Rural Mental Health Integration Initiative

Poor mental health is a major public health issue, affecting millions of people in their pursuit to lead optimal emotional, social, and professional lives. Depression alone can worsen other medical conditions, often doubling over-all healthcare costs, and result in a significant decrease in quality of life and overall functioning.

Rural communities and residents of those communities face significant social and health disparities as compared with urban and suburban residents. Residents of rural areas are more likely to experience health disparities. They are more likely to have chronic health conditions, less likely to receive healthcare of any kind, and less likely to receive evidence-based treatments when they do access care. Geographic maldistribution of mental health specialists from all disciplines and education levels (e.g. psychology, social work, psychiatry) creates significant access challenges. Rural areas also experience workforce shortages for primary care, where most rural mental health treatment occurs, further exacerbating access barriers. In underserved rural areas in Washington and Alaska, a severe shortage of mental health providers compounds these problems.

In an effort to ameliorate some of these disparities, the AIMS Center is partnering with Premera Blue Cross to support 23 clinics in rural Washington and Alaska to implement Collaborative Care.

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Contact
ruralmh@uw.edu

St. Luke’s Health System Collaborative Care Implementation

The AIMS Center provided training and technical assistance to St. Luke’s Health System as they implemented a Collaborative Care program in April 2017. This implementation took place over 12 months and included three clinics in spring 2017 and two clinics in fall 2017. Eventually collaborative care will be spread across the entire of network of clinics at St. Luke’s Health System, the only Idaho-based, not-for-profit health system.

New York State Learning Network

The New York State Office of Mental Health (OMH) asked Performing Provider Systems (PPSs) from all over the state that chose Collaborative Care for their Delivery System Reform Incentive Program (DSRIP) to nominate at least one of their clinics to participate in the Learning Network. Through a rigorous application process, 19 clinics were selected to participate. As a part of the Learning Network, these clinics will eventually be eligible to bill the monthly Medicaid case rate once they are trained and have the necessary staffing, infrastructure, and workflows in place to deliver effective Collaborative Care (CoCM).

In order to achieve these goals, OMH provided clinics with training, site visits, and access to tools that facilitate the implementation of Collaborative Care, including access to the AIMS Center’s Care Management Tracking System.
While Collaborative Care training and support provided by OMH is only available to these clinics for one year, OMH hopes that creating a network of clinics learning together will facilitate the success of Collaborative Care for clinics beyond additional training support. As part of the Learning Network, clinics are encouraged to build relationships with the other clinics through communicating and learning from one another along the way. Individual clinics are matched with similarly structured clinics to form several training cohorts to better facilitate learning. An experienced coach works with each training cohort throughout the implementation process. Regular calls with the training cohort will keep clinics connected and provide the opportunity to receive additional training support, discuss challenges, and learn what the other sites are doing.

The AIMS Center, NYS OMH, Qualis Health, and, most importantly, the training cohorts will provide clinics with the support and tools needed to ensure a successful CoCM program implementation. We hope that each clinic’s care team will continue to communicate with the other members of the learning network after the close of the year and the discontinuation of services.

TEAMcare

Health care providers and systems need effective strategies for management of individuals with multiple coexisting chronic conditions, who are now the norm rather the exception. Among patients with diabetes, the presence of co-morbid depression is associated with increased risk of complications, cardiovascular events and mortality—and higher medical costs. The TEAMcare study was a randomized controlled trial that demonstrated the effectiveness of the collaborative care model (CoCM) for treatment of depression, diabetes, and coronary heart disease in primary care. This multi-center trial was conducted by the University of Washington in collaboration with the Group Health Research Institute with funding from the National Institute of Mental Health (NIMH).

The TEAMcare findings were published in the New England Journal of Medicine in 2010. The primary result was that (when compared to usual care) a multi-disciplinary team providing measurement-based care and nurse care management significantly improved outcomes for depression and coronary heart disease and/or diabetes at a lower cost over a 12-month treatment period.

Behavioral Health Integration Program (BHIP)

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.

Collaborative Care for Pregnant People and Primary Caregivers in Lower Income Communities

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

Kaiser Permanente

More than 20 years of research evidence across more than 80 randomized controlled trials has established Collaborative Care as the integrated care approach with the most research evidence across all kinds of clinical delivery systems, patient populations, and geographic regions. This research evidence is replicated in dozens of peer reviewed publications evaluating implementation of Collaborative Care in real-world settings. Kaiser Permanente is committed to providing the highest quality care possible to their patients. They participated in the largest research trial of Collaborative Care and one of their regions has been practicing Collaborative Care for many years. The senior leaders at each of the eight regions, along with leadership from the national Mental Health and Wellness group, have made implementing Collaborative Care system-wide a key priority. The AIMS Center is partnering with them to accomplish this goal.

The Maternal Infant Dyad Implementation (MInD-I) Initiative

The Departments of Family Medicine and Psychiatry and Behavioral Sciences at the University of Washington (UW) are providing an opportunity for primary care providers to receive training and technical assistance to implement a Collaborative Care (CoCM) program or spread their existing CoCM services to enhance care for women with perinatal depression and other behavioral health disorders through the Maternal Infant Dyad – Implementation (MInD-I) Initiative, pronounced ‘mind eye’.

Participating care teams receive 15 months of technical assistance and training support from the AIMS Center, including assistance building patient screening and outcome reports for continuous quality improvement. Training will focus on helping primary care clinics to implement or enhance their CoCM programs and build sustainable staffing strategies. Training and technical assistance is not limited to perinatal populations. The AIMS Center staff and faculty are available to assist providers to build a robust CoCM program that can capably serve all patient populations. Care teams also receive free access to the AIMS Caseload Tracker over the course of their participation in MInD-I, with the option of continuing to use the registry afterwards by paying an annual hosting fee.

Collaborative Care for Native American Health Centers

This project is a collaboration with the Portland Area Service Unit of the Indian Health Service (IHS) and George Fox University. George Fox University received a Health Services Resource Administration (HRSA) grant to promote integrated mental health care at two Oregon sites: the Chemawa Indian School’s Primary Care Clinic (operated by the Portland Area Service Unit) and Providence Medical Group in Newburg, OR. This project creates a learning collaborative among interested IHS and tribal clinics to implement Collaborative Care. Other clinics include the Warm Springs IHS unit and tribal clinics.

The AIMS Center is providing implementation coaching support and clinician training to support the project at the Indian Health Service and related sites.

Nurse-Led Clinics Implementing Integrated Care

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.