The COMPASS (Care Of Mental, Physical And Substance-use Syndromes) initiative, funded by the Center for Medicare & Medicaid Innovation, evaluated the large-scale implementation of the TEAMcare model treating patients with depression and comorbid diabetes and/or cardiovascular disease. The initiative was implemented in 18 medical groups and 172 clinics across eight states. Participating clinics differed significantly in size, organizational structure, patient populations, and payment systems, thus demonstrating the feasibility of implementing the TEAMcare intervention in “real world” clinical settings.
The initiative involved 3,609 Medicare and Medicaid patients in eight states and is one of the largest collaborative care implementations to date. The results of the trial were published in a 2016 issue of General Hospital Psychiatry. Among patients with uncontrolled disease at enrollment, 40% achieved depression response or remission, 23% achieved glucose control and 58% achieved blood pressure control over the 11-month treatment period. There were large variations in outcomes across the medical groups, and rigorous implementation was associated with increased effectiveness. Researchers learned best practices for treating patients in primary care settings who have multiple chronic conditions, demonstrated the model can be effective for the target population when implemented well, and identified financial models that can sustain and scale a multi-condition collaborative care program.
Developed in 2015, the Collaborative Care Medicaid Program (CCMP) is a state-based program to help clinics fully integrate behavioral health screening and treatment into primary care settings and to provide reimbursement for those services. CCMP grew out of a New York State Department of Health grant-funded demonstration program called the New York State Collaborative Care Initiative, which ran from 2011 to 2014. Having demonstrated robust feasability and acceptability, along with improved clinical outcomes during the grant period, the New York State Office of Mental Health (OMH) was able to secure legislative funding for the creation of the CCMP. CCMP was the first Medicaid program in the country to provide reimbursement for Collaborative Care services for adult depression. Anxiety diagnoses (including PTSD) were later added to the Medicaid payment, as well as a lower age threshold of 12 years. Another unique feature to the Medicaid payment structure is the Quality Supplemental Payment (QSP) payment, which gives some clinics the opportunity to get an additional payment by achieving quality outcomes.
Now, over 200 clinics participate in CCMP, receiving free training and technical assitance from the AIMS Center and Concert Health, as well as discounted access to the AIMS Centers’ Care Management Tracking System registry and discounted training in Problem Solving Treatment therapy. Part of participation requires the submission of quarterly process and outcomes data to OMH, which is used to further improve the training and technical assitance offered to CCMP clinics.
In an effort to increase access to mental health care in Seattle and King County, the AIMS Center at the University of Washington partnered with UW Medicine to launch the Behavioral Health Integration Program (BHIP). BHIP uses collaborative care to bring mental health treatment into all of the UW Neighborhood Clinics, a system of twelve primary care clinics located throughout greater Seattle, as well as clinics at Harborview Medical Center and the General Internal Medicine clinic at UWMC Roosevelt. Like elsewhere, mental health is a big part of primary care in Seattle and King County; in 2009, 19% of all clinic patients had a mental health diagnosis. Although Collaborative Care has been implemented around the world, the AIMS Center and UW Medicine are very proud to be able to provide it in our own community.
BHIP utilizes a web-based Care Management Tracking System that supports population-based care, provides patient outcome measures, and assists in quality improvement efforts. In October 2012, several goals were established for the BHIP program: to increase patient access by care managers and across all BHIP clinics, to improve patient outcomes on measures of depression and anxiety, to increase provider satisfaction with care management, and to improve provider satisfaction with psychiatric consultation. When measured in August 2013, the BHIP program had exceeded initial targets for each of the seven indicators.
BHIP won a Psychiatric Services Achievement Award from the American Psychiatric Association in 2014, and a Washington Award of Excellence in Healthcare Quality from Qualis Health in 2016.
Untreated mental health illnesses have serious consequences for families, but fewer than one in four depressed people who identify as mothers receive effective treatment. This project examined depression care and clinical outcomes for pregnant people and people who identify as either mothers or primary caregivers, treated in 14 clinics serving racially and ethnically diverse communities with lower incomes as part of the Mental Health Integration Program (MHIP). The outcome of this project was published in Family Practice. Huang H. et al (2012) found that although there was substantial depression improvement in all four of the ethnic groups studied (Asian, Black, Latinx, White), outcomes of Latinx patients were higher than those of Black patients regardless of other demographic or clinical factors. Notably, this study shows that more intensive care management in the first month of treatment for primary care can lead to better outcomes for pregnant people, and mothers or primary caregivers with lower incomes experiencing depression. Another study describes the experiences of care managers working in this program and found that motivational interviewing skills were a valuable asset in engaging patients in care, which generally leads to better outcomes.
References
- Huang, H., Chan, Y.-F., Katon, W., Tabb, K., Sieu, N., Bauer, A. M., Wasse, J. K., & Unützer, J. (2012). Variations in depression care and outcomes among high-risk mothers from different racial/ethnic groupsV. Family Practice, 29(4), 394–400. https://doi.org/10.1093/fampra/cmr108
- Huang, H., Bauer, A. M., Wasse, J. K., Ratzliff, A., Chan, Y.-F., Harrison, D., & Unützer, J. (2013). Care managers’ experiences in a collaborative care program for high risk mothers with depression. Psychosomatics, 54(3), 272–276. https://doi.org/10.1016/j.psym.2012.07.011
The number of older adults is rising sharply and is expected to increase from 40.3 million to 72.1 million between 2010 and 2030. According to the Pew Research Center, 92% of adults aged 65 and older use text messaging. Despite misconceptions to the contrary, text messaging as part of primary care for older adults is growing. Text messaging holds promise as a strategy for engaging older adults in Collaborative Care depression treatment through frequent contact with a behavioral health care manager. The purpose of this research project is to develop and pilot test a text messaging intervention delivered in California primary care settings serving a patient population that is at least 25% older adults. Published research (Bao et. al. 2015) demonstrated that early follow-up contact predicts better clinical outcomes for patients. A recent analysis published by the AIMS Center (Renn et. al. 2021) showed that Collaborative Care was equally effective in older and younger adults but that older adults needed more contact with the behavioral health care manager to achieve these equivalent outcomes. Text messaging may be an effective strategy for both early and more frequent contact with patients. The AIMS Center is partnering with the Archstone Foundation on this project.
This project was borne of a unique partnership between two federal entities, HRSA and NIMH, who contracted with the AIMS Center to train and support care teams in Nurse-led clinics to implement Collaborative Care. The project began in 2017 with11 clinics in diverse regions of the US for two years. All the sites were safety-net clinics providing care to underserved, predominantly uninsured patient populations, and were located in rural, suburban, and urban areas. Target populations included low-income, homeless, and/or LGBTQ adults facing significant financial, geographic, cultural-linguistics barriers. Patients served in these clinics suffered from chronic disease conditions (e.g. diabetes, hypertension) and untreated/undertreated mental health conditions or substance abuse.
AIMS Center practice coaches provided individualized support to each clinic as they laid the groundwork for their Collaborative Care teams, which included hiring staff, developing workflows, and financial planning. Teams had highly variable staffing models and experience with integrated care, but after several months of remote team meetings and didactic webinars with practice coaches, in-person trainings, and site visits, all 11 sites launched Collaborative Care in early 2018. Each site then received ongoing clinical training for behavioral health care managers and psychiatric consultants, as well as monthly sessions with a practice coach to refine workflows and team communications, report on and improve quality metrics, and plan for financial and clinical sustainment.
A unique aspect of this project is that site visits were conducted early in Year Two of the project, and a formalized set of evaluation tools were developed and used to assess site progress and identify areas in need of support. The site visits were conducted by the AIMS practice coach and clinical trainers and thoroughly documented for reporting back to HRSA and NIMH, as well as to the sites themselves. This was a rich method for thoroughly understanding any implementation challenges these sites faced and helping them solve these problems in real time. The project concluded in June of 2019.
This NIMH-HRSA collaboration supported Strategic Objective Four (4) of the NIMH Strategic Plan, which is to strengthen the public health impact of NIMH-supported research by providing training and health information dissemination.