Longitudinal Remote Coaching for Implementation of Perinatal Collaborative Care: A Mixed-Methods Analysis

The collaborative care model (CoCM) is an integrated behavioral health framework for the treatment of common mental disorders in primary care. Strong evidence supports its efficacy and cost-effectiveness in diverse populations and in clinical settings, including prenatal care and primary care (1, 2). CoCM is a population health model that tracks defined patient populations in registries. Symptoms are measured regularly, and treatment is actively changed until clinical goals are achieved. Trained primary care or prenatal providers along with behavioral health professionals in the clinic provide evidence-based medication or psychosocial treatments and are supported by regular systematic case review (SCR) with a psychiatric consultant (3). During SCR, care managers and psychiatric consultants use a patient registry to guide treatment recommendations for a panel of patients.

Despite the model’s effectiveness, there are barriers to implementing CoCM with sustained fidelity because it is a complex multicomponent intervention that requires training multiple personnel and redesigning systems of care. Although training and technical assistance are rigorous, monitored, and sustained in research settings, support during implementation is often limited to a one-time training session with minimal support thereafter, reducing the likelihood of success. Identifying scalable and effective implementation strategies for CoCM is critical to accelerating the adoption of evidence-based mental health care in primary care settings.

SCR is a critical element of CoCM that allows for population- and measurement-based care and is associated with better patient outcomes. However, many psychiatrists and psychiatric trainees report low confidence in their ability to conduct SCR. We have found that key challenges to implementing SCR include a requirement to reorganize resources, a team approach that can be unfamiliar to both the primary care team and the psychiatric consultant, and lack of experience with the clinical successes of a fully functioning CoCM practice that reinforces fidelity to the model.

Practice facilitation (external facilitation or coaching) are quality-management implementation strategies that can improve uptake and help maintain fidelity in the delivery of evidence-based practices (4). Coaches support changing practices through a range of implementation strategies, such as training, assessment of progress (audit and feedback), technical assistance, and quality improvement, carried out in an iterative manner and guided by care data (5). Implementation of complex care processes, including both procedural and clinical elements, can require facilitation by a coach who has significant specialized experience and skill, limiting the ability to support many sites through standardized training alone. Additionally, ongoing or longitudinal coaching is more effective than one-time training for making significant and sustained changes in the behaviors of mental health clinicians that result in improved patient outcomes (6). On the basis of these considerations and positive experiences over the course of ongoing implementation efforts (7), we evaluated a novel longitudinal intervention-specific coaching model for CoCM teams, longitudinal remote coaching (LRC), as an implementation strategy for perinatal CoCM. LRC uses intervention-specific coaching and facilitation during SCR, a key process within CoCM during which all CoCM members are available at the same time. The intervention-specific coaching that LRC offers is distinct from but complementary to general practice facilitation, which targets more-general clinical processes. Thus, LRC addresses a gap in the implementation support system for complex interventions such as CoCM; it addresses specific needs of the generalist-specialist interaction early, at a critical developmental period of implementation to help these new teams gain the experience needed for clinical success (5). In LRC, a psychiatrist with expertise in CoCM and perinatal CoCM coaches a local clinical team that is new to the model by regularly joining their routine SCR meetings via video conferencing to observe and provide feedback in order to support implementation of and fidelity to CoCM (Figure 1). Direct observation is the major component of LRC, and additional activities include ongoing training in CoCM, review of fidelity measures with follow-up steps to improve fidelity, and addressing obstacles to implementation. Using remote video and audio communications technology for this observation enhances the scalability of LRC. The LRC expert evaluates individual and team functioning to assess mastery of CoCM. Next, we describe the design and feasibility of LRC for perinatal CoCM in three clinics. To our knowledge, this is the first description of LRC for a complex multicomponent intervention such as CoCM.