Collaborative care models for management of mental and

behavioral health concerns in Federally Qualified Health Centers

1Bethany M. Kwan, 1Benjamin F. Miller, 1,2Marion R. Sills, 1Mika K. Hamer, 1Lisa M. Schilling, & the SAFTINet Consortium 1University of Colorado School of Medicine, 2Children’s Hospital Colorado

Background & Objectives

Collaborative care (also known as integrated behavioral health in primary care) is a model of

care in which primary care medical clinicians and mental and behavioral health clinicians (e.g.,

psychiatrists, psychologists, social workers) work together with patients to identify and treat

mental and behavioral health concerns, from a “whole person” perspective.

Although models vary, basic elements of Collaborative Care (CC) include: (Peek, 2011) • A collaborative team comprised of mental/behavioral health and medical clinicians

• Protocols for identifying, triaging, treating, and tracking mental health concerns from within primary care

• Supporting information technology infrastructure

Dimensions on which CC models may vary: (Miller, Mendenhall, & Malik, 2009)

• Type of collaboration between medical and behavioral health clinicians

• Type of spatial arrangement in which behavioral health clinicians interact with patients and

medical clinicians

• The range of behavioral health concerns addressed in primary care settings

Collaborative care is an effective model for improving access to behavioral health services and

health outcomes, especially in the context of depression and anxiety (Butler et al., 2008).

There is a range of mental & behavioral health (MBH) concerns for which behavioral health

providers (BHPs) can be useful in primary care, such as counseling for health behavior change

and psychosocial issues (Miller et al., under review). There is limited evidence on translation

and implementation of CC models in the real world, especially in low-resource settings (Kwan &

Nease, 2013).

Research Objective:

• To explore the variety of CC models used by Federally Qualified Health Centers (FQHCs) to

provide services for a range of mental and behavioral health (MBH) concerns of primary care

patients.

Research Questions:

1. What CC models do FQHCs use (type of collaboration and spatial arrangement: referral-

based, co-location, full integration) and for which MBH concerns (range of functions and

expertise: health behavior change, psychosocial concerns, mental health, serious mental

illness)?

2. How many and what types of MBH providers work in FQHCs? How many full time equivalents

(FTEs) are employed given practice size?

3. In what practice settings and patient populations are various CC models used?

Methods

Setting: SAFTINet (Scalable Architecture for

Federated Translational Inquiries Network)

• Practice-based research network (PBRN) of

Federally Qualified Health Centers (FQHCs)

and FQHC look-alikes

• 100 member practices in Colorado,

Tennessee, Vermont, and California

• Founded in 2010, in part based on a

collective interest in understanding the

impact of models of care such as the Patient

Centered Medical Home (PCMH) and

Collaborative Care

• Using practice-level surveys, we characterized member practices’ existing models of collaborative care in

terms of staffing, service delivery mechanisms, and the range of mental and behavioral health concerns

systematically addressed within the practice

Measures: Representatives from 47 member FQHCs and FQHC look-alikes from 4 health care organizations in

Colorado and Tennessee completed practice-level surveys in summer 2013

Practice Characteristics

• Designation as FQHC

• Specialties (Adult internal medicine, family medicine, pediatrics, geriatrics)

• Total # of unique patients and patient encounters/year

• Demographics of patient population (ages, gender, race/ethnicity, preferred language, and payer mix)

• Staffing: # and full-time equivalents (FTE) of MBH providers

• LCSW/MSW: master’s level mental health clinicians

• PsyD/PhD or doctoral candidates

• PCMH recognition status (currently recognized, pursuing recognition, not pursuing recognition)

• Participation in reimbursement programs (e.g., Bundled payments, pay for performance)

Results

Distribution of CC models within practices

Mechanism(s) by which any MBH concern is addressed within primary care:

Distribution of CC models by MBH concern

For each MBH concern, to what extent do practices offer services using a systematic

mechanism, and with what CC model(s)?

CC models by practice characteristics

• Practices with family medicine providers were more likely to have full integration (26/34)

than practices without family medicine (7/13), although the difference was not statistically

significant (OR = 2.79, p = .14), likely due to small sample sizes.

• Practices with full integration care for more unique pts than practices without full

integration (M = 6168 vs 3744; p = .08)

Staffing of CC models in FQHCs

• On average, practices with on-site providers employed 1.35 FTEs (SD = 2.1, median = 0.50;

range 0-8.5) of a master’s level provider (LCSW/MSW) and 1.25 FTEs (SD = 2.6, median =

0.50, range 0-14.7) of a doctoral level psychologist (PsyD/PhD) per 5000 unique patients.

• Those with fully integrated models reported a median of 0.58 FTEs for LCSW/MSW and 0.52

FTEs for PsyD/Phd, compared to .16 and .25, respectively, for those without full integration.

Conclusions • A significant proportion of SAFTINet practices are engaged in integrated care

• It is feasible for FQHCs to provide on-site MBH services for a range of mental and behavioral

health concerns. These models are staffed by both masters and doctoral level MBH providers.

• There remains variability in how practices address mental health

• Multiple CC models can be used within a practice across the range of MBH concerns

• There appear to be opportunities to better measure and test the effects of integration

through networks like SAFTINet.

Policy Implications • While SAFTINet practices may not be typical of FQHCs in the U.S., it appears collaborative care is gaining

ground as a valued model for addressing behavioral concerns in primary care.

• Meeting the needs of front line primary care practices will require a better understanding of the workforce

skills and training required (Blount & Miller, 2009; Burke et al., 2013) and the best ways to allocate resources

and pay for these services (Kathol, DeGruy, & Rollman, 2014).

• In order to make a stronger policy case for integration, we must have more consistency in how we define,

evaluate, and advocate for CC models

Future Plans SAFTINet partners plan to conduct comparative effectiveness research on the effects of collaborative care

models on health outcomes for patients with multiple chronic conditions. We also plan to investigate the role of

payment models and reimbursement structures on implementation and sustainability of CC models. Ultimately,

we will disseminate our findings and “best practices” to support more widespread implementation of the model.

Health behavior

change

Psychosocial Mental health Serious mental

illness or

substance abuse

Any MBH

concern

Referral 6 (12.8%) 6 (12.8%) 7 (14.9%) 19 (40.4%) 19 (40.4%)

Co-location 12 (25.5%) 15 (31.9%) 17 (36.2%) 14 (29.8%) 17 (36.2%)

Full integration 33 (70.2%) 33 (70.2%) 33 (70.2%) 26 (55.3%) 33 (70.2%)

No systematic

mechanism

1 (2.1%) 1 (2.1%) 1 (2.1%) 3 (6.4%) 3 (6.4%)

Table 1. #/% Practices using various CC models to address range of MBH concerns

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ORG

1_1

ORG

3_9

ORG

3_7

ORG

2_11

ORG

2_12

ORG

2_17

ORG

2_20

ORG

2_4

ORG

2_6

ORG

2_9

ORG

3_1

ORG

3_2

ORG

3_4

ORG

3_6

ORG

1_10

ORG

1_9

ORG

2_13

ORG

2_18

ORG

1_2

ORG

1_4

ORG

1_5

ORG

1_6

ORG

1_8

ORG

2_1

ORG

2_10

ORG

2_16

ORG

2_5

ORG

2_7

ORG

3_5

ORG

3_1.1

ORG

3_3

ORG

1_11

ORG

1_7

ORG

3_8

ORG

3_9.1

ORG

4_1

ORG

4_2

ORG

4_4

ORG

4_5

ORG

4_6

ORG

4_7

ORG

4_8

ORG

4_9

ORG

2_2

ORG

2_3

ORG

3_10

ORG

4_3

Mix

of

CC

models

wit

hin

pra

cti

ce

none

full

colocate

refer

• Most practices reported some form of collaborative care for

providing care to patients across the full range of MBH concerns.

• 70% of practices (33/47) reported the use of a fully integrated

model (on-site BHPs with shared clinic space with medical

providers) to address health behavior, psychosocial, and/or

mental health concerns.

• 55% (26/47) reported using a fully integrated model for SMI/SA,

while 40% (19/47) reported referral to off-site providers for

SMI/SA.

% of practices offering services for

HEALTH BEHAVIOR

Referral

Co-Location

Full Integration

R+C

R+F

C+F

R+C+F

No system

% of practices offering services for

PSYCHOSOCIAL CONCERNS

Referral

Co-Location

Full Integration

R+C

R+F

C+F

R+C+F

No system

% of practices offering services for

MENTAL HEALTH

Referral

Co-Location

Full Integration

R+C

R+F

C+F

R+C+F

No system

% of practices offering services for

SMI/SA

Referral

Co-Location

Full Integration

R+C

R+F

C+F

R+C+F

No system

Measures continued… Mental & Behavioral Health (MBH) Services • By what mechanisms (if any) do this practice’s patients receive MBH services?

• Referral-based model: Referral to off-site MBH providers

• Co-location model: Co-located MBH providers, who spend some but not all their time in the same clinic

space as medical providers

• Full integration model: On-site behavioral health providers, who share clinic space with medical

providers

• No CC model: No systematic mechanism for delivering MBH services

• For each existing mechanism, for which types of MBH concerns are those services available?

• Health behavior change counseling (e.g., diet, exercise, smoking cessation)

• Counseling for psychosocial/social determinants of health issues (e.g., domestic violence, social

support)

• Diagnosis and/or treatment of mental health conditions (e.g., depression, anxiety)

• Diagnosis and/or treatment of serious mental illness or substance abuse (SMI/SA)

• Note: Practices could report more than one mechanism overall and for each type of MBH concern

• Information exchanged periodically with minimally shared care plans or workflows

Referral-triggered periodic exchange

• Regular communication and coordination, usually via separate systems and workflows, but with care plans coordinated to a significant extent

Regular communication/coordination

• Fully shared treatment plans and documentation, regular communication facilitated and/or clinical workflows that ensure effective communication and coordination

Full collaboration/integration

Separa

te

space

Behavioral health and medical clinicians spend little time with each other practicing in same clinic space.

Patient has to see providers in at least two buildings. C

o-l

ocate

d

space

Behavioral health and medical clinicians in different parts of the same building, spending some but not all their time in same medical clinic space.

Patient typically has to move from primary care to behavioral health. space

Fully s

hare

d

space

Behavioral health and medical clinicians share the same provider rooms, spending all or most of their time seeing patients in that shared space.

Typically, both clinicians see the patient in same exam room.

• Identifying and treating health behavior needs

• Health behavior activation & self-management support

• E.g., Diet, physical activity, smoking cessation

Basic health behavior

• Identifying social barriers for patients in receiving their health care

• Connecting patients with community resources

• Providing social and community support for patients

Psychosocial concerns

• Screening, assessment, and management of acute mental health problems, with triage, referral and consultation when necessary

• Appropriate psychological and pharmaceutical interventions

• E.g., Depression, anxiety

Mental health

• Screening, assessment, and management of acute SMI/SA problem, with triage, referral and consultation when necessary

• Appropriate psychological and pharmaceutical interventions

Serious mental illness & substance abuse (SMI/SA)

*CC models and MBH concern categories are not mutually exclusive

Acknowledgments We would like to thank the entire SAFTINet Consortium for their contributions to this work. We would especially like to

acknowledge the important contributions of current and past leadership at network partner sites, including Parinda Khatri, Jena Saporito,

Andrea Auxier, Arthur Davidson, Jeanne Rozwadowski, Maria DeJesus Diaz-Perez, and Alicyn Kaiser.

Funding provided by AHRQ 1R01HS019908 (Scalable Architecture for Federated Translational Inquiries Network) and AHRQ R01HS022956

(SAFTINet: Optimizing Value and Achieving Sustainability)

References available upon request