Core principles and components of effective integrated behavioral health care developed in consultation with national experts and support from the John A. Hartford Foundation, the Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality, and the California HealthCare Foundation.
Compared to usual care, Collaborative Care is shown to increase the effectiveness of depression treatment and lower total healthcare costs. This handout outlines those differences using data from the IMPACT trial.
Effective behavioral health integration implementations are informed by measurement-based care and treatment to target. The evidence supporting the effects of these principles is derived largely from the research done on Collaborative Care.
Using clinical outcome measures is a relatively new idea in the world of behavioral health yet has been in other areas of health care for decades. Every time a patient visits a primary care clinic, someone takes their blood pressure. Increasingly, primary care practices and some behavioral health organizations are using this same principle to screen for the most common behavioral health conditions such as depression or anxiety.
A literature review, led by John Fortney, PhD, examined theoretical and empirical support for measurement-based care (MBC) and found that MBC is at a tipping point in the mental health care field. In addition to the publication, there is a video of Dr. Fortney summarizing the article.
There are a variety of well validated measures that can help identify behavioral health conditions and some track treatment progress over time. The Meadows Mental Health Policy Institute published a comprehensive report outlining a set of validated outcome measures for mental health and substance use conditions. These measures can play an important role in identifying people who may not otherwise be recognized as needing care for a behavioral health condition. However, their most important role is measuring the effect of treatment on symptoms. Once a patient has been identified as having a behavioral health condition and has started treatment for that condition, it’s very important to re-measure the symptoms at each contact so that the treating provider has specific information about whether or not symptoms are improving and which symptoms are or are not improving.
Some people are concerned that the concept of measuring mental health with a validated rating instrument invalidates the patient’s feelings or experience or disregards the complexity of the patient’s story. These measures are an important piece of information about the patient but are not meant to represent the entire clinical picture of the patient, nor are they meant to replace the clinical judgment of the provider. They are an important tool to assist the clinician and the patient with identification of the specific symptoms causing difficulty for the patient and how well those symptoms respond to treatment over time.
Treatment to Target
Adjusting the treatment plan based on symptom measures is one of the most important components of Collaborative Care. Clinicians change the treatment until the patient has at least a 50% reduction in measured symptoms.
Frequent measurement of symptoms allows the treating providers and the patient to know whether the patient is having a full response, partial response or no response to treatment. These measures also provide clues about which symptoms are improving and which are not if there is a partial response to treatment. This information is critically important in making decisions about how to adjust treatment.
Collaborative Care requires a change in the treatment plan every 10-12 weeks if the patient has not had at least a 50% improvement in symptoms using a validated measure. This prevents the clinical inertia that is often found in usual care and is likely one of the key factors behind the better treatment outcomes that can be achieved with Collaborative Care. If the treatment plan started with medication therapy as the primary treatment, the adjustment might be a change in dosage and/or the addition of evidence-based psychotherapy. If the treatment plan started with evidence-based psychotherapy, the adjustment might be the addition of medication therapy.
The Collaborative Care Model (CoCM) has a robust evidence base with over eighty randomized controlled trials showing it is the best at treating depression in many populations and settings. CoCM is beneficial for Primary Care Providers (PCPs) and their patients because it offers an established evidence base, better medical outcomes, help with challenging patient cases, faster improvement, and the collaboration of a team.
We highly encourage that this document be shared with PCPs, stakeholders, and others looking to implement CoCM.
A substantial body of evidence for Collaborative Care has emerged since its development at the University of Washington in the 1990s. Beginning with the seminal IMPACT Trial published in 2002, more than ninety randomized controlled trials and several meta-analyses show that Collaborative Care (CoCM) is more effective than usual care for patients with depression, anxiety, and other behavioral health conditions.
CoCM is also shown to be highly effective in treating co-morbid mental health and physical conditions such as cancer, diabetes, and HIV. The document summarizes several selected research, review, and practice-based articles that demonstrate Collaborative Care significantly improves patient lives.
The Behavioral Health Integration Implementation Guide is the most recent addition to the landmark series of Safety Net Medical Home Initiative implementation guides produced by Qualis Health to help primary care practices become Patient-Centered Medical Homes (PCMH). The guide offers concrete strategies on behavioral health integration including creating a vision, building integrated care teams, monitoring progress, and providing population-level accountability, particularly important for organizations implementing Collaborative Care. For organizations looking for guidance and coaching that goes beyond this resource, the AIMS Center offers a wide range of coaching and implementation support.
Researchers from the Mayo Clinic conducted a retrospective study that found that collaborative care management improved the time to remission as well as shortened the duration of persistent depressive symptoms in patients diagnosed with depression.
This guide is for multi-disciplinary, primary care teams seeking to improve care access and behavioral health outcomes for children and adolescents through implementing Collaborative Care. Centered around the core principles of Collaborative Care, this guide serves as a roadmap to healthcare leaders, managers, clinicians, and staff in primary care as they:
- start a new Collaborative Care program, or
- expand an existing integrated care or Collaborative Care program to pediatrics, and/or
- partner with community and behavioral health agencies.
For training support and technical assistance implementing Pediatric Collaborative Care reach out to the AIMS Center at: email@example.com. Research has shown that clinics receiving implementation support from the AIMS Center have significantly better patient outcomes.
Integrated Care: Creating Effective Mental Health and Primary Health Care Teams provides the first comprehensive guide for teams to integrate effective mental health care into primary care clinics. Edited by a team of UW Medicine mental health experts, it includes practical information, skills, and clinical approaches needed to implement Collaborative Care, an evidence-based model of integrated care developed at the University of Washington. Importantly, it provides a common resource and framework for all members of the care team including care managers, psychiatrists, primary care providers, and administrators. Editors include UW psychiatrists Anna Ratzliff, MD, PhD, Jurgen Unutzer, MD, PhD, MA, and the late Wayne Katon, MD, as well as UW psychologist Kari Stephens, PhD.
Find resources for implementation within the free Integrated Care Online Appendix. These include a CoCM readiness checklist, BHCM documentation templates with examples, job descriptions, links to screening and symptom monitoring tools, and more. Please note that the Integrated Care Online Appendix was last updated in 2016 and there may be more current versions of items elsewhere in our resource library. Email firstname.lastname@example.org with specific questions.