Implementation Of Collaborative Care Research Articles

Barriers and facilitators to collaborative care implementation within the New York State Collaborative Care Medicaid Program

BackgroundSince 2015, the New York State Office of Mental Health has provided state primary care clinics with outreach, free training and technical assistance, and the opportunity to bill Medicaid for the Collaborative Care Model (CoCM) as part of its Collaborative Care Medicaid Program. This study aims to describe the characteristics of New York State primary care clinics at each step of CoCM implementation, and the barriers and facilitators to CoCM implementation for the New York State Collaborative Care Medicaid Program.MethodsIn this mixed-methods study, clinics were categorized into RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) steps. Clinics were sent a survey, which included questions related to payer mix, funding sources, billing codes used, and patient population demographics. Qualitative interviews were conducted with clinic representatives, focusing on barriers or facilitators clinics experienced affecting their progression to the next RE-AIM step.ResultsOne thousand ninety-nine surveys were sent to primary care clinics across New York State, with 107 (9.7%) completing a survey. Significant differences were observed among the different RE-AIM steps for multiple demographic variables including primary payer, percentage of patients with a diagnose of depression or anxiety, and percent of behavioral health services that are reimbursed, in addition to others. Three main themes regarding barriers and facilitators to implementing CoCM for New York State Medicaid billing emerged from 31 qualitative interviews: (1) Billing requirements, (2) Reimbursement rates, and (3) Buy-in to CoCM.ConclusionsSurvey data align with what we would expect to see demographically in NYS primary care clinics. Qualitative data indicated that CoCM billing requirements/structure and reimbursement rates were perceived as barriers to providing CoCM, particularly with New York State Medicaid, and that buy-in, which included active involvement from organizational leaders and providers that understand the Collaborative Care model were facilitators. Having dedicated staff to manage billing and data reporting is one way clinics minimize barriers, however, there appeared to be a disconnect between what clinics can bill for and the reimbursed amount several clinics are receiving, illustrating the need for stronger billing workflows and continued refinement of billing options across different payers.

Strategies to improve implementation of collaborative care for functional disorders and persistent somatic symptoms: A qualitative study using a Research World Café design

IntroductionPersistent somatic symptoms and functional disorders (PSS/FD) are often complex conditions requiring care from multiple disciplines. One way of bringing the different disciplines together is through collaborative care. Little is known about the implementation barriers faced and relevant strategies to tackle the barriers in this field. Therefore, using expert knowledge, we aim to develop realistic strategies for dealing with implementation barriers of collaborative care in PSS/FD. MethodsThe Research World Café method is a single-session, expert-based method with multiple focus-groups forming and reforming to answer a set of inter-related questions, under the guidance of moderators. Using this method, participants involved in PSS/FD care across different areas of healthcare in the Netherlands developed several realistic strategies for dealing with ten implementation barriers for collaborative care in PSS/FD that were previously identified in a Delphi study. Strategies were grouped into strategy clusters using a card-sorting task. ResultsThirty-three participants took part, representing ten different disciplines, most commonly physiotherapists, psychologists, and physicians. In total, 54 strategies, identified in response to the ten barriers, were grouped into eight strategy clusters. The strategy clusters were professional education, communication, care coordination, care pathways, joint consults, funding, patient involvement, and prevention. ConclusionWe identified a number of useful strategies for dealing with implementation barriers for collaborative care in PSS/FD. Many strategies provided ways to deal with multiple barriers at once. The effects of applying these strategies in collaborative care in PSS/FD will need testing through implementation studies, as well as in other areas needing multidisciplinary care.

Using Linkage-enhancement Strategies to Bridge Treatment Gap among Inmates and Former Inmates in Correctional Settings with Inadequate Mental Health Care

Abstract: Service linkage and skill enhancement strategies were devised in Nigerian prisons with inadequate mental health resources to support the provision of psycho-legal services, including the assessments, identification, and care of inmates and former inmates with mental illness. Over the study period, 74 individuals, consisting of 64 (86.5%) males with a mean age of 33.25 (SD=11.2) years received care or psycho-legal services through these strategies. Clinically, 49% of the participants were diagnosed with schizophrenia (International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code: F20.0–9), 66.7% had first formal clinical diagnosis of mental illness, and as many as 56.1% of the participants endorsed using psychoactive substances. Most participants (73.0%) were assessed and treated within the prison's general medical services with support from a multidisciplinary team from a regional psychiatric hospital. Of the 50 psycho-legal assessments conducted, eight (10.8%) and 12 (16.2%) participants were not criminally responsible and unfit to stand trial, respectively. We included an action-plan to support the implementation of collaborative care, skill-enhancement, and linkage of services as viable strategies in correctional settings with inadequate mental health care.

Amplifying and Diversifying Collaborative Care Implementation Through Demonstration of Meaningful Outcomes

Amplifying and Diversifying Collaborative Care Implementation Through Demonstration of Meaningful Outcomes

Addressing the Maternal Mental Health Crisis Through a Novel Tech-Enabled Peer-to-Peer Driven Perinatal Collaborative Care Model

Addressing the Maternal Mental Health Crisis Through a Novel Tech-Enabled Peer-to-Peer Driven Perinatal Collaborative Care Model

Patient-centered care and geriatric knowledge translation among healthcare providers in Vietnam: translation and validation of the patient-centered care measure

BackgroundPeople are living longer, and the majority of aging people reside in low- and middle-income countries (LMICs). However, inappropriate healthcare contributes to health disparities between populations of aging people and leads to care dependency and social isolation. Tools to assess and evaluate the effectiveness of quality improvement interventions for geriatric care in LMICs are limited. The aim of this study was to provide a validated and culturally relevant instrument to assess patient-centered care in Vietnam, where the population of aging people is growing rapidly.MethodsThe Patient-Centered Care (PCC) measure was translated from English to Vietnamese using forward-backward method. The PCC measure grouped activities into sub-domains of holistic, collaborative, and responsive care. A bilingual expert panel rated the cross-cultural relevance and translation equivalence of the instrument. We calculated Content Validity Indexing (CVI) scores at both the item (I-CVI) and scale (S-CVI/Ave) levels to evaluate the relevance of the Vietnamese PCC (VPCC) measure to geriatric care in the Vietnamese context. We piloted the translated instrument VPCC measure with 112 healthcare providers in Hanoi, Vietnam. Multiple logistic regression models were specified to test the a priori null hypothesis that geriatric knowledge is not different among healthcare providers with perception of high implementation compared with low implementation of PCC measures.ResultsOn the item level, all 20 questions had excellent validity ratings. The VPCC had excellent content validity (S-CVI/Ave of 0.96) and translation equivalence (TS- CVI/Ave of 0.94). In the pilot study, the highest-rated PCC elements were the holistic provision of information and collaborative care, while the lowest-rated elements were the holistic attendance to patients’ needs and responsive care. Attention to the psychosocial needs of aging people and poor coordination of care within and beyond the health system were the lowest-rated PCC activities. After controlling for healthcare provider characteristics, the odds of the perception of high implementation of collaborative care were increased by 21% for each increase in geriatric knowledge score. We fail to reject the null hypotheses for holistic care, responsive care and PCC.ConclusionThe VPCC is a validated instrument that may be utilized to systemically evaluate the practice of patient-centered geriatric care in Vietnam.

Collaborative Care to Treat Chronic Pain after Traumatic Brain Injury: A Randomized Controlled Trial

<h3>Research Objectives</h3> To examine the effectiveness of collaborative care (CC) compared to usual care (UC) to treat chronic pain in individuals with traumatic brain injury (TBI). <h3>Design</h3> Randomized Controlled Trial. <h3>Setting</h3> TBI Rehabilitation Clinics. <h3>Participants</h3> 158 individuals with TBI who were followed in Rehabilitation clinics and endorsed chronic pain. <h3>Interventions</h3> CC included up to 12 visits with a care manager focused on cognitive behavioral treatment (CBT) for pain and coordination with TBI expert group (Psychologist, Physiatrist, Psychiatrist and Neurology Headache Specialist) for medical recommendations. <h3>Main Outcome Measures</h3> Pain Interference as measured by the Brief Pain Inventory (BPI: 0=pain does not interfere to 10=pain completely interferes). <h3>Results</h3> 79 individuals were randomized to each group (CC and UC). 58% were female, injured 4 years ago on average (SD=5.9), 65% had mild TBI, with 19% severe TBI. Of those in CC, 90% completed 11 or 12 sessions. At 4 months post randomization, the CC group had significantly lower pain interference (3.46, SD=2.17) compared to UC (5.03, SD=2.28; p<.001). This difference was maintained at 8 months post randomization (CC=3.61(2.22); UC=4.68(2.51); P=.04). In addition, pain severity (0=no pain, to 10=worst pain) was significantly lower in the CC group at 4 months (3.63, SD=1.95) compared to UC (4.90, SD=2.07). Pain severity was not significantly different at 8 months (p=.07) though lower for both groups (CC=3.51(2.07); UC+4.40(2.27). <h3>Conclusions</h3> Collaborative Care, including CBT for pain and TBI-expert medical recommendations, is a promising approach to reduce pain interference after TBI. Chronic pain is often considered difficult to treat, and implementation of multi-disciplinary CC in Rehabilitation Clinics could benefit patients, providers, and payors as an evidence-based and cost-effective strategy for decreasing disability and increasing function. <h3>Author(s) Disclosures</h3> Authors have no conflicts.

Evaluating Implementation and Outcomes of the Achieving Depression and Anxiety Patient-Centered Treatment Collaborative Care Program in a Large, Integrated Health Care System: A Mixed Methods Observational Study Protocol.

Background Collaborative care is an evidence-based multidisciplinary model shown to improve patient depression and anxiety outcomes. Although there is robust literature showing the effectiveness of collaborative care on depression and anxiety symptoms, there is little published on outcomes of collaborative care implementation or the efficacy of collaborative care compared with psychiatric referrals. Reported here is a study protocol examining a novel depression and anxiety collaborative care program in a large, integrated health care system. Methods This is a mixed methods study of the Achieving Depression and Anxiety Patient-Centered Treatment (ADAPT) program as compared to outpatient psychiatric care at Kaiser Permanente Northern California, a large, integrated health care delivery system. The ADAPT program was designed using collaborative care principles, including measurement-based care, accurate diagnosis, and population management. Eligible participants will be ≥ 18 years old with mild to moderate-severe depressive symptoms as measured by the Patient Health Questionnaire-9. Exclusion criteria include acute suicide risk and serious mental health comorbidities. Implementation is examined using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework and interviews with program stakeholders. Results Pending. Conclusion Study data will help inform future collaborative care efforts while expanding the literature base. The Achieving Depression and Anxiety Patient-Centered Treatment program may improve patient outcomes and access to quality depression and/or anxiety care.

(11) A 3-Year Evaluation of the Impact of Collaborative Care Implementation on Provider Satisfaction, Productivity, and Confidence

(11) A 3-Year Evaluation of the Impact of Collaborative Care Implementation on Provider Satisfaction, Productivity, and Confidence

Collaborative care implementation: lessons learned.

The authors drafted a "Shared Values of Collaborative Care" document with fundamental principles to make better group decisions in implementing collaborative care.

A qualitative examination of the implementation of a perinatal collaborative care program.

To identify implementation strategies for collaborative care (CC) that are successful in the context of perinatal care. Perinatal depression is one of the most common complications of pregnancy and is associated with adverse maternal, obstetric, and neonatal outcomes. Although treating depressive symptoms reduces risks to mom and baby, barriers to accessing psychiatric treatment remain. CC has demonstrated benefit in primary care, expanding access, yet few studies have examined the implementation of CC in perinatal care which presents unique characteristics and challenges. We conducted qualitative interviews with 20 patients and 10 stakeholders from Collaborative Care Model for Perinatal Depression Support Services (COMPASS), a perinatal collaborative care (pCC) program implemented since 2017. We analyzed interview data by employing the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to organize empirically selected implementation strategies from Expert Recommendations for Implementing Change (ERIC) to create a guide for the development of pCC programs. We identified 14 implementation strategies used in the implementation of COMPASS. Strategies were varied, cutting across ERIC domains (eg, plan, educate, finance) and across EPIS contexts (eg, inner context - characteristics of the pCC program). The majority of strategies were identified by patients and staff as facilitators of pCC implementation. In addition, findings show opportunities for improving the implementation strategies used, such as optimal dissemination of educational materials for obstetric clinicians. The implementation of COMPASS can serve as a model for the process of building a pCC program. The identified strategies can support the implementation of this evidence-based practice for addressing postpartum depression.

Does implementation of collaborative care mitigate racial disparities in screening and treatment of perinatal depression?

Collaborative care (CC) is an evidence-based health services intervention that improves health outcomes for individuals with depression. Our objective was to evaluate whether implementation of CC was associated with a reduction in racial disparities in perinatal depression care.

Population-based implementation of behavioral health detection and treatment into primary care: early data from New York state

BackgroundThe Collaborative Care Model is a well-established, evidence-based approach to treating depression and other common behavioral health conditions in primary care settings. Despite a robust evidence base, real world implementation of Collaborative Care has been limited and very slow. The goal of this analysis is to better describe and understand the progression of implementation in the largest state-led Collaborative Care program in the nation—the New York State Collaborative Care Medicaid Program.Data are presented using the RE-AIM model, examining the proportion of clinics in each of the model’s five steps from 2014 to 2019.MethodsWe used the RE-AIM model to shape our data presentation, focusing on the proportion of clinics moving into each of the five steps of this model over the years of implementation. Data sources included: a New York State Office of Mental Health clinic tracking database, billing applications, quarterly reports, and Medicaid claims.ResultsA total of 84% of clinics with which OMH had an initial contact [n = 611clinics (377 FQHCs and 234 non-FQHCs)] received some form of training and technical assistance. Of those, 51% went on to complete a billing application, 41% reported quarterly data at least once, and 20% were able to successfully bill Medicaid. Of clinics that reported data prior to the first quarter of 2019, 79% (n = 130) maintained Collaborative Care for 1 year or more. The receipt of any training and technical assistance was significantly associated with our implementation indices: (completed billing application, data reporting, billing Medicaid, and maintaining Collaborative Care). The average percent of patient improvement for depression and anxiety across 155 clinics that had at least one quarter of data was 44.81%. Training and technical assistance source (Office of Mental Health, another source, or both) and intensity (high/low) were significantly related to implementation indices and were observed in FQHC versus non-FQHC samples.ConclusionsOffering Collaborative Care training and technical assistance, particularly high intensity training and technical assistance, increases the likelihood of implementation. Other state-wide organizations might consider the provision of training and technical assistance when assisting clinics to implement Collaborative Care.

Primary care and mental health: Where do we go from here?

Primary care has been dubbed the “de facto” mental health system of the United States since the 1970s. Since then, various forms of mental health delivery models for primary care have proven effective in improving patient outcomes and satisfaction and reducing costs. Despite increases in collaborative care implementation and reimbursement, prevalence rates of major depression in the United States remain unchanged while anxiety and suicide rates continue to climb. Meanwhile, primary care task forces in countries like the United Kingdom and Canada are recommending against depression screening in primary care altogether, citing lack of trials demonstrating improved outcomes in screened vs unscreened patients when the same treatment is available, high false-positive results, and small treatment effects. In this perspective, a primary care physician and two psychiatrists address the question of why we are not making headway in treating common mental health conditions in primary care. In addition, we propose systemic changes to improve the dissemination of mental health treatment in primary care.

Implementation of collaborative care for depressive disorder treatment among accountable care organizations.

Collaborative care – primary care models combining care management, consulting behavioral health clinicians, and registries to target mental health treatment – is a cost-effective depression treatment model, but little is known about uptake of collaborative care in a national setting. Alternative payment models such as accountable care organizations (ACOs), in which ACOs are responsible for quality and cost for defined patient populations, may encourage collaborative care use.Determine prevalence of collaborative care implementation among ACOs and whether ACO structure or contract characteristics are associated with implementation.Cross-sectional analysis of 2017–2018 National Survey of ACOs (NSACO). Overall, 55% of ACOs returned a survey (69% of Medicare, 36% of non-Medicare ACOs); 48% completed at least half of core survey questions. We used logistic regression to examine the association between implementation of core collaborative care components – care management, a consulting mental health clinician, and a patient registry to track mental health symptoms – and ACO characteristics.Four hundred five National Survey of ACOs respondents answering questions on collaborative care implementation.Only 17% of ACOs reported implementing all collaborative care components. Most reported using care managers (71%) and consulting mental health clinicians (58%), =just 26% reported using patient registries. After adjusting for multiple ACO characteristics, ACOs responsible for mental health care quality measures were 15 percentage points (95% CI 5–23) more likely to implement collaborative care.Most ACOs are not utilizing behavioral health collaborative care. Including mental health care quality measures in payment contracts may facilitate implementation of this cost-effective model. Improving provider capacity to track and target depression treatment with patient registries is warranted as payment contracts focus on treatment outcomes.

Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program.

We developed and implemented a new model of collaborative care that includes a triage and referral management system. We present initial implementation metrics using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Primary care clinicians in 8 practices referred patients with any unmet mental health needs to the Penn Integrated Care program. Assessments were conducted using validated measures. Patients were primarily triaged to collaborative care (26%) or specialty mental health care with active referral management (70%). We conducted 50 qualitative interviews to understand the implementation process and inform program refinement. Our primary outcomes were reach and implementation metrics, including referral and encounter rates derived from the electronic health record. In 12 months, 6,124 unique patients were referred. Assessed patients reported symptoms consistent with a range of conditions from mild to moderate depression and anxiety to serious mental illnesses including psychosis and acute suicidal ideation. Among patients enrolled in collaborative care, treatment entailed a mean of 7.2 (SD 5.1) encounters over 78.1 (SD 51.3) days. Remission of symptoms was achieved by 32.6% of patients with depression and 39.5% of patients with anxiety. Stakeholders viewed the program favorably and had concrete suggestions to ensure sustainability. The Penn Integrated Care program demonstrated broad reach. Implementation was consistent with collaborative care as delivered in seminal studies of the model. Our results provide insight into a model for launching and implementing collaborative care to meet the needs of a diverse group of patients with the full range of mental health conditions seen in primary care.

PRimary Care Opioid Use Disorders treatment (PROUD) trial protocol: a pragmatic, cluster-randomized implementation trial in primary care for opioid use disorder treatment

BackgroundMost people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here.MethodsPROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16–90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be > 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims (“electronic health records,” [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization.DiscussionThe PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings.Trial registration # NCT03407638 (February 28, 2018); CTN-0074 https://clinicaltrials.gov/ct2/show/NCT03407638?term=CTN-0074&draw=2&rank=1

Evidence-Based Approaches to Suicide in Older Adults—Collaborative Care

This individual symposium abstract will focus another evidence-based approach to mental health treatment and in older adults, the collaborative care model. Collaborative care is a consultation-based approach in primary care that has been described with multiple clinical trials, with significant benefit for access and treatment. The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) using the collaborative care model found that those older adults receiving the intervention had a higher utilization of mental health treatment (psychotherapy and/or antidepressant treatment) and had a 2.2 times greater decline in suicidal ideation over 24 months. The authors will describe the utility of using the collaborative care model on the identification of suicidal ideation and subsequent mental health treatment for older adults. The authors will also share about challenges and successes related to collaborative care implementation in healthcare settings for older adults, and relevant policy and financing components for the model.

Enhancing integrated psychosocial oncology through leveraging the oncology social worker's role in collaborative care.

The collaborative care model is effective in delivering evidence-based psychosocial oncology care. Social workers comprise the largest proportion of psychosocial oncology providers in the United States. This study describes the process and perceptions of clinical oncology social workers at a large comprehensive cancer center who transitioned to practicing as care managers within collaborative care. We describe the process of engaging clinical oncology social workers as care managers as part of the implementation of collaborative care at the Seattle Cancer Care Alliance. We then present survey results from 2017 and 2020 of participating social workers' perceptions of the collaborative care model's advantages and disadvantages. Since the implementation of collaborative care at our institution, key functions of the social worker as care manager were defined. The majority of social workers surveyed in 2017 and 2020 agreed that collaborative care led to improved clinical outcomes, timely access to care, and greater patient satisfaction. They also reported professional advantages: more interdisciplinary team integration, working at the top of their licensure, and improved job satisfaction. Challenges identified included missing important patient needs and creating extra work burden for social workers. Oncology social workers can be successfully deployed as care managers within a collaborative care model, thus leveraging existing clinical staff to address unmet psychosocial patient needs. This model is feasible and sustainable in a large academic cancer center, requires minimal additional resources, and is favorably viewed by participating social workers in terms of perceived benefits to patients and their own professional roles.

An Economic Analysis of the Implementation of Team-based Collaborative Care in Outpatient General Mental Health Clinics.

Collaborative Chronic Care Models represent an evidence-based way to structure care for chronic conditions, including mental health conditions. Few studies, however, have examined the cost implications of collaborative care for mental health. We aimed to conduct an economic analysis of implementing collaborative care in 9 outpatient general mental health clinics. Analyses were derived from a stepped wedge hybrid implementation-effectiveness trial. We conducted cost-minimization analyses from the health system perspective, incorporating implementation costs, outpatient costs, and inpatient costs for the year before collaborative care implementation and the implementation year. We used a difference-in-differences approach and conducted 1-way sensitivity analyses to determine the robustness of results to variations ±15% in model parameters, along with probabilistic sensitivity analysis using Monte Carlo simulation. Our treatment group included 5507 patients who were initially engaged in care within 9 outpatient general mental health teams that underwent collaborative care implementation. We compared costs for this group to 45,981 control patients who received mental health treatment as usual at the same medical centers. Collaborative care implementation cost about $40 per patient and was associated with a significant decrease in inpatient costs and a nonsignificant increase in outpatient mental health costs. This implementation was associated with $78 in cost savings per patient. Monte Carlo simulation suggested that implementation was cost saving in 78% of iterations. Collaborative care implementation for mental health teams was associated with significant reductions in mental health hospitalizations, leading to substantial cost savings of about $1.70 for every dollar spent for implementation.