Collaborative Care Model For Depression Research Articles

Bring It Up: An Adapted Collaborative Care Model for Depression in a Safety‐Net Primary Care Clinic

Bring It Up: An Adapted Collaborative Care Model for Depression in a Safety‐Net Primary Care Clinic

The Impact of a Collaborative Care Model on Health Trajectories among Patients with Co-Morbid Depression and Diabetes: The INDEPENDENT Study.

Collaborative care models for depression have been successful in a variety of settings, but their success may differ by patient engagement. We conducted a post-hoc analysis of the INDEPENDENT trial to investigate the role of differential engagement of participants on health outcomes over 3 years. INDEPENDENT study was a parallel, single-blinded, randomised clinical trial conducted at four socio-economically diverse clinics in India. Participants were randomised to receive either active collaborative care or usual care for 12 months and followed up for 24 months. We grouped intervention participants by engagement, defined as moderate (≤7 visits) or high, (8 or more visits) and compared them with usual care participants. Improvements in composite measure (depressive symptoms and at least one of three cardio-metabolic) were the primary outcome. Mean levels of depression and cardio-metabolic measures were analysed over time using computer package IBM SPSS Statistics 25. The composite outcome was sustained the highest in the moderate engagers [27.5%, 95% confidence interval (CI): 19.5, 36.7] and the lowest in high engagers (15.8%, 95% CI: 8.1, 26.8). This pattern was observed for individual parameters - depressive symptoms and glycosylated haemoglobin. Progressive reductions in mean depressive symptom scores were observed for moderate engagers and usual care group from baseline to 36 months. However, in high engagers of collaborative care, mean depressive symptoms were higher at 36 months compared to 12 months. Sustained benefits of collaborative care were larger in participants with moderate engagement compared with high engagement, although a majority of participants relapsed on one or more outcome measures by 36 months. High engagers of collaborative care for co-morbid depression and diabetes may need light touch interventions for longer periods to maintain health and reduce depressive symptoms.

Collaborative care model for depression in rural Nepal: a mixed-methods implementation research study

IntroductionDespite carrying a disproportionately high burden of depression, patients in low-income countries lack access to effective care. The collaborative care model (CoCM) has robust evidence for clinical effectiveness in improving...

Variation In The Effectiveness Of Collaborative Care For Depression: Does It Matter Where You Get Your Care?

Randomized controlled trials have demonstrated that the collaborative care model for depression in primary care is more effective than usual care, but little is known about the effectiveness of this approach in real-world settings. We used patient-reported outcome data from 11,303 patients receiving collaborative care for depression in 135 primary care clinics to examine variations in depression outcomes. The average treatment response across this large sample of clinics was substantially lower than response rates reported in randomized controlled trials, and substantial outcome variation was observed. Patient factors such as initial depression severity, clinic factors such as the number of years of collaborative care practice, and the degree of implementation support received were associated with depression outcomes at follow-up. Our findings suggest that the level of implementation support could be an important influence on the effectiveness of collaborative care model programs.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

Public health and health care systems face many challenges as indicators of acuity and demand for child mental health services increase.1McMartin SE Kingsbury M Dykxhoorn J et al.Time trends in symptoms of mental illness in children and adolescents in Canada.CMAJ. 2014; 186: E672-E678Crossref PubMed Scopus (35) Google Scholar, 2Kalb LG Stapp EK Ballard ED et al.Trends in psychiatric emergency department visits among youth and young adults in the US.Pediatrics. 2019; 143e2018292Crossref Scopus (100) Google Scholar, 3Ruch DA Sheftall AH Schlagbaum P et al.Trends in suicide among youth aged 10 to 19 years in the United States, 1975 to 2016.JAMA Netw Open. 2019; 2e193886Crossref PubMed Scopus (132) Google Scholar These systems have not been designed to detect problems early and intervene with potentially preventive interventions.4Leslie LK. Mehus CJ. Hawkins JD et al.Primary health care: potential home for family-focused preventive interventions.Am J Prev Med. 2016; 17: S106-S108Abstract Full Text Full Text PDF Scopus (115) Google Scholar,5Cuijpers P Van Straten A Smit F Preventing the incidence of new cases of mental disorders: a meta-analytic review.J Nerv Ment Dis. 2005; 193: 119-125Crossref PubMed Scopus (132) Google Scholar In addition, the child mental health workforce lacks sufficient capacity as it is presently configured.6AACAP work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar Integration of mental health services into primary care has been promoted as one answer to these challenges7Unützer J Carlo AD Collins PY Leveraging collaborative care to improve access to mental health care on a global scale.World Psychiatry. 2020; 19: 36-37Crossref PubMed Scopus (22) Google Scholar and is endorsed by national and international organizations.8Foy JM Green CM Earls MF Mental health competencies for pediatric practice.Pediatrics. 2019; 144: e20192757https://doi.org/10.1542/peds.2019-2757Crossref PubMed Scopus (45) Google Scholar,9World Health Organization (WHO)Caring for Children and Adolescents With Mental Disorders: Setting WHO Directions. World Health Organization, Geneva2003Google Scholar Nearly all children have primary care visits,10Bloom B Cohen RA Freeman G Summary health statistics for U.S. children: national health interview survey, 2010. National Center for Health Statistics.Vital Health Stat. 2011; 10Google Scholar and the philosophy of pediatric primary care in the United States is oriented toward universal prevention, surveillance, and early intervention.11Jellinek M Patel BP Froehle MC Bright Futures in Practice: Mental Health – Volume I, Practice Guide. National Center for Education in Maternal and Child Health, Arlington, Va2002Google Scholar Primary care providers are seen as credible sources of psychosocial information and guidance,12Moseley KL Freed GL Goold SD Which sources of child health advice do parents follow?.Clin Pediatr (Phila). 2011; 50: 50-56Crossref PubMed Scopus (45) Google Scholar and many families express a preference for getting psychosocial care in a primary care rather than a mental health setting.13Herman PM Ingram M Rimas H et al.Patient preferences of a low-income Hispanic population for mental health services in primary care.Adm Policy Ment Health. 2016; 43: 740-749Crossref PubMed Scopus (8) Google Scholar Some of this preference comes from primary care being a more familiar and potentially less stigmatizing place to receive mental health care,14Pingitore D Snowden L Sansone RA et al.Persons with depressive symptoms and the treatments they receive: a comparison of primary care physicians and psychiatrists.Int J Psychiatry Med. 2001; 31: 41-60Crossref PubMed Scopus (55) Google Scholar a factor that may be especially salient to patients who already experience racial or ethnic stigma.15Interian A Lewis-Fernández R Dixon LB Improving treatment engagement of underserved U.S. racial-ethnic groups: a review of recent interventions.Psychiatr Serv. 2013; 64: 212-222Crossref PubMed Scopus (70) Google Scholar Incorporating mental health as part of “routine” medical care also sends a message that emotional well-being is an essential part of one's overall wellness.16McEwen B. The untapped power of allostasis promoted by healthy lifestyles.World Psychiatry. 2020; 19: 57-58Crossref PubMed Scopus (17) Google Scholar Prior to the beginning of this century, very few pediatricians worked in close coordination with mental health professionals. Despite evidence that child/youth integrated care can be effective and practical,17Asarnow JR Rozenman M Wiblin J et al.Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis.JAMA Pediatr. 2015; 169: 929-937Crossref PubMed Scopus (323) Google Scholar,18Platt RE Spencer AE Burkey MD et al.What's known about implementing co-located paediatric integrated care: a scoping review.Int Rev Psychiatry. 2018; 30: 242-271Crossref PubMed Scopus (21) Google Scholar still only about half of US pediatricians consider that they work in practices co-located with a behavioral health professional.19Richman EL Lombardi BM Zerden LDS Where Is Behavioral Health Integration Occurring? Mapping National Co-Location Trends Using National Provider Identifier Data. UMSPH, University of Michigan Behavioral Health Workforce Research Center. Ann Arbor, Mich2018Google Scholar Integration continues to face significant barriers, including lack of consensus on how primary care and co-located mental health professionals should share roles, the need for substantial transformation in how practices operate if they are to provide mental health care,20Sarvet B. The need for practice transformation in children's mental health care.JAACAP. 2017; 56: 460-461Google Scholar financing schemes that do not incentivize treatment in primary care or collaboration with mental health providers,21American Academy of Child and Adolescent Psychiatry Committee on Healthcare Access and Economics, American Academy of Pediatrics Task Force on Mental HealthImproving mental health services in primary care. Reducing administrative and financial barriers to access and collaboration.Pediatrics. 2009; 123: 1248-1251Crossref PubMed Scopus (174) Google Scholar and a lack of mental health practitioners trained to work in primary care settings (especially in linguistically and culturally diverse communities).22Hails K Brill CD Chang T et al.Cross-cultural aspects of depression management in primary care.Curr Psychiatry Rep. 2012; 14: 336-344Crossref PubMed Scopus (9) Google Scholar,23Burkey MD Kaye DL Frosch E Training in integrated mental health-primary care models: a national survey of child psychiatry program directors.Acad Psychiatry. 2014; 38: 485-488Crossref PubMed Scopus (15) Google Scholar To these structural barriers, however, additional dilemmas have emerged as the field of integrated care has evolved. First, there is the realization that conceptualizing integrated care as a binary partnership between mental health and primary care does not address the high level of co-occurrence of mental health, developmental, and psychosocial problems that limit the effectiveness of mental health treatments when they are applied in isolation.24Spencer AE Baul TD Sikov J et al.The relationship between social risks and the mental health of school-age children in primary care.Acad Pediatr. 2020; 20: 208-215Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar As the United States and much of the world enter into an era of unprecedented social and economic challenge related to the novel coronavirus, which has disproportionately impacted populations already experiencing limited access to mental health services, the need to expand the scope of integration will only become greater.25Yoshikawa H Aber JL Beardslee WR The effects of poverty on the mental, emotional, and behavioral health of children and youth: implications for prevention.Am Psychol. 2012; 67: 272-284Crossref PubMed Scopus (559) Google Scholar Second, there is the difficulty of translating the most widely known models of integrated care, developed in adult medicine, into pediatrics.26Katon W Unützer J Collaborative care models for depression: time to move from evidence to practice.Arch Intern Med. 2006; 166: 2304-2306Crossref PubMed Scopus (103) Google Scholar Compared to adult integrated care, child mental health integration must contend with presentations that vary significantly with age, which complicates screening and other forms of case-finding.27Costello EJ Mustillo S Erkanli A et al.Prevalence and development of psychiatric disorders in childhood and adolescence.Arch Gen Psychiatry. 2003; 60: 837-844Crossref PubMed Scopus (2759) Google Scholar Child mental health treatment relies more on brief, practical psychosocial interventions compared to easier-to-deliver medication titration.28Locher C Koechlin H Zion SR et al.Efficacy and safety of selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents: a systematic review and meta-analysis.JAMA Psychiatry. 2017; 74: 1011-1020Crossref PubMed Scopus (192) Google Scholar,29Marchette LK Weisz JR Practitioner review: empirical evolution of youth psychotherapy toward transdiagnostic approaches.J Child Psychol Psychiatry. 2017; 58: 970-984Crossref PubMed Scopus (69) Google Scholar In addition, while nearly everyone's mental health is related to that of the people they live with, children's mental health outcomes are particularly dependent on their parents’ own mental health,30Eckshtain D Marchette LK Schleider J et al.Parental depressive symptoms as a predictor of outcome in the treatment of child internalizing and externalizing problems.J Abnorm Child Psychol. 2019; 47: 459-474Crossref PubMed Scopus (16) Google Scholar and thus treatment often must include plans to address parents’ treatment needs and parent-child interactions.31Shonkoff JP Fisher PA Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy.Dev Psychopathol. 2013; 25: 1635-1653Crossref PubMed Scopus (186) Google Scholar The American Academy of Pediatrics has issued a policy statement outlining what it sees as pediatric providers’ responsibilities to address parental mental health,32Earls MF Yogman MW Mattson G et al.Committee on psychosocial aspects of child and family health. Incorporating recognition and management of perinatal depression into pediatric practice.Pediatrics. 2019; 143: e20183259https://doi.org/10.1542/peds.2018-3259Crossref PubMed Scopus (105) Google Scholar but there remains little precedent for directly addressing parent mental health in pediatric primary care, despite its profound effects on children.33Young CA Burnett H Ballinger A et al.Embedded maternal mental health care in a pediatric primary care clinic: a qualitative exploration of mothers' experiences.Acad Pediatr. 2019; 19: 934-941Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar To date, integrated care has benefited from attempts at federal, state, and professional society levels to promote its implementation. With some exceptions, however, such as the Centers for Medicare and Medicaid Services’ InCK initiative, and efforts by the American Board of Pediatrics and the American Academy of Pediatrics,8Foy JM Green CM Earls MF Mental health competencies for pediatric practice.Pediatrics. 2019; 144: e20192757https://doi.org/10.1542/peds.2019-2757Crossref PubMed Scopus (45) Google Scholar,34Centers for Medicare and Medicade Services. Integrated Care for Kids (InCK) Model. Available at: https://innovation.cms.gov/innovation-models/integrated-care-for-kids-model. Accessed October 12, 2019.Google Scholar,35McMillan JA Land Jr, M Tucker AE Preparing future pediatricians to meet the behavioral and mental health needs of children.Pediatrics. 2020; 145: e20183796https://doi.org/10.1542/peds.2018-3796Crossref PubMed Google Scholar there has been a greater emphasis on doing so with care for adults.36Agency for Healthcare Research and Quality. The Academy. Integrating Behavioral Health & Primary Care. Available at: http://integrationacademy.ahrq.gov/. Accessed October 12, 2019.Google Scholar Other policy analyses have addressed how health systems as a whole, including those with integrated care components, can promote child and family well-being in general.37Bethell C Kennedy S Martinez-Vidal E Payment for Progress: Investing to Catalyze Child and Family Well-Being Using Personalized and Integrated Strategies to Address Social and Emotional Determinants of Health. AcademyHealth, Washington, DC2018Google Scholar The following recommendations focus more narrowly on integrating mental health into pediatric primary care. The recommendations are intended as a guide to policymakers, health system leaders and educators, and research funders; they address 4 goals that, based on the analysis above, we believe are central to the growth and effectiveness of pediatric integrated care.1.Transform pediatric practice to address family psychosocial needs First and foremost, policies must promote changes in the scope of pediatric primary care so that it can comprehensively address families’ psychosocial needs.38Freeman BK Coker TR Six questions for well-child care redesign.Acad Pediatr. 2018; 18: 609-619Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Multigenerational social and emotional wellness needs to be accepted as an integral part of pediatric care and these aspects of health need to be effectively assessed and treated by pediatricians and/or in collaboration with community-based services that address social determinants of health.31Shonkoff JP Fisher PA Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy.Dev Psychopathol. 2013; 25: 1635-1653Crossref PubMed Scopus (186) Google Scholar,39Shah PE Muzik M Rosenblum KL Optimizing the early parent-child relationship: windows of opportunity for parents and pediatricians.Curr Probl Pediatr Adolesc Health Care. 2011; 41: 183-187Crossref PubMed Scopus (8) Google Scholar State and federal programs have the ability to influence these transformations through regulatory changes, financial incentives, and corresponding technical assistance. Individual providers and health care organizations need the clear guidance, motivation, and knowledge of how to go about modifying their practices and building the community alliances they will need to provide truly integrated care. Requiring health care systems to report mental health-related metrics will allow state and federal authorities to optimally leverage incentives. Specific initiatives could include:a.Federal and/or state incentives for implementing “Advanced Medical Home” or “High Performing Medical Home”40North Carolina Department of Health and Human Services. Care Management-Ambulatory Mental Health Concept Paper. Available at:https://files.nc.gov/ncdhhs/documents/CareMgmt-AMH_ConceptPaper_FINAL_20180309.pdf. Accessed March 6, 2020.Google Scholar,41American Academy of Pedatrics. (n.d.). AAP agenda for children: medical home. Available at:https://www.aap.org/en-us/about-the-aap/aap-facts/AAP-Agenda-for-Children-Strategic-Plan/Pages/AAP-Agenda-for-Children-Strategic-Plan-Medical-Home.aspx. Accessed March 6, 2020.Google Scholar models that are foundations for integrated care. States can support these models by giving practices additional payments if they meet criteria for certification (see financing recommendations below). Incentives could be tailored to reward the use of integrated care to address disparities in mental health services and outcomes, as well as to reward coordination of child/youth and adult mental health services.b.The federal government could expand past policy statements regarding the detection and treatment of parental mental health problems as part of pediatric primary care.42Centers for Medicare & Medicaid Services Informational BulletinMaternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. Department of Health and Human Services, CMMS, Baltimore2016Google Scholar Expansions could include that attention to parental mental health extends beyond concern for maternal depression in the perinatal period, as well as stating the appropriateness of including relevant parent mental health information in the child's medical record. These statements, coupled with increased training for pediatricians in the detection and initial assessment of parental health issues, could help to clearly include attention to parental mental health as within the scope of pediatric practice.c.The federal government (through Medicaid, Substance Abuse and Mental Health Services Administration, the Indian Health Service, and Health Resources and Services Administration) or individual states could fund programs that provide practices or health systems with the technical assistance needed to adopt pediatric integrated care, such as New York State's Collaborative Care Medicaid Program.43University of Washington AIMS Center. Collaborative Care Medicaid Program. Available at: https://aims.uw.edu/nyscc/programs/collaborative-care-medicaid-program-ccmp. Accessed March 6, 2020.Google Scholar,44Dayton L Agosti J Bernard-Pearl D et al.Integrating mental and physical health services using a socio-emotional trauma lens.Curr Probl Pediatr Adolesc Health Care. 2016; 46: 391-401Crossref PubMed Scopus (15) Google Scholar Additionally, the federal government could fund a national clearinghouse on pediatric integrated care efforts such inckmarks.org (which helps disseminate information related to the Center for Medicare and Medicaid Innovation InCK demonstration program),34Centers for Medicare and Medicade Services. Integrated Care for Kids (InCK) Model. Available at: https://innovation.cms.gov/innovation-models/integrated-care-for-kids-model. Accessed October 12, 2019.Google Scholar or expansion of the current Substance Abuse and Mental Health Services Administration-sponsored integrated care site45National Council for Behavioral Health. Center of Excellence for Integrated Healthcare Solutions. Available at: http://www.thenationalcouncil.org/integrated-health-coe/. Accessed March 6, 2020.Google Scholar to showcase exemplar efforts of individual practices/systems that have implemented integrated care (ideally representing all states since they have relatively unique population and policy environments, as well as models that work in communities with varying levels of mental health resources).d.Health Resources and Services Administration could expand and institutionalize its support so that all states could have so-called “child psychiatry access programs” that promote interprofessional collaboration and education supporting mental health service delivery in the pediatric primary care.46Sarvet BD Ravech M Straus JH Massachusetts child psychiatry access project 2.0: a case study in child psychiatry access program redesign.Child Adolesc Psychiatr Clin N Am. 2017; 26: 647-663Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,47Stein BD Kofner A Vogt WB et al.A national examination of child psychiatric telephone consultation programs' impact on children's mental health care utilization.J Am Acad Child Adolesc Psychiatry. 2019; 58: 1016-1019Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar These programs provide informal mental health consultation to primary care providers around specific patient's problems, and many currently have primary care provider training and practice transformation components which could be expanded to include helping integrated behavioral health providers (including those in schools) adopt and use evidence-based brief interventions or telepsychiatry when necessary. Coordinated with these “access programs,” states, health care organizations, and philanthropy could fund additional mental health skills training for primary care providers, taking advantage of the “access programs” ability to provide long-term, ongoing consultation and support for practice transformation.48Mazurek MO Parker RA Chan J et al.Effectiveness of the extension for community health outcomes model as applied to primary care for autism: a partial stepped-wedge randomized clinical trial.JAMA Pediatr. 2020; 174e196306Crossref PubMed Scopus (22) Google Scholare.The federal government, as with earlier programs that supported adoption of electronic medical records, could have similar programs promoting collection of patient-reported outcome measures and the ability to communicate in a “closed referral loop” with key community social program partners.49Massachusetts Food Is Medicine State PlanCenter for Health Law and Policy Innovation. Harvard Law School, Cambridge2019Google Scholar,50Huber BJ Austen JM Tobin RM et al.Overcoming barriers to rural children's mental health: an interconnected systems public health model.Adv Sch Ment Health Promot. 2016; 9: 219-241Crossref Scopus (4) Google Scholar These efforts would include 1) additional federal funding for public-domain systems such as PROMIS that could facilitate collection of family-level outcomes,51Mazefsky CA Yu L Pilkonis PA Psychometric properties of the emotion dysregulation inventory in a nationally representative sample of youth.J Clin Child Adolesc Psychol. 2020; 7: 1-13Crossref Scopus (23) Google Scholar,52Blackwell CK Wakschlag L Krogh-Jespersen S et al.Pragmatic health assessment in early childhood: the PROMIS® of developmentally based measurement for pediatric psychology.J Pediatr Psychol. 2020; 45: 311-318Crossref PubMed Scopus (2) Google Scholar and 2) funding local development of programs that facilitate communication between primary care teams and external service providers such as schools, food and housing programs, and programs that economic security.53Scheid D Yeaman B Nagykaldi Z et al.Regional Health eDecisions: A Guide to Connecting Health Information Exchange in Primary Care. AHRQ, AHRQ Publication No. 13-0018-EF. Rockville, Md2013Google Scholarf.The federal and state governments could create programs that increase their ability to hold payers accountable for the delivery of child/youth mental health care. For example, states could require that insurers and managed care organizations collect and publish statistics on out-of-network child behavioral health referrals, stratified by age, gender, ethnicity, and professional type (ie, psychiatric providers, therapists, neuropsychological testing). These statistics can be a proxy for the (in)adequacy of a network's mental health resources and the extent to which they are accessible by different populations. If states are authorizing the use of “collaborative care codes” (see below in financing), compiling statistics on the use of these codes could serve as a marker for the implementation of integrated care and potentially increased access and early intervention. Requiring additional codes that indicate the results of mental health screening in primary care can help document whether primary care is serving as an effective gateway for child/youth mental health services.54Hacker KA Penfold RB Arsenault LN et al.Behavioral health services following implementation of screening in Massachusetts Medicaid children.Pediatrics. 2014; 134: 737-746Crossref PubMed Scopus (18) Google Scholar2.Make pediatric integrated care financially feasible Second, policies must make pediatric integrated care financially feasible for individual practices and health systems, especially at a time when limitations on overall social and health care resources may reduce the cross-subsidization of mental health care by services that have a positive “margin.”55Bailit M Harguanani D Taylor E Challenge Guide: Payment Reform to Address Social Determinants of Health in Children. Bailit Health, Needham, Mass2018Google Scholar Pediatric integrated care does not produce the short-term cost-offsets potentially obtainable from adult integrated care, and psychological interventions for families with children are more time-consuming to deliver than prescribing medications for adults. Business models must take into account the investment in time it takes providers to build relationships with families (especially those who have experienced trauma or discrimination), directly support parents, collaborate with schools and other community organizations, and track a practice's population of children and youth with psychosocial needs. Financial feasibility varies from state to state and among practices with different payer mixes. Steps that could create more uniform opportunities across the country include:a.The federal government, professional organizations, academics, and advocates can help disseminate to state health financing authorities examples of which components of integrated care can currently be paid for using Medicaid and Children's Health Insurance Program funds directly or as part of negotiating managed care contracts.56Ross DC Guyer J Lam A et al.Fostering Social and Emotional Health Through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change. Center for the Study of Social Policy, Washington, DC2019Google Scholar,57Tyler ET Hulkower RL Kaminski JW Behavioral Health Integration in Pediatric Primary Care: Considerations and Opportunities for Policymakers, Planners, and Providers. Milbank Memorial Fund, New York2017Google Scholar For example, states could preferentially award managed care contracts to organizations that have strong integrated care programs, provide or pay for preventive parenting services, have demonstrated, at-scale working linkages to services addressing the social determinants of health, coordinate parental and child mental health care, or reimburse for telepsychiatry as a method for implementing integrated care.b.States can take several actions to reduce barriers to fee-for-service payment for integrated mental health services including:21American Academy of Child and Adolescent Psychiatry Committee on Healthcare Access and Economics, American Academy of Pediatrics Task Force on Mental HealthImproving mental health services in primary care. Reducing administrative and financial barriers to access and collaboration.Pediatrics. 2009; 123: 1248-1251Crossref PubMed Scopus (174) Google Scholar,55Bailit M Harguanani D Taylor E Challenge Guide: Payment Reform to Address Social Determinants of Health in Children. Bailit Health, Needham, Mass2018Google Scholar, 56Ross DC Guyer J Lam A et al.Fostering Social and Emotional Health Through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change. Center for the Study of Social Policy, Washington, DC2019Google Scholar, 57Tyler ET Hulkower RL Kaminski JW Behavioral Health Integration in Pediatric Primary Care: Considerations and Opportunities for Policymakers, Planners, and Providers. Milbank Memorial Fund, New York2017Google Scholar•Making it easier to empanel mental health providers who work in primary care settings,•Making it easier to license primary care sites as also providing mental health services,•Allowing primary care providers to refer to co-located or collaborating mental health providers without the need for authorization,•Allowing first-line mental health treatment by co-located or collaborating mental health providers of all disciplines as part of medical benefits (without additional co-pays),•Not requiring a formal mental health diagnosis for an initial series of mental health visits, and•Allowing billing for mental health care on the same day as a primary care service.c.States can expand the use of billing codes that support collaborative work so that both primary care and psychiatric providers can be paid for indirect consultation, case review, and coordination of referrals for both children and parents.58Washington State Health Care Authority. WAC 182-531-0425 Collaborative Care. Available at: https://www.hca.wa.gov/health-care-services-supports/collaborative-care. Accessed March 6, 2020.Google Scholar As part of paying for collaborative care, states can also allow billing for the services of community health workers or navigators who can link families to needed follow-up services and reinforce/deliver mental health treatments (see below in workforce).d.The federal government and private insurers could allow wider latitude for billing for parent-directed services that also have potential for impact on the child.42Centers for Medicare & Medicaid Services Informational BulletinMaternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. Department of Health and Human Services, CMMS, Baltimore2016Google Scholar3.Develop a larger and more diverse integrated care workforce Third, policies need to encourage development of the workforce so that integrated care can be delivered at scale.6AACAP work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar Not only is there a general lack of child mental health workforce in most areas of the country, there is an even greater lack of providers trained to work at the interface of medicine, mental health, and community supports.6AACAP work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar,23Burkey MD Kaye DL Frosch E

Enhancing the scalability of the collaborative care model for depression using mobile technology.

The collaborative care model (CoCM) has substantial support for improving behavioral health care in primary care. However, large-scale CoCM adoption relies on addressing operational and financial implementation challenges across health care settings with varying resources. An academic medical center serving socioeconomically and racially diverse patients implemented the CoCM in seven practices. A smartphone application was introduced to facilitate CoCM care management during depression treatment (app-augmented CoCM). App features included secure texting, goal/appointment reminders, symptom monitoring, and health education material. A nonrandomized convenience patient sample (N = 807) was enrolled in app-augmented CoCM and compared with patients in standard CoCM (N = 3,975). Data were collected on clinical contact frequency, engagement, and clinical outcomes. App-augmented CoCM patients received more health care team contacts (7.9 vs. 4.9, p < .001) and shorter time to follow up compared with the standard CoCM sample (mean = 11 vs. 19 days, p < .001). App-augmented CoCM patients had clinical outcomes similar to the standard CoCM group (47% vs. 46% with ≥50% depression improvement or score <10), despite app-augmented patients having more prior depression treatment episodes. Further, the app-augmented group with greater app engagement demonstrated increased behavioral health appointment compliance, including more completed appointments and fewer no shows, and greater depression symptom improvement than those with less app engagement. App-augmented CoCM may improve patient engagement in treatment and provide opportunities to implement key CoCM elements without overburdening practice resources. CoCM sustainability and scalability in primary care may be enhanced by using this technology.

The collaborative care model for HIV and depression: Patient perspectives and experiences from a safety-net clinic in the United States.

Objectives:Collaborative care models may improve outcomes for both HIV and depression. The model includes routine screening and re-assessment of depressive symptoms as well as care coordination services delivered by an ancillary provider focused on mental health. We sought to explore patient experiences and attitudes about the services received through the collaborative care model, including measurement-based care using the Patient Health Questionnaire-9.Methods:We conducted 17 qualitative interviews with patients in a collaborative care model implemented at an HIV primary care clinic in a safety-net hospital in the United States. Interviews were analyzed using Framework Analysis.Results:Our findings illustrate the ways in which the collaborative care model for depression may be meaningful to patients in HIV care settings. Participants appreciated the support offered through the collaborative care model. Most participants perceived measurement-based care as useful to their providers, and an additional subset used the Patient Health Questionnaire-9 for their own self-management and awareness of depression. Over time, the collaborative care model appeared to motivate some patients to address depressive symptoms.Conclusion:The collaborative care model may be particularly helpful to patients in the way that it reinforces how depressive symptoms can be measured and managed. Furthermore, routine screening and re-measurement for depressive symptoms using the Patient Health Questionnaire-9 hold promise as an additional self-management tool to complement other clinical and supportive services.

Text messaging to support a perinatal collaborative care model for depression: A multi-methods inquiry.

Mental health care integrated into obstetric settings improves access to perinatal depression treatments. Digital interactions such as text messaging between patient and provider can further improve access. We describe the use of text messaging within a perinatal Collaborative Care (CC) program, and explore the association of text messaging content with perinatal depression outcomes. We analyzed data from an open treatment trial of perinatal CC in a rural obstetric clinic. Twenty five women with Patient Health Questionnaire-9 score of ≥10 enrolled in CC, and used text messaging to communicate with their Care Manager(CM). We used surveys and focus groups to assessacceptability of text messaging with surveys and focus groups. We calculated the number of text messages exchanged, and analyzed content to understand usage patterns. We explored association between text messaging content and depression outcomes. CMs initiated 85.4% messages, and patients responded to 86.9% messages. CMs used text messaging for appointment reminders, and patients used it to obtain obstetric and parenting information. CMs had concerns about the likelihood of boundary violations. Patients appreciated the asynchronous nature of text messaging. Text messaging is feasible and acceptable within a perinatal CC program. We need further research into the effectiveness of text messaging content, and response protocols.

Collaborative Care for Depression among Patients with Limited English Proficiency: a Systematic Review.

Patients with limited English proficiency (LEP) have high rates of depression, yet face challenges accessing effective care in outpatient settings. We undertook a systematic review to investigate the effectiveness of the collaborative care model for depression for LEP patients in primary care. We queried online PubMed, PsycINFO, CINAHL and EMBASE databases (January 1, 2000, to June 10, 2017) for quantitative studies comparing collaborative care to usual care to treat depression in adults with LEP in primary care. We evaluated the impact of collaborative care on depressive symptoms or on depression treatment. Two reviewers independently extracted key data from the studies and assessed risk of bias using the Cochrane bias and quality assessment tool (RCTs) and the Newcastle-Ottawa Quality Assessment Scale (non-RCTs). Of 86 titles identified, 15 were included (representing 9 studies: 5 RCTs, 3 cohort studies, and 1 case-control study). Studies included 4859 participants; 2679 (55%) reported LEP. The majority spoke Spanish (93%). The wide variability in study design and outcome definitions precluded performing a meta-analysis. Follow-up ranged from 3months to 2years. Three of four high-quality RCTs reported that 13-25% more patients had improved depressive symptoms when treated with culturally tailored collaborative care compared to usual care; the last had high treatment in the control arm and found equal improvement. Two non-RCT studies suggest that Spanish-speaking patients may benefit as much as, if not more than, English-speaking patients treated with collaborative care. The remaining studies reported increased receipt of preferred depression treatment (therapy vs. antidepressants) in the intervention groups. Eight of nine studies used bilingual providers to deliver the intervention. While limited by the number and variability of studies, the available research suggests that collaborative care for depression delivered by bilingual providers may be more effective than usual care among patients with LEP. Implementation studies of collaborative care, particularly among Asian and non-Spanish-speakers, are needed.

A Randomized Trial of Off‐Site Collaborative Care for Depression in Chronic Hepatitis C Virus

To test the effectiveness of a collaborative depression care model in improving depression and hepatitis C virus (HCV) care. Hepatitis C virus clinic patients who screened positive for depression at four Veterans Affairs Hospitals. We compared off-site depression collaborative care (delivered by depression care manager, pharmacist, and psychiatrist) with usual care in a randomized trial. Primary depression outcomes were treatment response (≥50 percent decrease in 20-item Hopkins Symptoms Checklist [SCL-20] score), remission (mean SCL-20 score, <0.5), and depression-free days (DFDs). Primary HCV outcome was receipt of HCV treatment. Patient data were collected by self-report telephone surveys at baseline and 12months, and from electronic medical records. Baseline screening identified 292 HCV-infected patients with depression, and 242 patients completed 12-month follow-up (82.9 percent). Intervention participants were more likely to report depression treatment response, remission, and more DFDs than usual care participants. Intervention participants were more likely to receive antiviral treatment; however, the difference was not statistically significant. Off-site depression collaborative care improved depression outcomes in HCV patients and may serve as a model for collaboration between mental health and specialty physical health providers in other high co-occurring conditions.

Collaborative Care for Depression in Chronic Hepatitis C Clinics.

Depression is highly prevalent yet underdiagnosed and undertreated among patients with chronic hepatitis C virus (HCV) infection. Collaborative care models have improved depression outcomes in primary care settings, and this study aimed to provide more information on testing such methods in specialty HCV care. Hepatitis C Translating Initiatives for Depression Into Effective Solutions (HEPTIDES) was a randomized controlled trial that tested a collaborative depression care model in HCV clinics at four Veterans Affairs facilities. The HEPTIDES intervention consisted of an offsite depression care team (depression care manager, pharmacist, and psychiatrist) that delivered collaborative care. Participant interview data were collected at baseline and at six months. The outcome was depression severity measured with the Hopkins Symptom Checklist (SCL-20) and reported as treatment response (≥50% decrease in SCL-20 item score), remission (mean SCL-20 item score <.5), and depression-free days (DFDs). Baseline screening identified 263 HCV-infected patients with depression. In unadjusted analyses, intervention participants' reports trended toward more treatment response (19% versus 13%) and remission (12% versus 6%), but total number of DFDs (50.9) was similar to that of usual care participants (50.7). These trends did not reach statistical significance for the overall sample in the adjusted analyses: response (odds ratio [OR]=2.02, 95% confidence interval [CI]=.98-4.20), remission (OR=2.63, CI=1.00-6.94), and DFDs (β=7.6 days, CI=-.99 to 16.2). However, the intervention was effective in improving all three outcomes for patients who did not meet criteria for remission at baseline (SCL-20 score >.5, N=245). Depression collaborative care resulted in modest improvements in HCV patient depression outcomes. Future research should investigate intervention modifications to improve outcomes in specialty HCV clinics.

Comparative Studies of Collaborative Team Depression Care Adoption in Safety Net Clinics

Purpose: To evaluate three approaches adopting collaborative depression care model in Los Angeles County safety net clinics with predominantly Latino type 2 diabetes patients. Methods: Pre–post differences in treatment rates and symptom reductions were compared between baseline, 6-month, and 12-month follow-ups for each approach: (a) Multifaceted Depression and Diabetes Program (MDDP) grant–hired social workers dedicated for depression care, (b) Diabetes–Depression Care-Management Adoption Trial (DCAT) supported care (SC) by clinic social workers in diabetes disease management teams, and (c) DCAT-automated care-management technology-facilitated care (TC) model. All social workers were guided by a depression care protocol. Results: All approaches significantly increased treatment rate, the largest improvement being MDDP (40%), followed by TC (30%) and then SC (20%). Similar patterns were found in symptom improvement (≥50% depression score reductions) and self-rated health. TC was the only approach to significantly improve patient diabetes self-care. Discussion: Activated social workers and technology facilitation provide promising effective adoption of collaborative depression team care in safety net.

A stepped-wedge evaluation of an initiative to spread the collaborative care model for depression in primary care1)

Het kost vaak veel inspanning om het gat tussen wetenschap en praktijk te dichten, maar zelden wordt het zo grootschalig aangepakt als in de staat Minnesota in de Verenigde Staten. Daar werd geconstateerd dat er voor de behandeling van depressie in de eerstelijns zorg zo’n enorm gat bestond. In 79 gerandomiseerde studies was aangetoond dat het ‘collaborative care model’ kosteneffectief was, maar zelfs in praktijken die in dergelijke studies hadden geparticipeerd werd deze benadering niet gecontinueerd. De essentie van het collaborative care model is de samenwerking tussen huisarts, een zorgcoordinator, vaak een verpleegkundige, en een consulterend psychiater. Een van de belangrijkste obstakels in de Verenigde Staten was dat verschillende componenten van het model niet werden vergoed. In het DIAMOND- project (Depression Improvement across Minnesota-Offering a New Direction) is getracht door een nieuw financieringssysteem, training en andere praktijkondersteuning de implementatie van het collaborative care model te bevorderen.

A Stepped-Wedge Evaluation of an Initiative to Spread the Collaborative Care Model for Depression in Primary Care

Scale-up and spread of evidence-based practices is one of the most important challenges facing health care. We tested whether a statewide initiative, Depression Improvement Across Minnesota-Offering a New Direction (DIAMOND), to implement the collaborative care model for depression in 75 primary care clinics resulted in patient outcome improvements corresponding to those reported in randomized controlled trials. Health plans provided a new monthly payment to participating clinics after a 6-month intensive training program with ongoing data submission, networking, and consultation. Implementation was staggered, with 5 sequences of 10 to 40 clinics every 6 months. Payers provided weekly contact information for members from participating clinics who were filling antidepressant prescriptions, and we conducted baseline and 6-month surveys of 1,578 patients about their care and outcomes. There were 466 patients in DIAMOND clinics who received usual care before implementation (UCB), 559 who received usual care in DIAMOND clinics after implementation (UCA), 245 who received DIAMOND care after implementation (DCA), and 308 who received usual care in comparison clinics (UC). Patients who received DIAMOND care after implementation reported more collaborative care depression services than the 3 comparison groups (10.9 vs 6.4-6.7, on a scale of 0 of 14, where higher numbers indicate more services; P <.001) and more satisfaction with their care (4.0 vs 3.4 on a scale 1 to 5, in which higher scores indicate higher satisfaction; P ≤.001). Depression remission rates, however, were not significantly different among the 4 groups (36.4% DCA vs 35.8% UCB, 35.0% UCA, 33.9% UC; P = .94). Despite the incentive of a supporting payment change and intensive training and support for clinics volunteering to participate, no difference in depression outcomes was documented. Specific unmeasured actions present in trials but not present in these clinics may be critical for successful outcome improvement.

Baseline screening tools as indicators for symptom outcomes and health services utilization in a collaborative care model for depression in primary care: a practice-based observational study

ObjectiveWithin a practice-based collaborative care program for depression, we examined associations between positive baseline screens for comorbid mental and behavioral health problems, depression remission and utilization after 1 year. MethodsThis observational study of 1507 depressed adults examined baseline screens for hazardous drinking (Alcohol Use Disorders Identification Test score≥8), severe anxiety (Generalized Anxiety Disorder 7-item score ≥15) and bipolar disorder [Mood Disorders Questionnaire (MDQ) positive screen]; 6-month depression remission; primary care, psychiatric, emergency department (ED) and inpatient visits 1 year postbaseline; and multiple covariates. Analyses included logistic and zero-inflated negative binomial regression. ResultsAt unadjusted baseline, 60.7% had no positive screens beyond depression, 31.5% had one (mostly severe anxiety), 6.6% had two and 1.2% had all three. In multivariate models, positive screens reduced odds of remission versus no positive screens [e.g., one screen odds ratio (OR)=0.608, p=.000; all three OR=0.152, p=.018]. Screening positive for severe anxiety predicted more postbaseline visits of all types; severe anxiety plus hazardous drinking predicted greater primary care, ED and inpatient; severe anxiety plus MDQ and the combination of all three positive screens both predicted greater psychiatric visits (all p<.05). Regression-adjusted utilization patterns varied across combinations of positive screens. ConclusionsPositive screens predicted lower remission. Severe anxiety and its combinations with other positive screens were common and generally predicted greater utilization. Practices may benefit from assessing collaborative care patients presenting with these screening patterns to determine resource allocation.

Depression Care Management for Chinese Americans in Primary Care: A Feasibility Pilot Study

This study describes a culturally relevant intervention using a collaborative depression care model to integrate mental health and primary care services for depressed low income Chinese-Americans at a community health center. A total of 6,065 patients were screened for depression. Of the 341 who screened positive, 57 participated and were randomly assigned to receive either enhanced physician care with care management (32) or enhanced physician care only (25). All enrolled participants were assessed at baseline and 4 monthly follow-up visits for depression, physical and mental health functioning, and perceived stigma toward receiving depression care, to determine the impact, if any, of their mental health treatment. Both groups reported significant reduction of depressive symptoms and improved mental health functioning from baseline to follow-up assessments although there was no significant difference between the two groups. Although the study found no advantage to adding the care management component in the treatment of depression, screening and assertive treatment of immigrant Chinese Americans who tend to underutilize mental health services is important and consistent with the increased adoption of team based care models in patient centered medical homes. High refusal rates for enrollment in the study have implications for future study designs for this group.

A Pilot for Improving Depression Care on College Campuses: Results of the College Breakthrough Series–Depression (CBS-D) Project

Objective: To implement a pilot quality improvement project for depression identification and treatment in college health. Participants: Eight college health center teams composed primarily of primary care and counseling service directors and clinicians. Methods: Chronic (Collaborative) Care Model (CCM) used with standardized screening to identify, treat, and track depressed students for 12 weeks to monitor predetermined process and clinical outcomes. Results: Of all students receiving primary medical care services between January 2007 and May 2008, 69% (n = 71,908) were screened for depression. A total of 801 depressed students were treated and tracked; most predetermined treatment process and clinical outcome targets were achieved. Conclusion: The CCM for depression shows promise for improving depression identification and care for college students.

Development and implementation of collaborative care for depression in HIV clinics

We sought to develop and implement collaborative depression care in human immunodeficiency virus (HIV) clinics in a project called HIV Translating Initiatives for Depression into Effective Solutions (HITIDES). Here we describe: (i) the formative evaluation (FE) conducted prior to implementation; (ii) the process used to adapt the primary care collaborative care model for depression to specialty HIV clinics; and (iii) the intervention itself. The overall design of HITIDES was a multi-site randomized trial in United States Department of Veterans Affairs (VA) HIV clinics comparing the depression collaborative care intervention to usual depression care. Qualitative methods were used for the FEs and informed the evidence-based quality improvement (EBQI) methods that were used for adapting and implementing the intervention. Baseline assessments were completed by 249 depressed HIV participants. Summaries of respective key informant interviews with eight HIV patients who were receiving depression treatment and 25 HIV or mental health (MH) providers were presented to each site. EBQI methods were used to tailor the HITIDES intervention to each site while maintaining true to the evidence base for depression collaborative care. EBQI methods provided a useful framework for intervention adaptation and implementation. The HITIDES study provides the opportunity to evaluate collaborative depression care in a specialty physical health clinic setting with a population that has a high prevalence of depression and MH comorbidity.

FC10-03 - Translation of an evidence-based collaborative care model for depression into 80 primary care practices. Outcomes and lessons learned

IntroductionThe DIAMOND (Depression Improvement Across Minnesota--Offering a New Direction) project is a clinical intervention that was developed and implemented by the Institute for Clinical Systems Improvement (ICSI) in Minnesota beginning in 2008. The ambitious goals of the project were to implement an evidence based model of depression into a variety of settings while changing the reimbursement system for these clinics in order to sustain this model over time. Two years later, the model is in 80 different primary care clinics and data is reported to the state.Objectives/aimsA review of the major outcomes from this translation of evidence into practice. Preliminary research on critical factors leading to best outcomes will be offered.MethodsPatients with a diagnosis of Major Depression or Dysthymia and a PHQ-9 score of 10 or greater are eligible for this model of care. Outcome measures include remission rates at six and twelve months. Process measures include the use of the primary tool (PHQ-9), the percentage of eligible patients activated into care management, and drop out or opt out rates. Site visits to all clinics were carried out after implementation by ICSI with preliminary results on best practices.ResultsResults are comparable to those found in randomized controlled trials. As of March 2010, 6-month response averaged 36% (range 8–60%) and 6-month remission averaged 27% (range 7–51%). All intent to treat.ConclusionsThe DIAMOND model was successfully disseminated into diverse settings with excellent results. Factors predicting best clinic outcomes will be reviewed.

Sustainability of collaborative care interventions in primary care settings

• Summary: We assessed patient and provider barriers and facilitators to sustainability of a collaborative depression care model for depression treatment in predominantly Hispanic diabetes patients in safety net care clinics. • Findings: Semi-structured interviews and focus groups were conducted with patients and providers at two community clinics participating in a randomized controlled effectiveness trial of the Multi-faceted Depression and Diabetes Program (MDDP), a socioculturally adapted collaborative care model. Analysis identified eight themes grouped into three categories: barriers, facilitators, and recommendations for program sustainability. Barriers included patient concerns about use of medication and provider concerns about use of psychotherapy, increased workload for clinic staff, delay in receiving outcomes data, and lack of resources to sustain the program. Facilitators included patient benefits such as improved clinical outcomes, quality of care received, access, and satisfaction; provider benefits such as increased awareness and reduced anxiety; and clinic benefits in the form of reduced costs of care. Recommendations included changes in communication patterns among providers, specific changes in procedures, changes in resources, and changes in clinic organizational culture. • Applications: Sustainable adoption of collaborative depression care for underserved populations in safety net care systems by organizational decision-makers and providers requires: stable funding and qualified staff; technologies to facilitate provider access to easily applied treatment guidelines, information exchange between primary care physicians and depression care providers, and routine monitoring of patient depression symptoms and treatment adherence and satisfaction; and treatment consistent with patient preferences.