participating in the evaluation project. “The ability to provide accessible mental health services through a model that is more effective than traditional mental health care means these moms can get the treatment they need and are more likely to get better, and to do so sooner.”

Anne Shields, an AIMS Center team member who oversaw PHSKC’s original implementation of the MHIP program, emphasized the importance of Collaborative Care for depressed, low-income mothers. “The downstream return on investment is huge. We know from numerous studies over the years that depression is an especially debilitating disease for low-income moms, often with far reaching negative impact on their family’s economic stability and their children’s well-being.”

One such study conducted by former AIMS Center faculty member Wayne Katon, MD and collaborators at UW Psychiatry showed that women who received Collaborative Care in OB/GYN clinics had better outcomes than women who received usual care. Further analysis showed that Collaborative Care was not only effective for women in general, but it was particularly effective for vulnerable populations such as those women with low-incomes or with unstable housing.

The MHIP for High-Risk Moms project is a subset of MHIP, a project providing high-quality behavioral health care to safety-net populations across Washington State. Evaluating the implementation of Collaborative Care using a prevalent population within MHIP was a natural progression. 

“Nurses and primary care providers typically establish strong relationships with pregnant women and moms, seeing them as frequently as they do over the course of pregnancy and after delivery,” said Anne Shields. “These providers can often quickly recognize efficient ways to monitor moms in their care and very much appreciate access to consultation, especially if psychiatric medications are a consideration for pregnant women or nursing moms.”

The fidelity measures developed for the MHIP for High-Risk Moms project have the potential to be applied to other Collaborative Care implementations. The AIMS Center’s continuing evaluation efforts represent significant steps towards a systematic evaluation of Collaborative Care to maximize its effectiveness in improving maternal depression outcomes in mothers, and have the potential to improve outcomes across other populations. 

This research project is supported by a philanthropic gift to the department, the Community Health Plan of Washington (CHPW), Public Health – Seattle & King County (PHSKC), and the National Institute of Mental Health (NIMH).