Collaborative Chronic Care Model Research Articles

Sustaining the collaborative chronic care model in outpatient mental health: a matrixed multiple case study.

Sustaining evidence-based practices (EBPs) is crucial to ensuring care quality and addressing health disparities. Approaches to identifying factors related to sustainability are critically needed. One such approach is Matrixed Multiple Case Study (MMCS), which identifies factors and their combinations that influence implementation. We applied MMCS to identify factors related to the sustainability of the evidence-based Collaborative Chronic Care Model (CCM) at nine Department of Veterans Affairs (VA) outpatient mental health clinics, 3-4years after implementation support had concluded. We conducted a directed content analysis of 30 provider interviews, using 6 CCM elements and 4 Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) domains as codes. Based on CCM code summaries, we designated each site as high/medium/low sustainability. We used i-PARIHS code summaries to identify relevant factors for each site, the extent of their presence, and the type of influence they had on sustainability (enabling/neutral/hindering/unclear). We organized these data into a sortable matrix and assessed sustainability-related cross-site trends. CCM sustainability status was distributed among the sites, with three sites each being high, medium, and low. Twenty-five factors were identified from the i-PARIHS code summaries, of which 3 exhibited strong trends by sustainability status (relevant i-PARIHS domain in square brackets): "Collaborativeness/Teamwork [Recipients]," "Staff/Leadership turnover [Recipients]," and "Having a consistent/strong internal facilitator [Facilitation]" during and after active implementation. At most high-sustainability sites only, (i) "Having a knowledgeable/helpful external facilitator [Facilitation]" was variably present and enabled sustainability when present, while (ii) "Clarity about what CCM comprises [Innovation]," "Interdisciplinary coordination [Recipients]," and "Adequate clinic space for CCM team members [Context]" were somewhat or less present with mixed influences on sustainability. MMCS revealed that CCM sustainability in VA outpatient mental health clinics may be related most strongly to provider collaboration, knowledge retention during staff/leadership transitions, and availability of skilled internal facilitators. These findings have informed a subsequent CCM implementation trial that prospectively examines whether enhancing the above-mentioned factors within implementation facilitation improves sustainability. MMCS is a systematic approach to multi-site examination that can be used to investigate sustainability-related factors applicable to other EBPs and across multiple contexts.

Adaptation for sustainability in an implementation trial of team-based collaborative care.

Sustaining healthcare interventions once they have been implemented is a pivotal public health endeavor. Achieving sustainability requires context-sensitive adaptations to evidence-based practices (EBPs) or the implementation strategies used to ensure their adoption. For replicability of adaptations beyond the specific setting in question, the underlying logic needs to be clearly described, and adaptations themselves need to be plainly documented. The goal of this project was to describe the process by which implementation facilitation was adapted to improve the uptake of clinical care practices that are consistent with the collaborative chronic care model (CCM). Quantitative and qualitative data from a prior implementation trial found that CCM-consistent care practices were not fully sustained within outpatient general mental health teams that had received 1 year of implementation facilitation to support uptake. We undertook a multistep consensus process to identify adaptations to implementation facilitation based on these results, with the goal of enhancing the sustainability of CCM-based care in a subsequent trial. The logic for these adaptations, and the resulting adaptations themselves, were documented using two adaptation-oriented implementation frameworks (the iterative decision-making for evaluation of adaptations [IDEA] and the framework for reporting adaptations and modifications to evidence-based implementation strategies [FRAME-IS], respectively). Three adaptations emerged from this process and were documented using the FRAME-IS: (a) increasing the scope of implementation facilitation within the medical center, (b) having the internal facilitator take a greater role in the implementation process, and (c) shortening the implementation timeframe from 12 to 8 months, while increasing the intensity of facilitation support during that time. EBP sustainability may require careful adaptation of EBPs or the implementation strategies used to get them into routine practice. Recently developed frameworks such as the IDEA and FRAME-IS may be used to guide decision-making and document resulting adaptations themselves. An ongoing funded study is investigating the utility of the resulting adaptations for improving healthcare.

One-Year All-Cause Mortality and Delivery of the Collaborative Chronic Care Model in General Mental Health Clinics.

This study aimed to determine whether the evidence-based collaborative chronic care model (CCM) is associated with reduced all-cause mortality among adult patients treated in general mental health clinics. Data came from a stepped-wedge, cluster-randomized CCM implementation trial across nine U.S. Department of Veterans Affairs medical centers. Survival analysis was used to estimate the relative effect of the treatment (N=5,570) compared with a control group (N=46,443) over 1 year. After adjustment for site-level and individual-level acute care utilization factors, analyses indicated that patients treated with the CCM experienced a reduction in all-cause mortality relative to patients in the control cohort (hazard ratio=0.76, 95% CI=0.60-0.95). This study is the first in which CCM has been shown to reduce all-cause mortality for patients treated in general mental health clinics. Care delivery models should be considered part of efforts to reduce the life expectancy gap between individuals with psychiatric conditions and those without such conditions.

Interdisciplinary behavioral health provider perceptions of implementing the Collaborative Chronic Care Model: an i-PARIHS-guided qualitative study

BackgroundThe evidence-based Collaborative Chronic Care Model (CCM), developed to help structure care for chronic health conditions, comprises six elements: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. As the CCM is increasingly implemented in real-world settings, there is heightened interest in understanding specific influences upon implementation. Therefore, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we (i) identified innovation-, recipient-, context-, and facilitation-related influences on CCM implementation and (ii) assessed the influences’ relationship to each CCM element’s implementation.MethodsUsing semi-structured interviews, we examined interdisciplinary behavioral health providers’ experiences at nine VA medical centers that implemented the CCM. We used i-PARIHS constructs as a priori codes for directed content analysis, then analyzed the data for cross-coding by CCM element and i-PARIHS construct.ResultsParticipants (31 providers) perceived the CCM innovation as enabling comprehensive care but challenging to coordinate with existing structures/procedures. As recipients, participants recounted not always having the authority to design CCM-consistent care processes. They perceived local leadership support to be indispensable to implementation success and difficult to garner when CCM implementation distracted from other organizational priorities. They found implementation facilitation helpful for keeping implementation on track. We identified key themes at the intersection of i-PARIHS constructs and core CCM elements, including (i) the CCM being an innovation that offers a formal structure to stepping down care intensity for patients to encourage their self-management, (ii) recipients accessing their multidisciplinary colleagues’ expertise for provider decision support, (iii) relationships with external services in the community (e.g., homelessness programs) being a helpful context for providing comprehensive care, and (iv) facilitators helping to redesign specific interdisciplinary team member roles.ConclusionsFuture CCM implementation would benefit from (i) facilitating strategic development of supportive maintenance plans for patients’ self-management, (ii) collocating multidisciplinary staff (on-site or virtually) to enhance provider decision support, (iii) keeping information on available community resources up to date, and (iv) making clearer the explicit CCM-consistent care processes that work roles can be designed around. This work can inform concrete tailoring of implementation efforts to focus on the more challenging CCM elements, which is crucial to better account for multiple influences that vary across diverse care settings in which the CCM is being implemented.

Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis.

Our goal was to investigate the sustainability of care practices that are consistent with the collaborative chronic care model (CCM) in nine outpatient mental health teams located within US Department of Veterans Affairs (VA) medical centers, three to four years after the completion of CCM implementation. We conducted qualitative interviews (N = 30) with outpatient mental health staff from each of the nine teams. We based our directed content analysis on the six elements of the CCM. We found variable sustainability of CCM-based care processes across sites. Some care processes, such as delivery of evidence-based psychotherapies (EBPs) and use of measurement-based care (MBC) to guide clinic decision-making, were robustly maintained or even expanded within participating teams. In contrast, other care processes-which had in some cases been developed with considerable effort-had not been sustained. For example, care manager roles were diminished in scope or eliminated completely in response to workload pressures, frontline care needs, or the COVID-19 pandemic. Similarly, processes for engaging Veterans more fully in decision-making had generally been scaled back. Leadership support in the form of adequate team staffing and time to conduct team meetings were seen as crucial for sustaining CCM-consistent care. Given the potential impact of leadership turnover on sustainability in mental health, future efforts to implement CCM-based mental health care should strive to involve multiple leaders in implementation and sustainment efforts, lest one key departure undo years of implementation work. Our results also suggest that implementing CCM processes may best be conceptualized as a partnership across multiple levels of medical center leadership.

Does balancing site characteristics result in balanced population characteristics in a cluster-randomized controlled trial?

BackgroundIntervention trials with nested designs seek to balance sites randomized regarding key site characteristics. Among the goals of such site-level balancing is to accrue patient-level equivalence among treatment arms. We investigated patient-level equivalence in a cluster randomized controlled trial, which balanced study waves on site-level characteristics.MethodsThe Behavioral Health Interdisciplinary Program—Collaborative Chronic Care Model project utilized a stepped wedge design to stagger implementation of an evidence-based team-oriented mental health patient management system at 9 Veteran Affairs Medical Centers. Study sites were balanced on eight site-level characteristics over time (3 balanced waves [consecutive time periods] with 3 sites per wave) to minimize trend. Sites were balanced on selected site-level characteristics but not on patient-level variables. We explored internal differences in patient demographics across the three study waves. Eligible patients had at least two visits to a participating mental health clinic in the prior year and did not have a diagnosis of dementia (n = 5,596).ResultsWe found modest but statistically significant inter-site differences in age, marital status, ethnicity, service-related disability, mental health hospitalizations, and selected diagnoses by study wave. Although many of the differences in patient demographics by study wave were statistically significant, only a few results were practically meaningful as measured by effect size. A bipolar diagnosis (49.0%, 21.0%, 17.0% in waves 1–3, respectively; Cramer’s V = 0.3124) and Hispanic ethnicity (2.9%, 29.6%, 2.0% in waves 1–3, respectively; Cramer’s V = 0.3949) resulted in differences that were considered a ‘moderate’ effect size. The number of patient characteristics that were both statistically and meaningfully different by study wave among all possible site assignments was comparable to the 34 most balanced site assignments identified in our balancing algorithm.ConclusionsUsing a balancing algorithm to reduce imbalance among site characteristics across time periods did not appear to negatively affect the balance of patient characteristics across sites over time. A site-level balancing algorithm that includes characteristics with a direct relationship to relevant patient-level factors may improve the overall balance across key elements of the study, and aide in the interpretation of results.

Time-motion analysis of external facilitation for implementing the Collaborative Chronic Care Model in general mental health clinics: Use of an interval-based data collection approach.

Background: Facilitation is an effective strategy to implement evidence-based practices, often involving external facilitators (EFs) bringing content expertise to implementation sites. Estimating time spent on multifaceted EF activities is complex. Furthermore, collecting continuous time-motion data for facilitation tasks is challenging. However, organizations need this information to allocate implementation resources to sites. Thus, our objectives were to conduct a time-motion analysis of external facilitation, and compare continuous versus noncontinuous approaches to collecting time-motion data. Methods: We analyzed EF time-motion data from six VA mental health clinics implementing the evidence-based Collaborative Chronic Care Model (CCM). We documented EF activities during pre-implementation (4-6 weeks) and implementation (12 months) phases. We collected continuous data during the pre-implementation phase, followed by data collection over a 2-week period (henceforth, "a two-week interval") at each of three time points (beginning/middle/end) during the implementation phase. As a validity check, we assessed how closely interval data represented continuous data collected throughout implementation for two of the sites. Results: EFs spent 21.8 ± 4.5 h/site during pre-implementation off-site, then 27.5 ± 4.6 h/site site-visiting to initiate implementation. Based on the 2-week interval data, EFs spent 2.5 ± 0.8, 1.4 ± 0.6, and 1.2 ± 0.6 h/week toward the implementation's beginning, middle, and end, respectively. Prevalent activities were preparation/planning, process monitoring, program adaptation, problem identification, and problem-solving. Across all activities, 73.6% of EF time involved email, phone, or video communication. For the two continuous data sites, computed weekly time averages toward the implementation's beginning, middle, and end differed from the interval data's averages by 1.0, 0.1, and 0.2 h, respectively. Activities inconsistently captured in the interval data included irregular assessment, stakeholder engagement, and network development. Conclusions: Time-motion analysis of CCM implementation showed initial higher-intensity EF involvement that tapered. The 2-week interval data collection approach, if accounting for its potential underestimation of irregular activities, may be promising/efficient for implementation studies collecting time-motion data.

Time course and heterogeneity of treatment effect of the collaborative chronic care model on psychiatric hospitalization rates: A survival analysis using routinely collected electronic medical records.

Health systems are undergoing widespread adoption of the collaborative chronic care model (CCM). Care structured around the CCM may reduce costly psychiatric hospitalizations. Little is known, however, about the time course or heterogeneity of treatment effects (HTE) for CCM on psychiatric hospitalization. Assessment of CCM implementation support on psychiatric hospitalization might be more efficient if the timing were informed by an expected time course. Further, understanding HTE could help determine who should be referred for intervention. (i) Estimate the trajectory of CCM effect on psychiatric hospitalization rates. (ii) Explore HTE for CCM across demographic and clinical characteristics. Data from a stepped wedge CCM implementation trial were reanalyzed using 5 570 patients in CCM treatment and 46 443 patients receiving usual care. Time-to-event data was constructed from routine medical records. Effect trajectory of CCM on psychiatric hospitalization was simulated from an extended Cox model over one year of implementation support. Covariate risk contributions were estimated from subset stratified Cox models without using simulation. Ratios of hazard ratios (RHR) allowed comparison by trial arm for HTE analysis, also without simulation. No standard Cox proportional hazards models were used for either estimating the time-course or heterogeneity of treatment effect. The effect of CCM implementation support increased most rapidly immediately after implementation start and grew more gradually throughout the rest of the study. On the final study day, psychiatric hospitalization rates in the treatment arm were 17% to 49% times lower than controls, with adjustment for all model covariates (HR 0.66; 95% CI 0.51-0.83). Our analysis of HTE favored usual care for those with a history of prior psychiatric hospitalization (RHR 4.92; 95% CI 3.15-7.7) but favored CCM for those with depression (RHR 0.61; 95% CI: 0.41-0.91). Having a single medical diagnosis, compared to having none, favored CCM (RHR 0.52; 95% CI 0.31-0.86). Reduction of psychiatric hospitalization is evident immediately after start of CCM implementation support, but assessments may be better timed once the effect size begins to stabilize, which may be as early as six months. HTE findings for CCM can guide future research on utility of CCM in specific populations.

Collaborative chronic care model implementation within outpatient behavioral health care teams: qualitative results from a multisite trial using implementation facilitation

BackgroundThis paper reports on a qualitative evaluation of a hybrid type II stepped-wedge, cluster randomized trial using implementation facilitation to implement team-based care in the form of the collaborative chronic care model (CCM) in interdisciplinary outpatient mental health teams. The objective of this analysis is to compare the alignment of sites’ clinical processes with the CCM elements at baseline (time 1) and after 12 months of implementation facilitation (time 2) from the perspective of providers.MethodsWe conducted semi-structured interviews to assess the extent to which six CCM elements were in place: work role redesign, patient self-management support, provider decision support, clinical information systems, linkages to community resources, and organizational/leadership support. Interviews were transcribed and a priori CCM elements were coded using a directed content analysis approach at times 1 and 2. We sought consensus on, and compared, the extent to which each CCM element was in place at times 1 and 2.ResultsWe conducted 27 and 31 telephone interviews at times 1 and 2, respectively, with outpatient mental health providers at nine participating sites. At time 1 and time 2, three CCM elements were most frequently present across the sites: work role redesign, patient self-management support, and provider decision support. The CCM elements with increased implementation from time 1 to time 2 were work role redesign, patient self-management support, and clinical information systems. For two CCM elements, linkages to community resources and organizational/leadership support, some sites had increased implementation at time 2 compared to time 1, while others had reductions. For the provider decision support element, we saw little change in the extent of its implementation.ConclusionsSites increased the extent of implementation on several CCM elements. The most progress was made in the CCM elements where sites had CCM-aligned processes in place at time 1. Teams made progress on elements they could more easily control, such as work role redesign. Our results suggest that maximizing the benefits of CCM-based outpatient mental health care may require targeting resources and training toward specific CCM elements—especially in the use of clinical information systems and linking with community resources.Trial registrationClinical Trials NCT02543840.

Implementing the Collaborative Chronic Care Model in Mental Health Clinics: Achieving and Sustaining Clinical Effects.

Collaborative chronic care models (CCMs) were established with implementation support in nine mental health clinics. This study sought to determine whether their clinical impact was maintained after implementation support ceased. Posttrial data were analyzed from a randomized stepped-wedge CCM implementation trial in general mental health clinics in nine Department of Veterans Affairs medical centers. Sites received 1 year of implementation support, which was associated with reduced mental health hospitalization rates compared with non-CCM clinics in the same medical centers. Hospitalization rates for the year after implementation support were analyzed by using repeated measures logistic regression comparing the same clinics. Hospitalization rates for the postsupport year did not differ from comparison clinics either in the population that initially showed the difference or the population active in the clinics at the end of the year of implementation support. Clinical effects of the CCM may wane after cessation of active implementation support.

Comparative effectiveness of external vs blended facilitation on collaborative care model implementation in slow-implementer community practices.

To evaluate the comparative effectiveness of external facilitation (EF) vs external+internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low-level implementation support. Primary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12months following randomization. Sites that failed to meet a pre-established implementation benchmark after six months of low-level implementation support were randomized to add either EF or EF/IF support for up to 12months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators' analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow-up analyses. Sites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team. N=21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12months (ΔEF/IF-EF =4.4 patients, 95% CI=1.87-6.87). Moderators' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (ΔEF/IF-EF =9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (ΔEF/IF-EF =-0.9; 95% CI: -4.40, 2.60). Number of providers trained and practice size were not significant moderators. Although stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low-level strategy. Once one or more providers were delivering the CCM, additional on-site personnel did not appear to add value to the implementation effort.

External facilitators\u2019 perceptions of internal facilitation skills during implementation of collaborative care for mental health teams: a qualitative analysis informed by the i-PARIHS framework

BackgroundFacilitation is a key strategy that may contribute to successful implementation of healthcare innovations. In blended facilitation, external facilitators (EFs) guide and support internal facilitators (IFs) in directing implementation processes. Developers of the i-PARIHS framework propose that successful facilitation requires project management, team/process, and influencing/negotiating skills. It is unclear what IF skills are most important in real-world settings, which could inform recruitment and training efforts. As prior qualitative studies of IF skills have only interviewed IFs, the perspectives of their EF partners are needed. Furthermore, little is known regarding the distribution of implementation tasks between IFs and EFs, which could impact sustainability once external support is removed. In the context of an implementation trial, we therefore: 1) evaluated IFs’ use of i-PARIHS facilitation skills, from EFs’ perspectives; 2) identified attributes of IFs not encompassed within the i-PARIHS skills; and 3) investigated the relative contributions of IFs and EFs during facilitation.MethodsAnalyses were conducted within a hybrid type II trial utilizing blended facilitation to implement the collaborative chronic care model within mental health teams of nine VA medical centers. Each site committed one team and an IF to weekly process design meetings and additional implementation activities over 12 months. Three EFs worked with three sites each. Following study completion, the EFs completed semi-structured qualitative interviews reflecting on the facilitation process, informed by the i-PARIHS facilitation skill areas. Interviews were analyzed via directed content analysis.ResultsEFs emphasized the importance of IFs having strong project management, team/process, and influencing/negotiating skills. Prior experience in these areas and a mental health background were also benefits. Personal characteristics (e.g., flexible, assertive) were described as critical, particularly when faced with conflict. EFs discussed the importance of clear delineation of EF/IF roles, and the need to shift facilitation responsibilities to IFs.ConclusionsKey IF skills, according to EFs, are aligned with i-PARIHS recommendations, but IFs’ personal characteristics were also emphasized as important factors. Findings highlight traits to consider when selecting IFs and potential training areas (e.g., conflict management). EFs and IFs must determine an appropriate distribution of facilitation tasks to ensure long-term sustainability of practices.Trial registrationClinicaltrials.gov, September 7, 2015, #NCT02543840.

The Collaborative Chronic Care Model for Mental Health Conditions: From Evidence Synthesis to Policy Impact to Scale-up and Spread.

Background:Extensive evidence indicates that Collaborative Chronic Care Models (CCMs) improve outcome in chronic medical conditions and depression treated in primary care. Beginning with an evidence synthesis which indicated that CCMs are also effective for multiple mental health conditions, we describe a multistage process that translated this knowledge into evidence-based health system change in the US Department of Veterans Affairs (VA).Evidence Synthesis:In 2010, recognizing that there had been numerous CCM trials for a wide variety of mental health conditions, we conducted an evidence synthesis compiling randomized controlled trials of CCMs for any mental health condition. The systematic review demonstrated CCM effectiveness across mental health conditions and treatment venues. Cumulative meta-analysis and meta-regression further informed our approach to subsequent CCM implementation.Policy Impact:In 2015, based on the evidence synthesis, VA Office of Mental Health and Suicide Prevention (OMHSP) adopted the CCM as the model for their outpatient mental health teams.Randomized Implementation Trial:In 2015–2018 we partnered with OMHSP to conduct a 9-site stepped wedge implementation trial, guided by insights from the evidence synthesis.Scale-Up and Spread:In 2017 OMHSP launched an effort to scale-up and spread the CCM to additional VA medical centers. Seventeen facilitators were trained and 28 facilities engaged in facilitation.Discussion:Evidence synthesis provided leverage for evidence-based policy change. This formed the foundation for a health care leadership/researcher partnership, which conducted an implementation trial and subsequent scale-up and spread effort to enhance adoption of the CCM, as informed by the evidence synthesis.

Change in Patient Outcomes After Augmenting a Low-level Implementation Strategy in Community Practices That Are Slow to Adopt a Collaborative Chronic Care Model: A Cluster Randomized Implementation Trial.

Implementation strategies are essential for promoting the uptake of evidence-based practices and for patients to receive optimal care. Yet strategies differ substantially in their intensity and feasibility. Lower-intensity strategies (eg, training and technical support) are commonly used but may be insufficient for all clinics. Limited research has examined the comparative effectiveness of augmentations to low-level implementation strategies for nonresponding clinics. To compare 2 augmentation strategies for improving uptake of an evidence-based collaborative chronic care model (CCM) on 18-month outcomes for patients with depression at community-based clinics nonresponsive to lower-level implementation support. Providers initially received support using a low-level implementation strategy, Replicating Effective Programs (REP). After 6 months, nonresponsive clinics were randomized to add either external facilitation (REP+EF) or external and internal facilitation (REP+EF/IF). The primary outcome was patient 12-item short form survey (SF-12) mental health score at month 18. Secondary outcomes were patient health questionnaire (PHQ-9) depression score at month 18 and receipt of the CCM during months 6 through 18. Twenty-seven clinics were nonresponsive after 6 months of REP. Thirteen clinics (N=77 patients) were randomized to REP+EF and 14 (N=92) to REP+EF/IF. At 18 months, patients in the REP+EF/IF arm had worse SF-12 [diff, 8.38; 95% confidence interval (CI), 3.59-13.18] and PHQ-9 scores (diff, 1.82; 95% CI, -0.14 to 3.79), and lower odds of CCM receipt (odds ratio, 0.67; 95% CI, 0.30-1.49) than REP+EF patients. Patients at sites receiving the more intensive REP+EF/IF saw less improvement in mood symptoms at 18 months than those receiving REP+EF and were no more likely to receive the CCM. For community-based clinics, EF augmentation may be more feasible than EF/IF for implementing CCMs.

Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health

Collaborative chronic care models (CCMs) have extensive randomized clinical trial evidence for effectiveness in serious mental illnesses, but little evidence exists regarding their feasibility or effect in typical practice conditions. To determine the effectiveness of implementation facilitation in establishing the CCM in mental health teams and the impact on health outcomes of team-treated individuals. This quasi-experimental, randomized stepped-wedge implementation trial was conducted from February 2016 through February 2018, in partnership with the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention. Nine facilities were enrolled from all VA facilities in the United States to receive CCM implementation support. All veterans (n = 5596) treated by designated outpatient general mental health teams were included for hospitalization analyses, and a randomly selected sample (n = 1050) was identified for health status interviews. Individuals with dementia were excluded. Clinicians (n = 62) at the facilities were surveyed, and site process summaries were rated for concordance with the CCM process. The CCM implementation start time was randomly assigned across 3 waves. Data analysis of this evaluable population was performed from June to September 2018. Internal-external facilitation, combining a study-funded external facilitator and a facility-funded internal facilitator working with a designated team for 1 year. Facilitation was hypothesized to be associated with improvements in both implementation and intervention outcomes (hybrid type II trial). Implementation outcomes included the clinician Team Development Measure (TDM) and proportion of CCM-concordant team care processes. The study was powered for the primary health outcome, mental component score (MCS). Hospitalization rate was derived from administrative data. The veteran population (n = 5596) included 881 women (15.7%), and the mean (SD) age was 52.2 (14.5) years. The interviewed sample (n = 1050) was similar but was oversampled for women (n = 210 [20.0%]). Facilitation was associated with improvements in TDM subscales for role clarity (53.4%-68.6%; δ = 15.3; 95% CI, 4.4-26.2; P = .01) and team primacy (50.0%-68.6%; δ = 18.6; 95% CI, 8.3-28.9; P = .001). The percentage of CCM-concordant processes achieved varied, ranging from 44% to 89%. No improvement was seen in veteran self-ratings, including the primary outcome. In post hoc analyses, MCS improved in veterans with 3 or more treated mental health diagnoses compared with others (β = 5.03; 95% CI, 2.24-7.82; P < .001). Mental health hospitalizations demonstrated a robust decrease during facilitation (β = -0.12; 95% CI, -0.16 to -0.07; P < .001); this finding withstood 4 internal validity tests. Implementation facilitation that engages clinicians under typical practice conditions can enhance evidence-based team processes; its effect on self-reported overall population health status was negligible, although health status improved for individuals with complex conditions and hospitalization rate declined. ClinicalTrials.gov Identifier: NCT02543840.

Collaborative Care for Returning Veterans

Background: Treatment of Returning Veterans (RVs) involves heterogeneous challenges including post traumatic stress disorder, traumatic brain injuries, and substance dependence. Individual RVs fall along a diagnostic and functional spectrum ranging from remarkably resilient to extremely impaired. Successful treatment requires systems capable of managing such complex, varied presentations and may require adaptations to meet the needs of this population. The Collaborative Chronic Care Model (CCM) may be useful in this regard. Methods: We interviewed 20 staff members at a large urban VA medical center who care for RVs to determine strengths and areas for improvement. We used qualitative methods to assess whether the CCM could be applied to organize care to serve RV needs and prevent chronicity. Results: Analysis of interview data and fit of emergent themes to CCM elements led to consensus that the CCM was likely to be an effective framework for organizing care of RVs provided certain adaptations are made. Need for adaptation was based on analysis of themes that did not match to CCM elements. Of these, “Unique Characteristics of RVs” and “Patient Engagement” were judged to be most essential to informing adaptations to the CCM. Conclusion: Results show the CCM as likely to be an effective method of organizing care for this non-chronic population if expanded emphasis is placed on understanding unique population characteristics as a means of fostering patient engagement. Follow-up studies using RVs and other non-chronic populations as primary sources and testing of hypotheses at multiple sites would further clarify meaning and generalizability of these findings.

Anticipation Said Key to Success of Collaborative Chronic MH Care

Back to table of contents Previous article Next article Professional NewsFull AccessAnticipation Said Key to Success of Collaborative Chronic MH CareAaron LevinAaron LevinSearch for more papers by this authorPublished Online:16 Nov 2012https://doi.org/10.1176/pn.47.22.psychnews_47_22_11-aAbstractGetting ahead of a patient’s mental health and illness may be one key to good medical care, said Mark Bauer, M.D., at APA’s Institute on Psychiatric Services in New York in October.Mark Bauer, M.D., tells participants at APA’s Institute on Psychiatric Services that the collaborative chronic care model is designed to provide “evidence-based, anticipatory, continuous, collaborative care.”Ellen DallagerThe approach has, of course, proven effective for other chronic illnesses.“The collaborative chronic care model has worked in diabetes, asthma, arthritis, congestive heart failure, and depression treated in primary care,” said Bauer, a professor of psychiatry at Harvard Medical School and associate director of the VA Center for Organization, Leadership, and Management Research in Boston.Originally proposed by Edward Wagner, Brian Austin, and Michael Von Korff in an article in the Milbank Quarterly in 1996, the goal of collaborative chronic care is to provide “evidenced-based, anticipatory, continuous, collaborative care,” said Bauer.The central word in that list is “anticipatory,” he said.“Historically, patients have come into our offices with a problem; we fix it, and they come back the next time with a new problem,” he said. “Anticipatory care identifies what is likely to go wrong with the patient and minimizes potential problems while maintaining close contact with the patient and other involved providers.”But achieving collaborative, preventive, continuous care that will improve outcomes takes more than a phrase. Bauer listed several essential areas for change.Practices must be redefined, he said. “Work roles may change, and so may scheduling practices, follow-up, and outreach for missed appointments.”Patients will also need support for enhanced self-management that goes beyond education about their illness.For this model to succeed, clinicians require access to expert consultation, whether in person or online. Interactive information-management techniques must get the right information into prescribers’ hands at the right time—like having lithium levels available before the scheduled appointment time rather than after.Finally, the patient must be linked to community resources, including peer support.Bauer presented results of a study that included a meta-analysis and a systematic review of clinical trials testing the model.The meta-analysis of 57 clinical trials showed significant effects for collaborative-care models across disorders and care settings for depression and for mental and physical quality of life, Bauer said.“A broad, diverse set of trials favored collaborative chronic care models,” he said. “There were smaller effect sizes in mixed, messy, real-world populations but they were still clinically significant.”Costs in this model of collaborative chronic care were not different compared with those for controls.The next step in using the collaborative chronic care model is learning how to enhance clinic-based care to get greater treatment effects while moving beyond the clinic walls.For the latter, adoption could be hampered by practice size, said Bauer.“Most primary behavioral health care practices in the U.S. are too small to adopt the model,” he said. “We may have to think about linking clinics together in groups,” possibly in cooperation with state-sponsored and commercial insurance plans. “Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis” is posted at http://ajp.psychiatryonline.org/article.aspx?articleid=1213771. ISSUES NewArchived

Comorbid Mental Health Symptoms and Heart Diseases: Can Health Care and Mental Health Care Professionals Collaboratively Improve the Assessment and Management?

On the basis of current epidemiological and clinical research, this article describes how mental health symptoms are associated with heart disease, a major chronic condition that occurs primarily in middle and late life. The article describes the culturally and historically important link between heart and mind. It then describes depression and anxiety, both as manifestations of heart disease and as contributors to the disease prognosis. In addition to discussing risk factors, the article discusses factors that protect against the co-occurrence of mental health problems and heart disease such as positive attitudes, coping mechanisms, social supports, and spirituality. Further, the article highlights issues concerning the clinical assessment of mental health symptoms and interventions to address them. Finally, it summarizes the collaborative chronic care model, in which health care professionals-including medical, mental health, gerontological, and community social workers-assess and manage patients with comorbid mental health symptoms and heart disease.

Is the collaborative chronic care model effective for patients with bipolar disorder and co-occurring conditions?

The effectiveness of bipolar collaborative chronic care models (B-CCMs) among those with co-occurring substance use, psychiatric, and/or medical conditions has not specifically been assessed. We assessed whether B-CCM effects are equivalent comparing those with and without co-occurring conditions. We reanalyzed data from the VA Cooperative Study #430 (n=290), an 11-site randomized controlled trial of the B-CCM compared to usual care. Moderators included common co-occurring conditions observed in patients with bipolar disorder, including substance use disorders (SUD), anxiety, psychosis; medical comorbidities (total number), and cardiovascular disease-related conditions (CVD). Mixed-effects regression models were used to determine interactive effects between moderators and 3-year primary outcomes. Treatment effects were comparable for those with and without co-occurring substance use and psychiatric conditions, although possibly less effective in improving physical quality of life in those with CVD-related conditions (Beta=-6.11;p=0.04). Limitations included multiple comparisons and underpowered analyses of moderator effects. B-CCM effects were comparable in patients with co-occurring conditions, indicating that the intervention may be generally applied. Specific attention to physical quality of life in those with CVD maybe warranted.

A Note on the Partnership Between Psychiatry and Primary Care

A Note on the Partnership Between Psychiatry and Primary Care