Lessons Learned from 20 years of Implementing Integrated Behavioral Healthcare

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Lesson #1: Collaborative Care Starts with the Primary Care Provider

Collaborative Care Team Structure, with the Patient at the center of a triangle and the Primary Care Provider (PCP), Behavioral Health Care Manager (BHCM), and Psychiatric Consultant each in a corner. The graphic illustrates the PCP in frequent contact with the BHCM and Patient. The BHCM in frequent contact with the Patient and the Psychiatric Consultant, and the Psychiatric Consultant in infrequent contact with the PCP and Patient, and connected with the BHCM vial a Registry.

Quick Read

- Primary Care Providers (PCP) are central to Collaborative Care (CoCM).

- To run a successful CoCM program you need buy-in and active participation from your PCPs.

- PCPs benefit from training and tools designed to aid them in their CoCM role.

It is impossible to overstate the importance of the Primary Care Provider (PCP) in Collaborative Care (CoCM). There is a reason why they are at the apex of the care triangle (graphic above). CoCM often starts with the relationship between the patient and the PCP. Additionally, the PCP directs the care delivered by the CoCM team. When building the CoCM treatment team, implementing organizations often expend substantial time, money, and energy hiring the Behavioral Health Care Manager and Psychiatric Consultant. While this is important, organizations should ensure the PCP is a primary partner in CoCM implementation. When the PCP is an afterthought we sometimes see in implementations that struggle.

LINCHPIN FOR SUCCESSFUL COCM IMPLEMENTATION

When patients are identified through screening, the PCP is often best positioned to connect the patient to CoCM. They are typically the one who talks with the patient about the symptoms they are experiencing and the treatment the clinic offers. Additionally, when the clinic is billing the CoCM codes, the PCP is also the person who obtains verbal consent from the patient (except in FQHCs and RHCs where clinical staff can serve in that role).

A robust endorsement from the PCP is a powerful engagement tool. Most patients care what their provider thinks, and a strong recommendation to participate in Collaborative Care can set the care journey off on the right path. To do this well, the PCP needs an informative and engaging ‘elevator pitch’ about CoCM to use with patients.

SUPPORTING PCPS IN COCM

Collaborative Care is not a referral model. The PCP remains an active member of the treatment team, prescribing medications when that is part of the treatment plan. Sometimes PCPs feel underprepared to play that role and don’t understand why the psychiatric provider doesn’t just take over the patient’s care. Or they may feel like they have everything under control and don’t need support from the psychiatric provider, but 20 years of research has shown that patients receiving treatment from their PCP alone are half as likely to improve.

As a key partner in building successful CoCM, PCPs benefit from orientation and preparation for their vital role. The AIMS Center provides tools and materials designed to support PCPs, including free training developed in partnership with the American Psychiatric Association.

Lesson #2: Collaborative Care Reduces Health Disparities

Quick Read

Historically marginalized communities can have limited access to behavioral health treatment and can experience less robust clinical outcomes because of poorer quality care.
Research shows Collaborative Care (CoCM) improves behavioral health outcomes for patients from racial and ethnic minority groups.
CoCM reduces health disparities by expanding access to evidence-based behavioral health care and offering non-medication treatment options.

Although the prevalence of mental health conditions is equivalent between racial/ethnic groups, treatment access and clinical outcomes can be significantly worse for people from historically marginalized communities. They are less likely to access mental health services and, when they do access care, are more likely to receive lower quality of care and to have poorer outcomes. Collaborative Care (CoCM) can reverse that.

What Research Shows

A landmark study in 2005 compared clinical outcomes between White, Black and/or African American, and Latinx patients receiving either usual depression treatment or Collaborative Care (CoCM).¹ As the graph below shows, all patients were significantly more likely to have a 50% or greater improvement in depression symptoms when treated with CoCM as compared with usual depression treatment. The relative benefit of CoCM was highest for patients who were Black and/or African American (31% greater likelihood of depression improvement) and Latinx (28% greater likelihood) than for White patients (24% greater likelihood), though this difference was not statistically significant.

A systematic review of 19 studies published in 2020² included ten randomized controlled trials (the highest quality of research evidence) and nine observational studies. All of the studies included the five core principles of CoCM. One of the challenges they encountered is that there is no standard definition of culturally sensitive care. Despite this, these studies demonstrated that CoCM – even without cultural or linguistic tailoring – was effective at improving depression outcomes for Black and/or African American, Latinx, Asian, and American Indian or Alaska Native patients, including those from low socioeconomic backgrounds.

How Collaborative Care Reduces Disparities

Patients from racial and ethnic minority groups often experience entrenched and systemic health disparities. Collaborative Care (CoCM) works to reduce these disparities by:

1. Increasing access to care in a less stigmatizing environment than traditional specialty behavioral health settings.
2. Offering non-medication treatments. Research has shown that patients from racial/ethnic minority groups have a stronger preference for non-medication treatments. One of the things that differentiates CoCM from usual care is the addition of behavioral treatments offered in the medical setting.
3. CoCM increases access to evidence-based behavioral health care, something that is not available to all patients equitably.

To learn more and to read the studies behind the headlines, visit our evidence-base page and select “Treating Racial and Ethnic Groups with CoCM.”

1. Arean P, et. al. Improving depression care for older, minority patients in primary care. Medical Care, Apr 2005; 43(4):381-390.

2. Hu J, et. al. The effectiveness of Collaborative Care on depression outcomes for racial/ethnic minority populations in primary care: A systematic review. Psychosomatics. Nov-Dec 2020; 61(6):632-644.

Lesson #3: Systematic Caseload Review is Key

QUICK READ

Successful Collaborative Care programs include a well-run, weekly Systematic Caseload Review meeting between the Behavioral Health Care Manager and the Psychiatric Consultant.
The Systematic Caseload Review allows the Psychiatric Consultant to oversee treatment progress and make proactive changes to the treatment plan.
A set weekly meeting ensures high-quality patient care, resulting in more people receiving care and their symptoms improving faster.

Over the past 20 years, we have seen that if the Systematic Caseload Review (SCR) is not functioning optimally, it will undermine the effectiveness of your entire Collaborative Care (CoCM) program. The SCR sets CoCM apart from other integrated care approaches. In this weekly meeting, the Behavioral Health Care Manager (BHCM) and the Psychiatric Consultant have dedicated time to examine a registry and identify which patients need an individual case review that week.

Within the SCR, the Psychiatric Consultant can assist with diagnostically complex patients and make treatment suggestions based on information they receive from the registry, the electronic health record (EHR), and the BHCM. This structure allows the team to leverage limited Psychiatric Consultant expertise as, typically, the Psychiatric Consultant does not see patients directly.

What Collaborative Care Experts Know

It is not enough to schedule time between the Psychiatric Consultant and the BHCM and assume everything will go well. An article by Bauer and colleagues articulates the vital features of an effective SCR and the threats to success and their solutions. These are some of the main points that align with our experience:

Regularity and duration: Meetings should occur weekly, even if the program is new and caseloads are small. It is essential for this not to be an ad hoc meeting or a 'call me when you have questions' scenario. The length of the meeting should match the number and complexity of patients. If the BHCM has a caseload above 75 patients, the SCR may need longer than an hour. Similarly, if there is more than one BHCM in the SCR meeting, the length should increase commensurately.
Set an agenda and come prepared: An effective SCR has a focused agenda that enables the team to review six to ten patients each hour. Before the meeting, the BHCM and Psychiatric Consultant should create an agenda and review the registry to prepare for the SCR. One of the biggest mistakes we see is that the Psychiatric Consultant does not have an equal role in preparing for the SCR and setting the agenda. Having a second set of eyes on the registry is critically important to identify patients who are not improving quickly enough or those who are ready for relapse prevention planning and ending their episode of care.
Action items and follow-through: A good Systematic Caseload Review generates action items. The BHCM and the Psychiatric Consultant must clearly articulate each action item and who is responsible for follow-through. It is a best practice for the Psychiatric Consultant to make their treatment recommendations directly to the Primary Care Provider (PCP) through the EHR, as this creates a communication channel for the PCP to ask questions about the recommendations. Before each SCR, the BHCM should check the EHR to determine if recommendations from last week's SCR have been implemented. If not, the BHCM and Psychiatric Consultant should discuss an action plan for follow-up with the PCP.
Behavioral Health Care Manager support: A good SCR is about more than treatment recommendations - it's an opportunity for the Psychiatric Consultant to support the BHCM. In their clinic, the BHCM may be the only person in their role or the only behavioral health provider. They benefit from having an opportunity to talk with the Psychiatric Consultant about the challenges they face and receive support and advice. It is also an opportunity for the Psychiatric Consultant to teach the BHCM about medications, differential diagnosis, and other topics that will help them work together more successfully.

The Systematic Caseload Review offers an efficient and cost-effective method of bringing specialist-driven care into the primary care setting. Ensuring a defined population of patients can receive care informed by a Psychiatric Consultant, usually allowing the Psychiatric Consultant to treat more patients than they could directly. A well-functioning Systematic Caseload Review will set your Collaborative Care program up for success.

Lesson #4: Metrics Matter

Quick Read

Just as you measure outcomes with your patients, it is essential to measure outcomes of your Collaborative Care program.
Performance metrics can be mapped onto the core principles for Collaborative Care.
Your team should meet regularly to review metrics and use a continuous quality improvement approach to improve your program.

Effective Collaborative Care (CoCM) programs utilize metrics to track their progress and results. Regularly measuring your program’s performance allows you to diagnose implementation challenges and intervene before they become entrenched and undermine your success. You can monitor a variety of metrics that correspond to the core principles of CoCM.

Patient-Centered

Measuring patient satisfaction allows CoCM programs to hear directly from their patients. Patient feedback is powerful. In the landmark IMPACT research trial, patients receiving CoCM were significantly more satisfied with their care than patients receiving usual care. Your team can identify strategies to collect this vital feedback.

Population-Based

It is crucial to understand the reach of your program. Standard areas of focus include:

- - - - Does your screening workflow have adequate reach and match the patient population you want to serve with CoCM?
      - Is the average time between identification and the first visit with the Behavioral Health Care Manager (BHCM) under two weeks?
      - Is the referral rate of new patients adequate to build and sustain the program?
      - Do patients who are referred enroll?
      - Are patients being seen more than once per month on average?
      - Are patients out of contact for over two months being deactivated from the caseload to make room for new patients?

Measurement-Based Treatment to Target

Most CoCM programs monitor patient clinical outcomes – improvement, response, remission – and compare their outcome rates to published standards. If your program is not getting as many people better as expected, you can dig into potential reasons. Are symptoms being remeasured frequently enough to be able to see improvement? Are you reaching 6-10 patients per 1.0 FTE BHCM with the weekly Systematic Caseload Review (SCR)? Are patients not improving quickly enough prioritized for discussion during the SCR?

Evidence-based Treatments

Your team needs to consider the common conditions targeted by your CoCM program. Are patients offered the full range of evidence-based treatments, including medications and behavioral treatments? Are evidence-based psychotherapies being used?

Accountable

At the core of this principle is the process of monitoring metrics and adjusting care delivery as needed. Do the processes of care and clinical outcomes align with your organization’s vision, goals, and expectations?

Once you have selected a set of metrics, your team should meet regularly, at least quarterly, to review them with clinical and organizational leadership. If you are not achieving your goals, investigate potential causes and use a continuous quality improvement approach to try interventions to improve them. If you are hitting your targets, perhaps it’s time to stretch beyond where you are now by setting them a bit higher or identifying new impact areas to monitor.

Lesson #5: Utilizing Collaborative Care in Specialty Medical Settings

Nurse and woman with cancer patient,

Quick Read

There is robust research on the effectiveness of Collaborative Care in specialty medical settings.
Patients facing complex medical diagnoses also experience a heightened depression risk and Collaborative Care significantly improves their outcomes.
Successful implementation of Collaborative Care in specialty medical settings requires deliberate strategy and thoughtful execution.

Collaborative Care (CoCM) often brings to mind primary care settings, but its benefits extend far beyond. Specialty medical settings have been using CoCM for years to address the complex needs of patients with various comorbid medical conditions. Implementing a successful CoCM program in this context requires careful consideration and planning. Yet, the substantial improvement in patient health outcomes justifies the effort.

Collaborative Care's Impact on...

Patients with Diabetes

According to the Centers for Disease Control and Prevention, individuals with diabetes face a higher risk of depression compared to the general population. For those with Type 1 Diabetes, this risk doubles, and with Type 2, it triples. The reciprocal relationship between diabetes and depression (depression can exacerbate diabetes, and vice versa) complicates patient care. Over the past two decades research examining the effects of CoCM on depression and diabetes outcomes, reveals that when patients receive CoCM focused solely on depression they have a significant improvement in depression but no improvement in glycemic control/HbA1c values. However, when the CoCM approach addressed depression and diabetes, patients showed improvement in both areas.

Patients with Heart Disease

A quarter of patients battling heart disease experience depression - a rate that is more than double that of those without cardiovascular conditions. Similar to diabetes, there's a reciprocal relationship between heart disease and depression, where one condition can worsen the other. Most studies of CoCM for patients with cardiovascular disease have shown a significant improvement in mood and quality of life. However, differences have not been observed in rates of hospitalization or mortality.

Patients with Cancer

Up to 25% of patients with cancer experience depression, which can negatively affect the quality of life and the ability to engage effectively in cancer treatment. When treated with CoCM as compared to usual care, patients with cancer and depression experienced decreases in depressive symptoms, pain, and fatigue.

Implementation Considerations

Implementing CoCM in specialty medical settings requires thoughtful consideration of the differences between primary and specialty care. For example, a common issue that arises is who will prescribe psychiatric medications when they are part of the treatment plan. Many specialists may hesitate to take on the role of primary prescriber for psychotropic medications. To manage this challenge, some organizations offer the specialty provider extra support from the Psychiatric Consultant, who takes on that role, sometimes including a one-time psychiatric evaluation and closer communication about medication initiation and changes.

When the healthcare organization provides both primary and specialty care to the patient, they can coordinate prescribing with the Primary Care Provider. Other aspects of CoCM, including the contributions of the Behavioral Health Care Manager and the Psychiatric Consultant, are provided in collaboration with the specialty care CoCM team.

While it takes some extra thought to implement CoCM in specialty medical settings, it can be successful. The benefits for the patient's quality of life, mental health symptoms, and physical health symptoms make it worth the effort.

Lesson #6: Expanding the Scope: The Effectiveness of CoCM for Diverse Behavioral Health Conditions

Quick Read

Since its inception, CoCM has evolved significantly and the evidence base shows it is significantly more effective than usual care in treating a variety of behavioral health conditions.
Providing CoCM for diverse conditions sometimes requires an adjustment to how the model is delivered.
It is important to consider which health conditions your CoCM program will address and tailor your hiring and training to meet these specific health needs.

Initial studies on the Collaborative Care Model (CoCM) were primarily centered around depression, the foremost cause of disability globally. Once a solid evidence base was built for the effectiveness of CoCM in managing depression, the scope of research broadened to include anxiety disorders. With the oldest and most robust research on CoCM examining depression and anxiety, some have the misconception that the efficacy of CoCM is limited to just these conditions, but that is not the case.

Over the past 20 years, researchers have studied the effectiveness of CoCM for diverse conditions, and it has proven to be significantly more effective than usual care for several other conditions. However, it’s important to note that achieving these outcomes sometimes necessitates modifications in how the model is delivered.

The Impact of CoCM on Various Conditions

Post-traumatic Stress Disorder (PTSD)

There is now a significant evidence base supporting CoCM as an effective treatment for PTSD. Much of this work has occurred in the Veterans Administration (VA) healthcare delivery system (such as this 2015 study examining telehealth for PTSD). Studies from outside the VA have further demonstrated its effectiveness. For instance, this study found that the use of CoCM for people hospitalized for acute injuries resulted in lower PTSD symptom burden and alcohol abuse/dependence.

Bipolar Disorder

The 2021 SPIRIT study examined CoCM for patients with bipolar disorder and/or PTSD and compared CoCM to care provided by both a psychologist and a psychiatrist. Researchers found that CoCM was equally effective as care delivered by a specialist team. This finding is impressive but it’s important to keep in mind that patients in the CoCM arm of the study had a one-time diagnostic interview with a psychiatric provider, and the psychiatric consultant discussed their case much more frequently than standard CoCM protocols for treating depression or anxiety. This suggests potential adjustments in resource allocation, for example, reducing a Behavioral Health Care Manager's (BHCM) caseload size.

Dementia

As the population ages and life expectancy increases, there is growing evidence that CoCM can be effective with dementia. A review published in 2020 showed that patients being treated with CoCM had fewer behavioral symptoms of dementia, improved functioning and quality of life, lower utilization of acute medical services, and decreased caregiver burden when compared with usual care.

Substance Use Disorders

The landmark SUMMIT research trial examined a CoCM approach to treating alcohol and opioid use disorders in primary care. Patients receiving CoCM were significantly more likely than patients in usual care to access treatment and abstain from alcohol and drugs. The American Psychiatric Association summarizes some of the important considerations when treating substance use disorders with CoCM.

Tailoring CoCM program to meet diverse needs

Collaborative Care can be used to treat a wide range of behavioral health conditions in primary care and other medical settings. Its proven effectiveness across diverse conditions underscores its pivotal role in enhancing patient outcomes and reducing healthcare disparities.

As the evidence base evolves, many practices are now developing caseloads capable of treating patients with a wide range of mental health conditions. When implementing a CoCM program, it’s crucial to think about the specific conditions your team will address. This should guide your hiring and training decisions. For example, if your program will focus on substance abuse, consider bringing on a Psychiatric Consultant who has experience with addictions. Or, providing training to the BHCM on brief behavioral interventions proven effective with diverse behavioral health conditions, like behavioral activation (which was used in the SPIRIT study), could also be beneficial. Remember, many of these conditions come with a range of physical and behavioral health co-morbidities. So, when determining the caseload size for the BHCM, make sure to account for this complexity.

Lesson #7: Insights on the Effectiveness of Collaborative Care for Diverse Patient Populations

Quick Read

Collaborative Care has been proven significantly more effective than usual care across various patient populations

Adjustments may be needed to the Collaborative Care Model to best serve the specific populations you are treating

The effectiveness of Collaborative Care across diverse patient populations makes it a valuable model of care for many healthcare settings

Robust research on using Collaborative Care (CoCM) to treat diverse patient populations has found CoCM to be significantly more effective than usual care within every population. This month, we dive into the research on several of these patient populations and the evidence for using CoCM to help them improve.

Collaborative Care for Older Adults

One of the largest effectiveness trials of CoCM was the IMPACT study, which evaluated older adults. The participants had on average, three comorbid chronic medical conditions, and one-third had some level of cognitive impairment. In addition to significantly reduced depression symptoms, patients randomized to the CoCM arm of the study reported less health-related functional impairment and greater overall quality of life compared to patients receiving usual depression care. This result held even when usual care included co-located Master’s level behavioral health clinicians providing therapy. The American Psychiatric Association has a resource that describes CoCM for diverse patient populations, including older adults.

Collaborative Care for Veterans

The Veteran’s Administration was one of the first large health systems to implement CoCM. Numerous studies have now evaluated the effectiveness of CoCM for veterans, including studies focused on depression and PTSD. While CoCM is still highly effective for veterans, one study found their treatment response was not as robust compared with civilians.

Collaborative Care for Children and Youth

While intense interest in CoCM for children and youth has been increasing recently, the research is a decade old. In 2014 two studies were published, one study demonstrated the effectiveness of CoCM for adolescents experiencing depression, and the other study examined CoCM for pediatric patients experiencing behavioral health disorders. CoCM often needs adaptations for this population, and the American Psychiatric Association offers guidance on this. Additionally, the AIMS Center has a comprehensive Pediatric Implementation Guide that includes specifics for implementing CoCM for this population.

Conclusion

Over the past 20 years, CoCM has been studied with a variety of patient populations, including these older adults, veterans, and pediatrics, and has been proven to be significantly more effective than usual care in all contexts. Other patient populations include low-income patients, racial/ethnic minority groups (see Lessons Learned #2), active duty military, and monolingual Spanish speaking individuals.

Overall, CoCM is a significantly more effective approach than usual care across various patient populations, making it a valuable model for many healthcare settings.

Lesson #8: Relapse Prevention Planning: Too Important To Overlook

Relapse prevention planning, the utilization of strategies to prevent the reoccurrence of mental health symptoms, is not just an optional component of Collaborative Care (CoCM); it is essential for ensuring long-term mental health stability. This critical component of care should be completed for all patients to help them maintain their well-being.

A relapse prevention plan can prevent the recurrence of symptoms by reminding a person what they can do to feel better. However, relapses are common. Approximately 50% of people who recover from a first episode of depression have one or more additional episodes in their lifetime. Therefore, a relapse prevention plan should also help a person recognize a recurrence of symptoms and include a plan for returning to services. Below are suggestions on prioritizing high-quality relapse prevention planning in your CoCM program.

Quick Read

Components of the relapse prevention plan: A comprehensive plan covers personal warning signs, maintenance medications, healthy behaviors and activities, and a plan for recurrence of symptoms.

Start early: Create a relapse prevention plan early in treatment when symptoms are fresh in the patient’s mind.

Regular review: Share the relapse prevention plan with the patient and remind them to review it and assess their symptoms regularly.

What the Research Shows

A systematic review by Moriarty and colleagues published in 2020 examines the role of relapse prevention for depression within CoCM. They identified 31 research studies of CoCM that included a relapse prevention plan, demonstrating that relapse prevention planning has been an important component of many CoCM trials.

Key Components of a High-Quality Plan:

1. Personal Warning Signs:

Depression and other behavioral health conditions can affect clarity of thinking and motivation; therefore, it is easy for a person to experience a relapse of symptoms without being aware that it is happening. Documenting that patient's personal warning signs and symptoms is the first step toward recognizing when a relapse may be beginning. Reviewing symptoms endorsed on screening tools and behaviors experienced at the beginning of treatment (e.g. not getting dressed, avoiding friends, etc.) can contribute to a comprehensive list of warning signs. Consider providing a validated screening tool such as the PHQ-9 and GAD-7 for periodic symptom checks.

2. Maintenance Medications:

When the treatment plan includes medications, include information about the dose and frequency in the relapse prevention plan. Review the rationale for staying on medications and the importance of discussing any concerns or changes with their provider before stopping or changing how medications are taken.

3. Healthy Behaviors & Activities:

Patients should identify the things they can continue doing to prevent symptoms from returning. This may include healthy behaviors such as exercise and sleep, as well as activities that improve mood, such as social or pleasant activities.

4. Plan for Recurrence of Symptoms:

Ensure patients know who to contact if symptoms appear to return. Include specific information about how to return for another episode of CoCM if needed in the future.

Practical Tips

Start working on the relapse prevention plan early in treatment. When patients are still experiencing some symptoms it is easier for them to remember their warning signs. Getting a head start on relapse prevention planning also reduces missed opportunities if a patient drops out of the program because they are feeling better.

Remember to share the plan with the patient and encourage them to keep it somewhere easy to find with a plan for regular review and assessment of symptoms. If a patient stops coming before a final visit you can send the plan through an EHR portal or mail it to the patient with a letter.

Additional Resources

If you want to learn more about effectively incorporating relapse prevention planning into your practice, check out our Advanced Skills for the Behavioral Health Care Manager training, which includes relapse prevention planning.

Lesson #9: Bridging the Gap: Perinatal Collaborative Care

Quick Read

A strong and growing evidence base supports Collaborative Care in the perinatal population.

Trusting relationships between providers and perinatal individuals are crucial for Collaborative Care implementation.

Adjustments may be needed to account for care transitions and the reproductive safety of medications.

The Importance of Perinatal Collaborative Care

Depression and anxiety affect 10-30% of individuals during pregnancy and the perinatal period (up to one year postpartum). These conditions are more common than other well-known pregnancy complications, such as gestational diabetes and hypertension, and are a leading cause of maternal mortality in the United States. Yet only 4% of women with perinatal depression are treated to remission.

This gap in care has far-reaching consequences for the health of parents and their children. Collaborative Care (CoCM) can bridge this divide by leveraging frequent perinatal healthcare visits for effective mental health screening and treatment.

The Evidence Base

Over a decade of research into Perinatal CoCM has found that:

Perinatal CoCM is feasible and effective.
Patients prefer to receive mental health care in the prenatal setting through the Collaborative Care model, rather than a referral to specialty mental health.
Program evaluations have found that perinatal CoCM can increase perinatal depression screening and recommendations for treatment by obstetric clinicians, and can reduce racial disparities in screening and treatment recommendation for perinatal depression.

Customizing Care for Perinatal Needs

Address unique parenting challenges

Pregnancy and the transition to parenting can be one of the most significant milestones in a person’s life. Depression and anxiety can negatively impact parenting. The treatment plan should address challenges specific to the perinatal experience, i.e., the need for parenting support or the additional stigma parents with mental health concerns often face.

Expand the CoCM team

The core CoCM team includes the Primary Care or Prenatal Provider (PCP), Behavioral Health Care Manager, and Psychiatric Consultant. Perinatal CoCM can expand this team to include Pediatric Providers and community-based providers such as home-visiting nurses and doulas.

Use screeners that include pregnancy-specific measures

Evidence-based screenings are an essential feature of CoCM. For prenatal patients, these screenings can include pregnancy-specific measures such as the Edinburgh Postnatal Depression Scale (EPDS) and Perinatal Anxiety Screening Scale (PASS). Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 item scale (GAD-7) can also be used.

Know perinatal-specific diagnoses and treatments

The CoCM team will need to familiarize themselves with diagnoses that are specific to the perinatal population, such as postpartum blues and postpartum psychosis. Similarly, treatment considerations in the perinatal period are unique. Evidence-based therapies such as Cognitive Behavioral Therapy and Interpersonal Therapy can be modified to the perinatal context. Medication management, if needed, must include a detailed informed consent discussion that balances the risk of untreated mental health conditions against the risk of taking medications during pregnancy and lactation.

Transitioning care

Transitions of care within the healthcare system can be complicated in the perinatal period. Although many patients consider their obstetric provider to be the PCP, pregnancy is an episode of care that ends at six weeks postpartum in many obstetric practices. It is important to have a plan for continuity of care after that point, like coordinating with the PCP early in the perinatal period. Parents may miss their postpartum visits, but keep their child’s well-child appointments, so the CoCM team should consider coordinating with the child’s pediatrician as well.

The Future of Perinatal Mental Health

The perinatal period, while a time of heightened mental health risks, also offers a unique opportunity for effective treatment through CoCM. By implementing CoCM, we can significantly improve parental mental health and reduce the negative impacts on children -- providing a potential positive intergenerational effect.

Want to learn more? Watch our Enhancing Perinatal Health through Collaborative Care Webinar for in-depth insights from the AIMS Center.

Lesson #10: Sustaining Collaborative Care: Key Strategies for Long-Term Success

Quick Read

Early clinical improvements are crucial. Use monitoring metrics to compare outcomes with benchmarks and intervene quickly if patients aren’t improving.

Ensure your Behavioral Health Care Manager (BHCM) is dedicated full-time to CoCM activities for stronger program sustainment.

Engagement from Primary Care Providers (PCPs) and Psychiatric Consultants is essential. Their support boosts patient engagement and overall program success.

Successfully launching a Collaborative Care (CoCM) program is a huge accomplishment. It’s an enormous practice change that involves multiple types of providers and system changes at the clinic/organization level. Sustaining CoCM once you’ve got it going requires ongoing attention to keep things on track.

According to a paper by Moise and colleagues, specific factors are associated with CoCM sustainment. To successfully sustain your CoCM program, you should focus on the following:

1. Ensure clinical improvement early in implementation

Maintaining enthusiasm for a complex practice change can be difficult if you don’t quickly see the benefits for your patients. It is critically important to design program monitoring metrics that allow you to compare the clinical outcomes you are achieving with published benchmarks. If patients are not improving as expected, quickly intervene with a quality improvement intervention and keep at it until you see outcomes that match the benchmark.

2. Provide adequate staffing resources

Clinics with a full-time Behavioral Health Care Manager (BHCM) have stronger sustainment than those without one. It is important to note that "full-time" refers to the amount of time the BHCM devotes to CoCM, not simply the time they work at the clinic. If 50% of their time is spent on general social work activities or crisis management, then only 50% of FTE is for CoCM.

3. Maintain full caseloads

In clinics that sustained CoCM, the BHCM treated an average of 137 patients a year, compared with only 58 patients at clinics that didn’t sustain. Becoming comfortable and proficient in the role takes practice.

Clinics that didn’t sustain CoCM reported several barriers, including a lack of engagement in the program from Primary Care Providers (PCPs) and Psychiatric Consultants. As noted in the first of our Lessons Learned, CoCM starts with the PCP. When PCPs are not engaged and supportive of the program, it is a barrier to implementation and sustainment. Another barrier is patient engagement. We see a link between PCP engagement and patient engagement. When the PCP recommends and endorses CoCM to the patient, patients are more likely to engage.

When investing in the launch of a CoCM Program, be sure to look to the future. Set in motion a process and culture to ensure the program thrives whether or not you’re still with the clinic as its champion.

Lesson #11: Addressing the Youth Mental Health Crisis: The Role of Collaborative Care

Quick Read

Primary care clinics are increasingly turning to Collaborative Care programs to serve their pediatric population.
Working with pediatric patients involves working with their caregivers as well.
Behavioral interventions are often the first line of treatment for youth in a Collaborative Care program.

In the United States, mental health conditions affect 1 in 6 youth ages 6-17, and shockingly, suicide is the second leading cause of death for young people ages 10-14. Primary care practices are on the frontline of this crisis. Increasingly, they are turning to Collaborative Care (CoCM) as part of the solution because the CoCM approach improves access and outcomes for patients. Treating young people earlier in their lifespan can reduce the overall negative impact of these conditions on quality of life and later health outcomes.

To date, the research on CoCM for youth has focused on adolescent depression, anxiety, and ADHD. In a meta-analysis of integrated care programs for children and adolescents, the authors note that, compared to usual primary care, CoCM in particular is associated with improved behavioral health outcomes.

Considerations for Working with Youth and Families in CoCM

Working with pediatric patients involves working with their parent/caregiver(s) when possible and often collaborating externally with schools and community resources. Be mindful that this type of coordination often requires additional time on the part of the Behavioral Health Care Manager and may impact their caseload size for this population.

Some practices are adding additional support to their CoCM team, such as a Community Health Worker or Care Coordinator, to assist with resource coordination and support for the parent/caregiver.

Symptom Monitoring Tools

While the PHQ-9 and GAD-7 are valid symptom monitoring tools starting at age 12, pediatric care teams often want to expand to other ages and conditions. Additional tools such as the Vanderbilt Assessment Scale for ADHD, the SCARED (Screen for Childhood Anxiety Disorders), and SMFQ (Short Mood and Feelings Questionnaire) are valid to monitor symptoms over time but can take longer to administer. Some of the tools, such as the Vanderbilt, require input from the parent/caregiver and/or school. Discuss this with your team to determine which measures to use, how often to administer the tools, how to calculate and track the scores, and the best way to collect the information.

Evidence-Based Behavioral Interventions

Evidence-based behavioral interventions are often the first line of treatment for children and adolescents in pediatric Collaborative Care. Brief behavioral interventions that work well in primary care settings include:

Behavioral Activation (BA) for adolescents
Cognitive Behavioral Therapy (CBT)
Solution Focused Therapy for children and adolescents
Behavioral Parent Training (BPT)

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Lesson #12: Building a Comprehensive Behavioral Health Strategy

Quick Read

Collaborative Care is one element of care within the behavioral health ecosystem.
Collaborative Care is designed to address conditions such as depression, anxiety, PTSD, and ADHD in outpatient medical settings.
For patients needing a higher level of care, Collaborative Care can bridge the gap to specialty behavioral health settings.

In this final installment of our 20th Anniversary Lessons Learned series, we explore the place of Collaborative Care (CoCM) within the behavioral health ecosystem.

The Role of Collaborative Care

Depending on the situation, CoCM is not the only – or even the best – solution for a patient experiencing behavioral health concerns. CoCM is designed to address behavioral health diagnoses that can be appropriately treated in an outpatient medical setting, which research has shown includes conditions like depression, anxiety, post-traumatic stress disorder, and ADHD.

Other elements of the behavioral health ecosystem can better serve patient needs and conditions. For instance, patients with subclinical symptoms may find adequate support in self-management strategies and/or evidence-based digital therapeutics. Self-management strategies can also be combined with CoCM or other behavioral health interventions and treatments.

Individuals without a diagnosed behavioral health condition, but whose symptoms affect their health status, may find support with other forms of behavioral health integration like Primary Care Behavioral Health (PCBH). Some healthcare organizations implement both PCBH and CoCM to reach as many primary care patients as possible.

Bridging to Specialty Care

When a healthcare organization designs its CoCM service, they define the specific patient population they want to reach. Creating a plan for patients who don’t fit within those parameters is important, especially since primary care providers often want to offer immediate help for their most acute and clinically challenging cases. CoCM is usually more accessible than specialty behavioral health services, but some patients need more intensive treatment than is appropriate or available in primary care and other outpatient medical settings.

If a healthcare organization has its own specialty behavioral health services, providers can make an internal referral. If it does not have a behavioral health service line, the patient will need a referral to a community-based behavioral health specialty setting. In either case, your CoCM program may still be called upon to "bridge" the patient until they can get into that higher level of care.

Planning with the Full Behavioral Health Ecosystem in Mind

Medical settings offering any level of behavioral health services must plan to address the full behavioral health ecosystem. You will have patients who don’t fit within your CoCM program and need a strategy to support them. Patients may also need a combination of services from different areas of the behavioral health ecosystem. Patients may move along the spectrum of the behavioral health ecosystem, either forward or backward, and it’s important to have options for smoothing those transitions. Ultimately, building out the behavioral health ecosystem will ensure that you can meet the needs of your entire patient population.