For 20 years the AIMS Center has supported diverse healthcare organizations to integrate behavioral health services into medical settings. We’ve learned some things along the way! To celebrate our 20th Anniversary, we will be sharing our insights throughout 2024 in monthly “Lessons Learned”.
Miss a lesson? Find the archive below.
Quick Read
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- Primary Care Providers (PCP) are central to Collaborative Care (CoCM).
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- To run a successful CoCM program you need buy-in and active participation from your PCPs.
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- 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.
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:
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- Increasing access to care in a less stigmatizing environment than traditional specialty behavioral health settings.
- 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.
- 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.
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.
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:
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- 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?
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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.