Escalating prescription opioid use and abuse have emerged as major public health problems in Washington. Rural communities in particular have been hit hard due to their limited access to specialists. This project allows mental health specialists in urban areas to support health care providers in rural areas using videoconferencing technology. Patient evaluations and recommendations, caseload supervision, and education are all done remotely via telehealth. This project aims to establish acceptance, effectiveness, and cost-efficacy of telehealth for delivery of mental health and pain medicine care in rural primary care.
This implementation is part of California’s Mental Health Services Act and LA County’s Prevention and Early Intervention (PEI) Plan. The PEI Plan focuses on prevention and early intervention services, education, support, and outreach to help inform and identify individuals and their families who may be affected by some level of mental health issue. The Mental Health Integrated Care Program in particular targets adults with depression, anxiety, and mild to moderate PTSD. Providing mental health education, outreach and early identification (prior to diagnosis) can mitigate costly negative long-term outcomes for mental health consumers and their families.
When hurricanes Katrina and Rita devasted New Orleans, the AIMS Center worked on a Red Cross funded initiative to rebuild the primary care system to include Collaborative Care. The project enhanced the availability of evidence-based mental health services to uninsured, disadvantaged, and minority community members offered through REACH NOLA’s Mental Health Infrastructure and Training Project. It also showed the benefits of integrated mental health care after disasters, particularly for depression and post-traumatic stress disorder (PTSD). To our knowledge, the program is the first time that a Collaborative-Care-based quality improvement approach for mental health treatment had been applied in a post-disaster recovery setting.
Alameda County in California provides affordable health care to its uninsured residents, but primary care clinics struggle to meet the demand. The AIMS Center, in partnership with the Alameda Health Consortium, helped 30 primary care clinics develop an integrated mental health care initiative targeting depression, anxiety, and PTSD to increase the effectiveness of care. A key component of the project was determining how organizations can successfully use funding from Medicaid to implement Collaborative Care.
The Mental Health Integration Program (MHIP), supported and administered by the Community Health Plan of Washington in partnership with Public Health -Seattle and King County, integrates mental health screening and treatment in a collaborative care model (CoCM), including psychiatric case review and consultation. MHIP collaborative care teams in Washington State safety-net primary care settings serve diverse Medicaid and uninsured populations. Since MHIP’s inception in 2007, over 50,000 individuals have received integrated mental health services. In 2007 it began as a state-funded, two-county pilot for high risk uninsured adults in King and Pierce counties, but MHIP expanded statewide in early 2009 to include over 130 primary care clinics.
MHIP uses a patient registry (CMTS) to track and measure patient goals and clinical outcomes, and facilitate treatment adjustment if a patient is not improving as expected. MHIP also utilizes pay-for-performance mechanisms to support model fidelity and prioritize patient outcomes. Training and workforce efforts for this project focus on the whole team and all providers are trained on the fundamentals of CoCM.
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.
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.
Around 2.1 million Americans aged 12 years and older had an opioid use disorder (OUD) in 2016. Among adults who misused opioids in the prior year, 43% also had a mental illness. There is strong evidence for the efficacy of the Collaborative Care model (CoCM) in treating common mental health disorders, but not for the treatment of OUD. The CHAMP study (Collaborating to Heal Opioid Addiction and Mental Health in Primary Care) will investigate whether CoCM that addresses both mental health conditions and co-occurring OUD can improve patient lives.
The Department of Psychiatry & Behavioral Science’s Population Health Division and the AIMS Center will support up to 24 primary care clinics in implementing either CoCM for OUD and mental health conditions, or for mental health conditions only. Training for the intervention began in late summer 2020.
Find out more about this clinical trial by visiting the CHAMP website.
Lori Ferro Phone: (206) 685-7538
Watch presenter Anna Ratzliff, MD, PhD give an introduction to the project and answer questions from attendees.
Introduction to CHAMP
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.