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Funds in the Integrated Health Care Initiative grant program were distributed through a Request for Proposals (RFP) process in April 2006. Through the RFP, the Foundation awarded more than $2.6 million over three years to Texas primary care and pediatric clinics to promote effective identification and treatment of mental health problems in primary care settings. The five grantee organizations were funded to adopt the collaborative care model, an integrated health care approach in which primary care and mental health providers partner to manage the treatment of mental health problems in the primary care or pediatric setting, and to address barriers to implementation that they encounter. Two decades of research have demonstrated that the collaborative care model improves primary care patients' mental health outcomes with a minimal investment of resources. With the help of national integrated health care experts and a distinguished evaluation team, the Foundation is working with the Integrated Health Care grantees over the three-year funding period to determine how best to implement collaborative care in "real world" settings. Lessons learned from the initiative will be used to promote integrated health care across Texas. This page provides an overview of integrated health care and the collaborative care model. Please use the links on the right side of the page to access more information about the Integrated Health Care Initiative grant program, as well as valuable clinical and research resources. •
Why is the Foundation focusing on integrated health
care? Why
is the Foundation focusing on integrated health care?
The
integrated health care subcommittee concluded that there are well-tested,
effective models for providing integrated care. However, substantial
barriers exist to their implementation. The groundwork has been
laid, and the time is ripe for addressing those real-world barriers.
Most
people seek help for mental health problems in primary care settings,
such as community health clinics. Some do so because they are uninsured
or their insurance does not provide adequate coverage of mental
health services. For people in rural settings, the closest specialty
mental health clinic can be miles away. Cultural beliefs and attitudes
toward mental illness leads some people, especially those in ethnic
minority groups, to seek help in medical settings. With the recent
changes in the state’s eligibility criteria for public mental
health services, people whose psychiatric diagnoses are no longer
covered must now seek care in other settings, including primary
care clinics. Integrated health care can be defined in many ways. For the purposes of the Foundation’s initiative, it means systematically combining physical and mental health services. This can be accomplished in a variety of ways, and integrated health care approaches vary in the extent to which they are truly integrated. The most common models of integrated health care focus on either referrals or collocation of services. With the referral approach, physical health care providers develop agreements with mental health providers, to whom they refer their patients with mental health needs. The physical health care providers typically do not follow up on the referral once it has been made. In a collocation model, physical health care providers and mental health providers are physically located in the same building or on the same premises, with the idea that the proximity of these services will make it easier for people to access care for their physical and mental health problems. While both referrals and collocated services are important elements of an integrated health care model, neither referrals alone or collocation alone produces lasting, positive patient outcomes. Over 20 years of solid research supports collaborative care as the most effective model of integrated health care. What is collaborative care? Collaborative care is an integrated health care model in which physical health and mental health providers partner to manage the treatment of mild to moderate psychiatric disorders and stable severe psychiatric disordersin the primary care setting. Collaborative care can be effectively implemented in a number of ways. It may include brief psychotherapy, or simply medication management and patient education. There are 4 essential elements that must be present in some form:
A
mental health assessment
tool is used to evaluate the presence of psychiatric disorders in
primary care patients who screen positive for, or are suspected
of having, a psychiatric disorder. It is also used to track the
recovery of those with identified mental health needs. There is a great deal of flexibility in the collaborative care model, even in the implementation of its required elements. Organizations can create and implement a collaborative care system that reflects their organizational resources and their patients’ needs. Diagnostic groups The bulk of research on collaborative care models has focused on the treatment of depression. However, emerging research has found the collaborative care approach to be useful with other diagnoses, and collaborative care experts agree that it can be useful in treating many types of mild to moderate psychiatric disorders or stable severe psychiatric disorders in the primary care setting. Patient identification Patients with mental health needs can be identified in different ways. Some providers choose to use a standardized screening instrument to systematically screen primary care patients for mental health problems. Other providers rely on informal means to identify patients with suspected mental health needs. Both approaches have their costs and benefits. Screening protocols improve the detection of mental health problems, but can be costly and time-consuming. Informal detection imposes less of a burden on primary care staff, but can lead to low rates of detection of mental health problems. The best approach depends on the resources of the organization. Assessment tools Any instrument that covers the psychiatric diagnoses to be treated in the primary care setting is appropriate, as long as it has adequate psychometric properties (i.e., adequate reliability and validity with the target population). Patients complete the assessment tool regularly, so the clinical care manager can monitor their response to treatment. The assessment tool is different from a screening instrument. A positive result on a screening instrument signals the physician that the patient is likely experiencing difficulties. An assessment tool is then used to establish that the patient is indeed experiencing difficulties and the nature of the problem. The physician supplements the assessment tool results with additional questions to confirm the diagnosis. Interventions Psychotropic medication is the most common intervention used to treatment mental health problems in the primary care setting. The primary care physician or other qualified staff (e.g., nurse practitioner) prescribes an antidepressant or other appropriate medication, and the care manager monitors the patient’s response and adherence to the medication. When pharmacotherapy is the intervention employed, the organization may require its providers to use a medication algorithm to guide the choice and dosage of medications. There are multiple algorithms available for organizations interested in adopting one. Collaborative care models can also include brief evidence-based psychotherapy as an intervention. There are several brief evidence-based psychotherapies that have been used in the primary care setting, including cognitive-behavioral therapy, interpersonal therapy, and problem solving therapy. Behavior management and related evidence-based treatments are also options for treating children. These therapies can be conducted by clinical care managers with the appropriate credentials or by a collocated mental health professional. Psychotherapy and behavior management approaches are particularly important options for children. Depending on the diagnosis, pharmacotherapy 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 to be effective caremanagers. Many of the research studies on collaborative carehave used licensed professionals in that role, including nurses, nurse practitioners, masters-level social workers or psychologists, and doctoral level psychologists. These professionals are effective in providing brief psychotherapy, too, if that is offered by the clinic. Paraprofessionals can be trained to serve in the clinical care manager role when their responsibilities are limited to monitoring treatment adherence and response and providing education to patients. Paraprofessionals are bachelor-level staff with some 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 patients through other means, including the telephone and televideo links. Consultation with the psychiatrist can also be done through these means. Patient registry The patient registry used to track those with identified mental health needs can be accomplished in several ways. It can be incorporated into the existing clinical database, as long as the necessary data are included and care managers are able to retrieve the information they need. The registry can also be kept separate from the database in a simple Excel or Access spreadsheet. Collaborative care researchers have free patient registry templates available in Excel and Access. View a sample registry template. The registry can also be created in a secure web-based application. Although expensive, 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 the patients’ progress, facilitating communication. Specialty mental health providers Weekly supervision of the clinical care manager by a psychiatrist is critical when the patient intervention involves psychotropic medication. In some collaborative care models, psychiatrists are also available to the primary care physician for direct consultation on difficult patients. The collaborative care model can also be set up such that mental health providers in the primary care setting work directly with collaborative care patients. Psychiatrists may provide medication management. Psychologists, social workers, and other qualified staff may provide counseling or brief evidence-based psychotherapy. When the patient intervention involves brief evidence-based psychotherapy, supervision by an experienced clinician (e.g., Ph.D. psychologist) can also be useful. How do patients move through a collaborative care system from detection to recovery? Patients who screen positive for a psychiatric disorder during a visit with their primary care physician, or who primary care staff suspect may have a mental health problem, complete the mental health assessment tool. If the score on the mental health assessment tool indicates the presence of a psychiatric disorder, the primary care physician asks other pertinent questions to confirm the diagnosis. After confirming the diagnosis, the physician explains the diagnosis and treatment options to the patient and together they decide on an initial treatment plan. If the patient’s psychiatric disorder is too severe to manage in the primary care setting, the physician refers the patient to a specialty mental health provider. The primary care physician or other staff provides the clinical care manager with the names of those who accept treatment. The clinical care manager gets in touch with the patient within one week of the initial diagnosis. In the first care management contact, the clinical care manager provides the patient with information about his or her psychiatric diagnosis and treatment, with the goal of empowering the patient and destigmatizing his or her disorder. The clinical care manager also assesses the patient’s initial treatment adherence and response and works with the patient to address any problems that have arisen. After the first contact, the clinical care manager follows up with the patient monthly or more frequently as needed. If the clinical care manager has face-to-face contacts with the patient, they are usually arranged to coincide with the patient’s appointments with the primary care physician. During each contact with the patient, the clinical care manager assesses the patient’s treatment adherence and administers the mental health assessment tool to track symptom severity. If the patient is not participating in treatment, the clinical care manager works with the patient to identify and address the barriers to treatment adherence. The clinical care manager logs all patient contacts,  all
attempts to contact the patient, treatment changes, and assessment
tool scores into the patient
registry. Information from contacts with the patients is routinely
conveyed to the primary care physician.If the patient is not responding to treatment, the clinical care manager conveys that information to the consulting psychiatrist during their weekly supervision. In preparation for the weekly supervision meeting, the clinical care manager uses the patient registry to identify patients who are not responding to treatment. The clinical care manager reviews these patients with the supervising psychiatrist. Any treatment recommendations, advice, or information that the psychiatrist provides is conveyed to the primary care physician by the clinical care manager. The clinical care management contacts continue until the primary care physician determines that the patient is in recovery. As treatment winds down, the clinical care manager focuses on relapse prevention with the patient.
What
is the evidence for collaborative care?
It
must be noted, however, that even a basic collaborative care package
involving just medication and telephonic treatment monitoring provided
by a paraprofessional is significantly more effective than usual
care in treating mental health problems in the primary care setting. There are barriers to integrated health care at all levels of the service delivery system, from the patient up to health plans and purchasers. Some of the major barriers to integrated health care are outlined below. Clinical barriers
Financial barriers
Policy barriers
Organizational barriers What are the Foundation’s goals for the Integrated Health Care Initiative? We know that collaborative care is an effective model for integrating mental and physical health care services. However, real-world barriers to implementing the model stand in the way of its adoption by community providers. The purpose of the Hogg Foundation for Mental Health’s Integrated Health Care Initiative is to address the barriers that inhibit the implementation of collaborative care approaches in the state of Texas. To fulfill this goal, the Foundation is partnering with grantees to address the clinical, financial, policy, and organizational barriers they encounter as they implement a collaborative care model for managing psychiatric disorders in the primary care setting. Learn more about the Foundation's Integrated Health Care Initiative grant program. Grant
Program •
Links & Resources •
Patient Registry
• Patient
Education • Recent
Research • Glossary
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©
2007 Hogg Foundation for Mental Health
The University of Texas at Austin |
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Providing
appropriate mental health treatment in the primary care setting
presents an important opportunity to reach groups who cannot or
will not access care in the specialty mental health setting. Treating
mental health problems in the primary care setting is also crucial
because many who seek help there have milder symptoms that, if treated
appropriately, can be prevented from developing into a more disabling
disorder.