Collaborative Care Found to Be Superior to Colocated Psychiatric Care
Case management by a behavioral health care manager and caseload review by a psychiatrist appear to be the components of CoCM that produce better outcomes, experts say.
The collaborative care model (CoCM) of integrating mental health and primary care was superior to “colocation” of mental health services in reducing depressive symptoms among primary care patients at a large urban academic medical center, according to a report published August 28 in Psychiatric Services in Advance.
From baseline to follow-up at 12 weeks, patients receiving care in the CoCM experienced significant improvement in depressive symptoms as measured by scores on the PHQ-9. That’s important because it demonstrates that the investment in resources and system change required to implement CoCM does improve care over and above simply locating a mental health specialist in the clinic.
Lead author Michelle A. Blackmore, Ph.D., and her colleagues noted that “identifying the most effective model for improving care quality and clinical outcomes while maximizing limited resources is crucial for convincing stakeholders to invest in sustaining and scaling integrated care.”
“Given the upfront investment and wide-scale system and culture changes involved in integrating behavioral health in primary care settings, identifying the most effective model for improving care quality and clinical outcomes while maximizing limited resources is crucial for convincing stakeholders to invest in sustaining and scaling integrated care,” wrote study author Michelle A. Blackmore, Ph.D., and colleagues at Montefiore Medical Center. “The CoCM appears to offer a more effective model for providing treatment of depression symptoms in primary care, compared with the colocation model.”
CoCM employs a care manager within the primary care site to monitor patient progress and outcomes through measurement-informed care facilitated by a patient registry. A psychiatrist works with the care manager to review the registry, recommend treatment adjustments, and consult about care for more complex patients.
By contrast, in a colocation model, a behavioral health specialist (licensed social worker, psychologist, advanced practice nurse, or psychiatrist) works in the same practice as the primary care team. Patients may be identified for referral to the specialist through screening or clinical recognition of symptoms. However, there is no registry or systematic measurement to track patients’ progress over time and no systematic case review by the psychiatrist.
A comparison of the two models was undertaken at Montefiore, an urban academic medical center with large ambulatory care practices primarily serving racially and ethnically diverse Medicaid and Medicare recipients.
Core CoCM Components Appear to Account for Differences in Outcome
Intensive case management by a care manager and caseload review by a participating psychiatrist are what appear to account for the differences in depression outcomes in a comparison of primary care sites offering the collaborative care model (CoCM) or “colocated” care.
Case management refers to follow-up phone calls and visits with a behavioral health care manager and/or social worker between visits with the primary care clinician. The care manager may monitor medication compliance or suggest behavioral changes that can speed recovery. Caseload review refers to the use of a registry by the participating psychiatrist to track the progress of the entire caseload population, recommend adjustments in care for particular patients, and identify patients with complex psychiatric and medical needs who may require direct care and supervision by the psychiatrist. Both are regarded as core components of the CoCM.
Starting in 2014, patients with behavioral health needs had access to integrated colocated behavioral health care with a psychiatrist and clinical social worker at 19 Montefiore sites. These sites used the Patient Health Questionnaire–2 (PHQ-2) to screen patients for depression, and patients had access to on-site clinical social work counseling, psychotherapy, and psychiatric consultation. The sites employed an electronic medical record (EMR) to integrate records of behavioral and general medical care.
In February 2015, a subgroup of seven sites began to implement the CoCM through a Health Care Innovations Award funded by the Center for Medicare and Medicaid Innovations. The CoCM initiative added an on-site behavioral health care manager to the primary care team. The care manager consults with the primary care physician (PCP) and provides follow-up with patients after visits with the PCP. Additionally, a psychiatrist works with the care manager, social workers, and PCP to review cases using a patient registry; patient progress is systematically tracked using the PHQ-9 and other validated measures.
Blackmore and colleagues identified potential study participants at colocation or CoCM sites by extracting baseline PHQ-9 scores of greater than 10 from the EMR. Potential participants were contacted by telephone for a follow-up PHQ-9 assessment by a trained research assistant blinded to the integration model (colocation versus CoCM).
Of 561 eligible patients who were contacted, 240 consented and enrolled (122 at colocation sites; 118 at the CoCM sites). The primary clinical outcome was severity of depression symptoms, as measured by the PHQ-9 at baseline and 12-week follow-up.
Patients in the CoCM sites overall had a 33 percent reduction in PHQ-9 scores, compared with a 14 percent reduction for patients in the colocation sites. The mean change in PHQ-9 from baseline to follow-up was 2.8 points greater in the CoCM group compared with the colocation group.
Blackmore and colleagues also found that patients in the CoCM sites had significantly more contacts with the treating team (502 for CoCM patients versus 297 for those in colocated sites). These contacts included significantly more PHQ-9 assessments to monitor treatment response compared with the colocation patient contacts.
Experts in integrated care said that the findings are important because colocation is widely regarded as easier to implement. “The natural tendency in primary care is to refer patients to specialists,” said Lori Raney, M.D., a pioneer in integrated care and a member of APA’s Committee on Integrated Care. “Similarly, the natural preference in these clinics is to colocate psychiatrists for referrals. But it’s difficult to get clinics and health centers to see that that doesn’t change outcomes. That’s why this study is valuable.”
She is principal at Health Management Associates, a consulting firm in Denver, Colo., and a trainer in the Transforming Clinical Practice Initiative for which APA is a Support and Alignment Network.
John Kern, M.D., a clinical professor of psychiatry at the AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington, agreed. “It’s very common to hear people say of the collaborative care model, ‘This is too much trouble—we don’t want to do all of that; we just want to locate a mental health clinician in the clinic,’ ” Kern told Psychiatric News. “For clinicians on the ground, it’s hard to see how the extra components of collaborative care can make a difference—all you know is that it involves steps.
“At the AIMS Center, we’ve been making the case that it is the case management and the caseload review by the psychiatrist using a registry that makes the difference in outcomes,” Kern said. “In this study, it’s those components—case management and caseload review—that the patients in the collaborative care sites received. So it’s not irrational to conclude that those are the components that make a difference.” ■
“Comparison of Collaborative Care and Colocation Treatment for Patients With Clinically Significant Depression Symptoms in Primary Care” can be accessed here. Information on CoCM training is posted on APA’s website.
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Published online: 18 September 2018
Published in print: September 8, 2018 – September 21, 2018
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