2006 IHC Questions and Answers: Collaborative Care Model

What is collaborative care?

Collaborative care is an integrated health care model in which physicians and mental health providers partner to manage the treatment of mental health conditions in the primary care setting. It can be effectively implemented in many ways. It may include short-term psychotherapy or medication management and consumer education.

What makes collaborative care different?

Collaborative care has four essential elements:

Mental health assessment tool: used to screen patients for psychiatric disorders and track recovery when treatment begins.

Clinical care manager: a professional or paraprofessional who works with mental health consumers in the primary care setting and monitors their response to treatment. Unlike a care coordinator, the clinical care manager focuses on mental health treatment and does not address social services needs. The clinical care manager regularly contacts consumers to provide information about mental health conditions, answer questions and track adherence to treatment. The manager also provides information to family members of children and youth, such as educating parents about what questions to ask of the pediatrician or psychotherapist treating their child. The typical caseload for a full-time clinical care manager is 90 to 120 patients (or three to five new patients per week). A full-time clinical care manager typically provides support to six or seven full-time primary care physicians.

Patient registry: database tool used by clinical care managers to record consumer contacts, scores on mental health assessment tools, and other relevant information.

Psychiatric consultation: a psychiatrist supervises the clinical care manager. Together, the psychiatrist and care manager review the patient registry, focusing on those who are not responding or adhering to treatment. When needed, the psychiatrist makes recommendations for modifications to treatment, such as a change in medication, which the care manager communicates to the patient’s primary care physician.

How do providers use the collaborative care model?

The collaborative care model is flexible and can be adapted to accommodate provider resources and consumer needs. Here are some things to consider in designing a collaborative care system.

Diagnosis: The collaborative care model can be used to treat a variety of mild-to-severe mental health conditions in primary care patients. Health care providers identify consumers’ mental health needs in different ways. Some use standardized instruments to screen and diagnose, while others rely on more informal means. Screening and assessment tools improve the detection of mental health conditions but can be costly and time-consuming. Informal detection imposes less of a burden on primary care staff, but yields a lower rate of detection. The best approach depends on the organization’s resources and can be revisited over time.

Screening and assessment tools: These serve different purposes. A screening test signals that a person likely is experiencing difficulties, while an assessment tool indicates a diagnosis of the problem. Physicians supplement the assessment tool with questions to confirm the diagnosis.

Treatment: Psychotropic medication is the most common treatment of mental health conditions in the primary care setting. The primary care physician or other qualified staff, such as a nurse practitioner, prescribes medication and the care manager monitors the consumer’s response. Collaborative care models also include short-term psychotherapy, including cognitive-behavioral, interpersonal and problem-solving. Behavior management and related treatments are options for treating children. These therapies, based on evidence from successful research, can be conducted by a clinical care manager with appropriate credentials or by a mental health professional in the collaborative care system Psychotherapy and behavior management approaches are particularly important options for treating children. Depending on the diagnosis, medication may not be the first-line remedy for children, given concerns about the safety and effectiveness of using psychotropic medications with children.

Clinical care manager: A variety of professionals and paraprofessionals can be trained as care managers, such as nurses, nurse practitioners, social workers and psychologists. Many can provide short-term psychotherapy, too. Paraprofessionals can serve as clinical care managers when their responsibilities are limited to monitoring treatment and response and providing education to consumers. These paraprofessionals typically have bachelor’s degrees and clinical experience, such as a licensed practical nurse.

Treatment monitoring: When face-to-face contacts are impractical or impossible, clinical care managers can work with consumers by telephone or televideo. The supervising psychiatrist also can supervise a care manager through remote means.

Patient registry: The patient registry can be incorporated into an existing clinical database, as long as it accommodates all the necessary data and care managers can retrieve the information they need. The registry can be kept separate from the clinical database in an Excel or Access spreadsheet. The registry also can operate in a secure Web-based application. This option can be especially useful to organizations in which the care manager, primary care physician and psychiatrist are geographically separated. With a Web-based registry, each member of the team can log on to the Web site from any computer with Internet access to enter information or view records. Collaborative care researchers offer for download free patient registry templates in Excel and Access.

Specialty mental health providers: Weekly supervision of the clinical care manager by a psychiatrist is critical when a consumer’s treatment involves psychotropic medication. In some collaborative care models, a psychiatrist also is available to the primary care physician for consultation on patient and treatment issues. Through the collaborative care model, mental health care providers sometimes work directly with collaborative care patients in the primary care setting. Psychiatrists may provide medication management. Psychologists, social workers, and other qualified staff may provide counseling or psychotherapy. Supervision by an experienced clinician, such as a psychologist with a PhD, can also be effective.

How does a collaborative care system work?

After confirming diagnosis, the physician explains the diagnosis and treatment options to the consumer, and together they decide on an initial treatment plan. Consumers who have a mental health conditions that cannot be managed in a primary care setting are referred to a specialized mental health care provider.

The clinical care manager makes initial contact with the consumer within one week of diagnosis to provide information about the diagnosis and treatment, assess the consumer’s response and address questions or problems that may arise.

The clinical care manager follows up at least monthly with the consumer and typically arranges face-to-face meetings to coincide with the consumer’s appointments with the primary care physician. During each contact, the clinical care manager administers the mental health assessment tool to track the progress of symptoms. If the consumer is not participating in treatment, the clinical care manager helps to identify and address barriers.

The clinical care manager logs all consumer contacts and attempted contacts, changes to treatment and periodic assessment tool scores into the registry. Information from these contacts is conveyed routinely to the primary care physician. If the consumer is not responding to treatment, the clinical care manager conveys that information to the consulting psychiatrist during weekly supervisory sessions. The clinical care manager conveys any treatment recommendations, advice or other information that come up during these sessions to the consumer’s primary care physician.

The clinical care management contacts continue until the primary care physician determines that the consumer is in recovery. As treatment winds down, the clinical care manager focuses on relapse prevention with the consumer.

What evidence supports collaborative care?

More than 20 years of well-designed studies by several groups of researchers support the effectiveness of the collaborative care approach. Health care providers have used the model with consumers of diverse ethnicity, age, gender, socioeconomic status, geographic location and insurance status.

Research shows that collaborative care is effective in decreasing mental health symptoms in primary care consumers and improving their psychosocial functioning and quality of life. Consumers report that they like the model. Physicians and other primary care staff also like the approach, which helps limit staff turnover.

Several variables have a significant impact on the effectiveness of the collaborative care model, however. Consumers respond better when:

They meet in person with clinical care managers instead of over the phone or by televideo.
Their clinical care managers are professionals such as nurses or psychologists rather than paraprofessionals.
Their treatment includes short-term psychotherapy in addition to medication and treatment monitoring.

Even a basic collaborative care approach involving just medication and treatment monitoring over the phone by a paraprofessional is significantly more effective than the traditional means of treating mental health problems in the primary care setting.

The evidence in support of the model is so strong that researchers are moving away from examining its effectiveness to focus on its implementation in real-world settings.

What are the barriers to integrated health care?

Health Care Service Barriers

Primary care providers’ lack of awareness of mental health screening tools.
Physicians’ limited training in mental health conditions and their treatment.
Limited options for referrals to mental health care providers, especially in rural settings.
Lack of time to treat mental health conditions in the primary care setting.
Physicians’ limited access to consultation with mental health care providers.
Consumers’ variable adherence to treatment and providers’ poor understanding of the factors that influence treatment adherence.
Physicians’ lack of interest in treating mental health conditions.
Physicians’ and consumers’ stigmatizing attitudes toward mental illness.
Lack of training in well-researched treatments for consumers of both primary care and mental health care providers.

Insurance Barriers

Lack of insurance parity for mental health conditions (this is being addressed through changes in federal law).
Medicaid’s low payment rates.
Restrictions on professional qualifications required for billing the services of paraprofessional clinical care managers.
Financial disincentives for physicians to treat mental health conditions.
Managed care carve-outs and their incentivization of certain practices in primary care settings, such as prescribing medications and referring consumers to specialty mental health providers.
Inability to bill essential collaborative care activities, such as consultations between psychiatrists and physicians.
Varying ability to bill for well-researched mental health treatments and the cost of providing these treatments, including staffing, training and consumer tracking.
Insurance plan incentivization of psychiatric treatments that are not based on research evidence.

Policy Barriers

Separation of physical health and mental health funding streams.
Difficulties in sharing information across organizations due to the Health Insurance Portability and Accountability Act and other federal and state policies.
Restrictions on activities at community health centers and community mental health centers.
Limitations on the population eligible for public mental health services.
Statutory or regulatory restrictions of public organizations.

Organizational barriers

Shortage of mental health care professionals, especially in rural settings.
Physical separation of medical and mental health provider offices.
Limited communication between medical and mental health care professionals and difficulties in sharing information across organizations.
Differences in cultures between medical and mental health care agencies.
Disagreement between medical and mental health care providers over who is responsible for consumer care.
Stigmatizing attitudes toward mental illness.