Collaborative Care Overview andUnderstanding Team Roles

March 7, 2019Ashley Heald, MA, CPHQSenior Project Manager and Practice Coach

UW AIMS Center

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Training Website

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https://aims.uw.edu/wastate/content/cohort 3 primary care settingswinter

Introductions (by Clinic)Clinics:

• Mason General Hospital• Providence Centralia• Providence East Olympia• Providence Hawk’s Prairie• Providence Lacey• Providence Panorama Geriatrics

Prompt(s):• What is your role?• Introduce your team.• Describe your clinic and your clinic’s experience with

collaborative care.

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Learning Objectives

• Recognize why we are doing this• Explore evidence behind collaborative care• Name the core principles of collaborativecare

• Describe team member roles in collaborativecare

• Identify keys to successful integration

BH Provider

BehavioralHealth

Provider/Specialist

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Behavioral Health Provider/Specialist will beused throughout the training and is synonymouswith Care Manager

Where Things Stand Today• Six out of ten people with

mental health disordersget no care.

• Of those who get care:• Only two out of ten see a

trained mental healthprofessional.

• Majority receive treatmentin primary care: 30 millionreceive a prescription for apsychiatric medication inprimary care.

• Only one in four improve.

Who Gets Treatment?

Wang et al., 2005Wang et al., 2005

No Treatment Primary Care Provider

Mental Health Provider

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Why Not Just Refer?: Patient Factors

Grembowski, Martin et al., 2002Simon, Ding et al., 2012

Half of those referred do not follow through

Mean # of visits = 2

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Mental Health in Primary Care Settings

HospitalHospital

Specialty BH Care

Primary Care Behavioral HealthCollaborative Care

Brief Behavioral Interventions

Traditional Primary CareTraditional Primary CarePatient Self Management

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> 80 Randomized Clinical Trials:Better care experience

Access to careClient & provider satisfaction

Better health outcomesLess depressionLess physical painBetter functioningBetter quality of lifeLower mortality

Lower health care costs

“The triple aim of health care reform.”

Treatment to Target Drives EarlyImprovement

Time to Remission for Depression with Collaborative CareManagement in Primary Care:http://www.ncbi.nlm.nih.gov/pubmed/26769872

JAM Board Fam Med, 2016 Jan Feb12

In a recent retrospective study (2008 – 2013) of over7,000 patients:

Usual primarycare: 614 days Collaborative care

program: 86 days

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Twice as Many People ImprovePe

rcen

tage

Participating Organizations

50 % or greater improvement in depression at 12 months

Unützer et al., 2002, 2004

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Usual Care IMPACT

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Not All Integration Efforts Effective

• Approaches that don’t work:– Screening without adequate treatment– Referral to specialty care without closecoordination

– Co located behavioral health specialists withoutsystematic tracking of outcomes or evidencebased treatments

• Patients ‘fall through the cracks’ or stay onineffective treatment for too long

Components of Collaborative Care

• Care Coordination and Care Management• Proactive Monitoring & Treatment to Target• Regular, Systematic Caseload Review

These components, first used to “define” collaborative care in a2013 CMS Health Homes Resource Center Brief, now widely usedas a “sound bite” definition.

Secret Sauce for Collaborative Care

Frequent early contact Treatment to target

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0.00

0.25

0.50

0.75

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Estim

ated

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ulat

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Pro

babl

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0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136

Weeks

Before P4P After P4P

Bao, Y., Druss, B.G., Jung, H.Y., Chan, Y.F. & Unützer, J. (2016)Psychiatr Serv. 2016 Apr 1;67(4):418-24.

Unutzer, J Chan, Y.F., Hafer, E., Knaster, J,. , Shields, A., Powers, D. &Veith, R. ( 2012) American Journal of Public Health Vol. 102, No. 6,pp. e41 e45

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Pause for a moment to reflect

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Core Principles of Collaborative Care

Evidence Based Care. Providers use treatments that haveresearch evidence for effectiveness.

Population Based Care. A defined group of patients istracked in a registry so that no one falls through the cracks.

Treatment to Target. Progress is measured regularly andtreatments are actively changed until clinical goals areachieved.

Patient Centered Care. Primary care and mental healthproviders collaborate effectively using shared care plans.

Accountable Care. Providers are accountable and reimbursedfor quality of care and clinical outcomes, not just volume ofcare.

Principle:Team Based and Patient Centered

New Roles

PCP

PsychiatricConsultant

BehavioralHealthProvider

Patient

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Behavioral Health Provider Role

• Facilitates patient engagement• Provides initial and follow up assessments• Systematically tracks treatment response• Supports treatment plan with PCP• Reviews patients with the psychiatricconsultant each week, with a focus on:– Patients new to caseload– Patients who are not improving under currenttreatment plan

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Motivational Interviewing

Distress Tolerance Skills

Behavioral Activation

Problem Solving Therapy

Behavioral Health Provider RoleEvidence based Brief Interventions Frequent, Persistent Follow up

Bao et al: Psych Serv 2015

Working with the Behavioral HealthProvider

• Does this description align with what you arecurrently doing in your clinic?

Psychiatric Consultant Role

New Roles

PCP

PsychiatricConsultant

BehavioralHealth Specialist

Patient

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PsychiatricConsultant8 hours

CareManager 1

50 80patients

CareManager 2

50 80patients

CareManager 3

50 80patients

Access: Leveraging a Psychiatric Consultant50 80 patients/caseload~3 hrs psych/week/care manager= a lot of patients getting care

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Psychiatric Consultant Role

Psych CaseloadReviews

• Routine schedule (ideallyweekly)

• Prioritize patients that arenot improving, new tocaseload

• Psychiatric providerresponsible for thecaseload

Availability to ConsultUrgently

• Diagnostic dilemmas• Education about diagnosesor medications

• Complex patients such aspregnant or nursingpatients, other medicallycomplicated

Primary Care Provider

New Roles

PCP

PsychiatricConsultant

BehavioralHealth Provider

Patient

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Primary Care Provider Functions• Primary treatment relationship• Links with Collaborative Care Team• Prescribes medication• Monitors medication management, togetherwith BH specialist

• Supports treatment plan• Consults with Collaborative Care team• Supports system change27

Other Primary Care TeamMembersRoles andResponsibilities for:• Medical Assistant• Front Desk / CallCenter

• Clinic Managers• Diabetes Educator• Triage Nurse• Outreach Staff• Pharmacists• Dietician

PCP

Patient BH Specialist

Psych Consultant

Other Primary

Care Team Members

Core CCTeam

Additional PCMH Resources

Community ResourcesSubstance Use Treatment, Vocational Rehabilitation, Specialty Mental Health

Services, Crisis Services, Long Term Care, Other Community Resources

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Principle: Population Based Care

©University of Washington

Free UW AIMS Registry: (https://aims.uw.edu/resource library/patient tracking spreadsheet example data )

Behavioral Health Caseload Tracking

Tracking systems and registries support proactivepatient engagement and active treatment strategies.

No one falls through the cracks!29

“Involves thesystematic use ofsymptom rating scalesto drive clinicaldecision making.”

Principle: Measurement BasedTreatment to Target

https://www.thekennedyforum.org/news/measurement basedcare issue brief30

The “PHQ 9” is like the “A1C” of Depression

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DepressionPHQ 9

DiabetesA1C

Proactive Monitoring andMeasurement Based Treatment to Target• Patients regularly monitored using validatedclinical rating scales (PHQ 9 for depression)and other clinical measures

• Measurable treatment goals defined

• Results of scales and other patient measuresmonitored

• Treatment results frequently evaluated andtreatment is changed until goals achieved

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Principle: Evidence Based Treatment

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Discussing Treatment Options

• The treatment that WORKS is the best one– Patient centered care means patient selectstreatments, not clinician preference

• Try to be unbiased when offering treatment options

• Supporting whole person treatment isimportant “One size fits few”– Medication is not right for everyone

• You can support medication therapy within scope ofpractice

– Psychotherapy is not right for everyone34

Effective Implementation: What is Needed?

Whitebird, et al. Am J Managed Care. 2014;20(9):699 707

Translating Research into Practice

“It is one thing to say with the prophet Amos,‘Let justice roll down like mighty waters,’ andquite another to work out the irrigationsystem.”

William Sloane Coffin

Social activist and clergyman

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Questions

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Resources

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Resource: http://aims.uw.edu A Better Way to Provide Care

http://aims.uw.edu/daniels story introduction collaborative care

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Caseload Tracker video link

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https://aims.uw.edu/resource library/aims caseload tracker

Thank You!

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