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Hernandez V, Nasser L, Do C, Lee WC. Healing the Whole: An International Review of the Collaborative Care Model between Primary Care and Psychiatry. Healthcare (Basel) 2024; 12:1679. [PMID: 39201237 PMCID: PMC11353489 DOI: 10.3390/healthcare12161679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/30/2024] [Accepted: 08/20/2024] [Indexed: 09/02/2024] Open
Abstract
The collaborative care model (CCM) was created to improve the delivery of mental health care and is reported to improve access, enhance treatment outcomes, and reduce healthcare costs. To understand the impacts of the CCM on symptom management, diverse populations, and sustainability in healthcare systems, a systematic review was conducted. Several databases were searched for articles assessing the CCM. The inclusion criteria limited the studies to those (1) published between January 2008 and January 2024; (2) written in the English language; (3) analyzing adult patients; (4) analyzing symptom improvement in major depressive disorder, generalized anxiety disorder, or post-traumatic stress disorder; and (5) fitting the given definition of a CCM. We identified 9743 articles. Due to missing information or duplication, 4702 were excluded. The remaining articles were screened, yielding 468 articles for full-text analysis, of which 16 articles met the inclusion criteria. Of these articles, five primarily focused on individual patient outcomes, five focused on specific populations, and six reviewed system impacts; eleven articles studied US populations and five studied international populations. An analysis revealed that in 12 of the final articles, the CCM led to a statistically significant improvement in anxiety and depression symptoms with viable implementation and sustainability strategies. The CCM is an effective method for improving patient symptoms and can be potentially affordable in healthcare systems.
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Affiliation(s)
- Veronica Hernandez
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA; (V.H.); (L.N.); (C.D.)
| | - Lucy Nasser
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA; (V.H.); (L.N.); (C.D.)
| | - Candice Do
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA; (V.H.); (L.N.); (C.D.)
| | - Wei-Chen Lee
- Department of Family Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
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Hodgins M, Zurynski Y, Burley J, Pelly R, Hibbert PD, Woolfenden S, Le J, Germano S, Khano S, Morris TM, Wheeler K, Hiscock H, Lingam R. Protocol for the implementation evaluation of an integrated paediatric and primary care model: Strengthening Care for Children (SC4C). BMJ Open 2022; 12:e063450. [PMID: 36171022 PMCID: PMC9621160 DOI: 10.1136/bmjopen-2022-063450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Implementation evaluations provide insight into how interventions are delivered across varying contexts and why interventions work in some contexts and not in others. This manuscript outlines a detailed protocol of an implementation evaluation embedded in a stepped-wedge cluster randomised controlled trial of a model of care, Strengthening Care for Children (SC4C), that integrates paediatric care in general practice. The purpose of this manuscript is to describe the pragmatic methods that will be used to capture implementation evaluation process and outcome data within this trial. METHODS AND ANALYSIS Our implementation evaluation will use a mixed methods design, with data collected in the intervention arm of the SC4C trial guided by a logic model developed using the Consolidated Framework for Implementation Research (CFIR) and Proctor and colleague's taxonomy of implementation outcomes. Data collection will be via questionnaires and semistructured interviews with general practitioners, paediatricians, general practice administrative staff and children and families. Each of the 21 general practices recruited into the study will be described in terms of staffing, patient throughput and location, in addition to the nuanced inner and outer contexts, use of the intervention and its acceptability. We will quantify implementation effectiveness in each general practice clinic using the CFIR validated scoring system. Importantly, we have embedded data collection post intervention to enable assessment of the sustainable adoption of the intervention. An inductive approach to the analysis of qualitative data will identify additional emerging themes that may not be covered by the formal frameworks underpinning our analysis. ETHICS AND DISSEMINATION Ethical approval was granted by the Royal Children's Hospital Ethics Committee in August 2020 (HREC: 65955). Results will be submitted for publication in peer-reviewed journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER Australia New Zealand Clinical Trials Registry 12620001299998 on 1 December 2020.
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Affiliation(s)
- Michael Hodgins
- Population Child Health Research Group, University of New South Wales, Sydney, NSW, Australia
| | - Yvonne Zurynski
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Jade Burley
- Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW, Australia
| | - Rachel Pelly
- Health Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Susan Woolfenden
- Population Child Health Research Group, University of New South Wales, Sydney, NSW, Australia
- Sydney Local Health District, Sydney, NSW, Australia
| | - Jane Le
- Health Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Stephanie Germano
- North Western Melbourne Primary Health Network, Parkville, Victoria, Australia
| | - Sonia Khano
- Health Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Tammy Meyers Morris
- Population Child Health Research Group, University of New South Wales, Sydney, NSW, Australia
| | - Karen Wheeler
- Central and Eastern Sydney Primary Health Network, Sydney, NSW, Australia
| | - Harriet Hiscock
- Health Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Health Services Research Unit, The Royal Children's Hospital, Parkville, Victoria, Australia
- Department of General Practice, The University of Melbourne, Parkville, Victoria, Australia
| | - Raghu Lingam
- Population Child Health Research Group, University of New South Wales, Sydney, NSW, Australia
- Sydney Children's Hospitals Network, Sydney, New South Wales, Australia
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Leung LB, Benitez CT, Dorsey C, Mahajan AP, Hellemann GS, Whelan F, Park NJ, Braslow JT. Integrating Mental Health in Safety-net Primary Care: A Five-year Observational Study on Visits in a County Health System. Med Care 2021; 59:975-979. [PMID: 34432766 PMCID: PMC9012483 DOI: 10.1097/mlr.0000000000001637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Beginning in 2010, Los Angeles County Departments of Health Services and Mental Health collaborated to increase access to effective mental health care. The Mental Health Integration Program (MHIP) embedded behavioral health specialists in primary care clinics to deliver brief, problem-focused treatments, and psychiatric consultation support for primary care-prescribed psychotropic medications. OBJECTIVE The aim was to compare primary care visits associated with psychiatric diagnoses before and after MHIP implementation. METHODS This retrospective cohort study (2009-2014) examined 62,945 patients from 8 safety-net clinics that implemented MHIP in a staggered manner in Los Angeles. Patients' primary care visits (n=695,354) were either associated or not with a previously identified or "new" (defined as having no diagnosis within the prior year) psychiatric diagnosis. Multilevel regression models used MHIP implementation to predict odds of visits being associated with psychiatric diagnoses, controlling for time, clinic, and patient characteristics. RESULTS 9.4% of visits were associated with psychiatric diagnoses (6.4% depression, 3.1% anxiety, <1% alcohol, and substance use disorders). Odds of visits being associated with psychiatric diagnoses were 9% higher [95% confidence interval (CI)=1.05-1.13; P<0.0001], and 10% higher for diagnoses that were new (CI=1.04-1.16; P=0.002), after MHIP implementation than before. This appeared to be fueled by increased visits for depression post-MHIP (odds ratio=1.11; CI=1.06-1.15; P<0.0001). CONCLUSIONS MHIP implementation was associated with more psychiatric diagnoses coded in safety-net primary care visits. Scaling up this effort will require greater attention to the notable differences across patient populations and languages, as well as the markedly low coding of alcohol and substance use services in primary care.
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Affiliation(s)
- Lucinda B. Leung
- VA Greater Los Angeles Healthcare System, HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy, Los Angeles, CA
- UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA
| | | | - Charmaine Dorsey
- Los Angeles County Department of Health Services, Los Angeles, CA
| | - Anish P. Mahajan
- UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA
- Los Angeles County Department of Health Services, Los Angeles, CA
| | - Gerhard S. Hellemann
- UCLA Semel Institute for Neuroscience and Human Behavior, Biostatistics Core, Los Angeles, CA
| | - Fiona Whelan
- UCLA Semel Institute for Neuroscience and Human Behavior, Biostatistics Core, Los Angeles, CA
| | - Nina J. Park
- UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA
- Los Angeles County Department of Health Services, Los Angeles, CA
| | - Joel T. Braslow
- UCLA Semel Institute for Neuroscience and Human Behavior, Center for Social Science and Humanities, Los Angeles, CA
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Freed MC. Remember the denominator: improving population impact of translational behavioral research. Transl Behav Med 2021; 10:667-673. [PMID: 32766861 DOI: 10.1093/tbm/ibz184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Michael C Freed
- Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, MD, USA
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Bauer MS, Stolzmann K, Miller CJ, Kim B, Connolly SL, Lew R. Implementing the Collaborative Chronic Care Model in Mental Health Clinics: Achieving and Sustaining Clinical Effects. Psychiatr Serv 2021; 72:586-589. [PMID: 33730885 DOI: 10.1176/appi.ps.202000117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Collaborative chronic care models (CCMs) were established with implementation support in nine mental health clinics. This study sought to determine whether their clinical impact was maintained after implementation support ceased. METHODS Posttrial data were analyzed from a randomized stepped-wedge CCM implementation trial in general mental health clinics in nine Department of Veterans Affairs medical centers. Sites received 1 year of implementation support, which was associated with reduced mental health hospitalization rates compared with non-CCM clinics in the same medical centers. Hospitalization rates for the year after implementation support were analyzed by using repeated measures logistic regression comparing the same clinics. RESULTS Hospitalization rates for the postsupport year did not differ from comparison clinics either in the population that initially showed the difference or the population active in the clinics at the end of the year of implementation support. CONCLUSIONS Clinical effects of the CCM may wane after cessation of active implementation support.
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Affiliation(s)
- Mark S Bauer
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Christopher J Miller
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Bo Kim
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Samantha L Connolly
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
| | - Robert Lew
- Center for Healthcare Organization and Implementation Research, and the Behavior Health Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs (VA), Boston (all authors); Department of Psychiatry, Harvard Medical School, Boston (Bauer, Miller, Kim, Connolly); Department of Biostatistics, Boston University School of Medicine, Boston (Lew)
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The Impact of Systematic Depression Screening in Primary Care on Depression Identification and Treatment in a Large Health Care System: A Cohort Study. J Gen Intern Med 2020; 35:3141-3147. [PMID: 32495093 PMCID: PMC7661597 DOI: 10.1007/s11606-020-05856-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/13/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Unless implementation of systematic depression screening is associated with timely treatment, quality measures based on screening are unlikely to improve outcomes. OBJECTIVE To assess the impact of integrating systematic depression screening with clinical decision support on depression identification and treatment. DESIGN Retrospective pre-post study. PARTICIPANTS Adults with a primary care visit within a large integrated health system in 2016 were included. Adults diagnosed with depression in 2015 or prior to their initial primary care visit in 2016 were excluded. INTERVENTION Initiation of systematic screening using the Patient Health Questionnaire (PHQ) which began in mid-2016. MAIN MEASURES Depression diagnosis was based on ICD codes. Treatment was defined as (1) antidepressant prescription, (2) referral, or (3) evaluation by a behavioral health specialist. We used an adjusted linear regression model to identify whether the percentage of visits with a depression diagnosis was different before versus after implementation of systematic screening. An adjusted multilevel regression model was used to evaluate the association between screening and odds of treatment. KEY RESULTS Our study population included 259,411 patients. After implementation, 59% of patients underwent screening. Three percent scored as having moderate to severe depression. The rate of depression diagnosis increased by 1.2% immediately after systematic screening (from 1.7 to 2.9%). The percent of patients with diagnosed depression who received treatment within 90 days increased from 64% before to 69% after implementation (p < 0.01) and the adjusted odds of treatment increased by 20% after implementation (AOR 1.20, 95% CI 1.12-1.28, p < 0.01). CONCLUSIONS Implementing systematic depression screening within a large health care system led to high rates of screening and increased rates of depression diagnosis and treatment.
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Carleton KE, Patel UB, Stein D, Mou D, Mallow A, Blackmore MA. Enhancing the scalability of the collaborative care model for depression using mobile technology. Transl Behav Med 2020; 10:573-579. [DOI: 10.1093/tbm/ibz146] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
The collaborative care model (CoCM) has substantial support for improving behavioral health care in primary care. However, large-scale CoCM adoption relies on addressing operational and financial implementation challenges across health care settings with varying resources. An academic medical center serving socioeconomically and racially diverse patients implemented the CoCM in seven practices. A smartphone application was introduced to facilitate CoCM care management during depression treatment (app-augmented CoCM). App features included secure texting, goal/appointment reminders, symptom monitoring, and health education material. A nonrandomized convenience patient sample (N = 807) was enrolled in app-augmented CoCM and compared with patients in standard CoCM (N = 3,975). Data were collected on clinical contact frequency, engagement, and clinical outcomes. App-augmented CoCM patients received more health care team contacts (7.9 vs. 4.9, p < .001) and shorter time to follow up compared with the standard CoCM sample (mean = 11 vs. 19 days, p < .001). App-augmented CoCM patients had clinical outcomes similar to the standard CoCM group (47% vs. 46% with ≥50% depression improvement or score <10), despite app-augmented patients having more prior depression treatment episodes. Further, the app-augmented group with greater app engagement demonstrated increased behavioral health appointment compliance, including more completed appointments and fewer no shows, and greater depression symptom improvement than those with less app engagement. App-augmented CoCM may improve patient engagement in treatment and provide opportunities to implement key CoCM elements without overburdening practice resources. CoCM sustainability and scalability in primary care may be enhanced by using this technology.
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Affiliation(s)
| | | | | | - David Mou
- Smartphone Application Vendor, Brooklyn, NY
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Lyon AR, Whitaker K, Richardson LP, French WP, McCauley E. Collaborative Care to Improve Access and Quality in School-Based Behavioral Health. THE JOURNAL OF SCHOOL HEALTH 2019; 89:1013-1023. [PMID: 31612501 DOI: 10.1111/josh.12843] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/27/2018] [Accepted: 08/12/2018] [Indexed: 06/10/2023]
Abstract
BACKGROUND Collaborative care (CC) is a well-established approach for the delivery of accessible behavioral health services in integrated health care settings. Substantial evidence supports its effectiveness in improving the quality and outcomes of adult services, and growing research indicates utility with child and adolescent populations. METHODS To date, studies examining CC models for youth have focused exclusively on primary-care settings. Nevertheless, as the most common integrated service delivery setting for youth, the education sector is an equally important context for improving access to behavioral health services for children and adolescents. RESULTS We provide a narrative review of the literature on CC, describes the relevance of CC to schools, and details its alignment with contemporary movements in education and school-based behavioral health. CONCLUSIONS Potential adaptations of the CC model for use in schools are detailed to improve: (1) behavioral health service accessibility, (2) the capacity of schools to provide behavioral health services, and (3) school service effectiveness through use of evidence-based practices. Although little research has explored the applicability of CC in the education sector, the model holds potential promise to improve the quality and efficiency of school-based behavioral health services.
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Affiliation(s)
- Aaron R Lyon
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115
| | - Kelly Whitaker
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115
| | - Laura P Richardson
- University of Washington/Seattle Children's Research Institute, 2001 8th Avenue, Suite 400, M/S CW8-6, Seattle, WA, 98121
| | - William P French
- University of Washington, 4800 Sand Point Way NE, M/S OA.5.154, PO Box 5371, Seattle, WA, 98145
| | - Elizabeth McCauley
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115
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Leung LB, Rubenstein LV, Yoon J, Post EP, Jaske E, Wells KB, Trivedi RB. Veterans Health Administration Investments In Primary Care And Mental Health Integration Improved Care Access. Health Aff (Millwood) 2019; 38:1281-1288. [DOI: 10.1377/hlthaff.2019.00270] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lucinda B. Leung
- Lucinda B. Leung is a core investigator in the Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, and an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the University of California Los Angeles (UCLA) David Geffen School of Medicine
| | - Lisa V. Rubenstein
- Lisa V. Rubenstein is a professor emerita of medicine in the Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, and the Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Jean Yoon
- Jean Yoon is a health economist at the Health Economics Resource Center, VA Palo Alto Healthcare System, in Menlo Park, California, and the University of California San Francisco
| | - Edward P. Post
- Edward P. Post is the national Primary Care–Mental Health Integration medical director in the Veterans Health Administration based out of the VA Ann Arbor Healthcare System and a professor of medicine in the Division of General Medicine, University of Michigan, in Ann Arbor
| | - Erin Jaske
- Erin Jaske is a data analyst in the Primary Care Analytics Team, VA Puget Sound Healthcare System, in Seattle, Washington
| | - Kenneth B. Wells
- Kenneth B. Wells is the director of the UCLA Center for Health Services and Society; a professor of psychiatry in the Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior; and an associate investigator at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System
| | - Ranak B. Trivedi
- Ranak B. Trivedi is a core investigator at the Center for Innovation to Implementation, VA Palo Alto Healthcare System, and an assistant professor of psychiatry in the Department of Public Mental Health and Population Sciences, Stanford University, in Menlo Park, California
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Bauer MS, Miller CJ, Kim B, Lew R, Stolzmann K, Sullivan J, Riendeau R, Pitcock J, Williamson A, Connolly S, Elwy AR, Weaver K. Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e190230. [PMID: 30821830 PMCID: PMC6484628 DOI: 10.1001/jamanetworkopen.2019.0230] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Collaborative chronic care models (CCMs) have extensive randomized clinical trial evidence for effectiveness in serious mental illnesses, but little evidence exists regarding their feasibility or effect in typical practice conditions. OBJECTIVE To determine the effectiveness of implementation facilitation in establishing the CCM in mental health teams and the impact on health outcomes of team-treated individuals. DESIGN, SETTING, AND PARTICIPANTS This quasi-experimental, randomized stepped-wedge implementation trial was conducted from February 2016 through February 2018, in partnership with the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention. Nine facilities were enrolled from all VA facilities in the United States to receive CCM implementation support. All veterans (n = 5596) treated by designated outpatient general mental health teams were included for hospitalization analyses, and a randomly selected sample (n = 1050) was identified for health status interviews. Individuals with dementia were excluded. Clinicians (n = 62) at the facilities were surveyed, and site process summaries were rated for concordance with the CCM process. The CCM implementation start time was randomly assigned across 3 waves. Data analysis of this evaluable population was performed from June to September 2018. INTERVENTIONS Internal-external facilitation, combining a study-funded external facilitator and a facility-funded internal facilitator working with a designated team for 1 year. MAIN OUTCOMES AND MEASURES Facilitation was hypothesized to be associated with improvements in both implementation and intervention outcomes (hybrid type II trial). Implementation outcomes included the clinician Team Development Measure (TDM) and proportion of CCM-concordant team care processes. The study was powered for the primary health outcome, mental component score (MCS). Hospitalization rate was derived from administrative data. RESULTS The veteran population (n = 5596) included 881 women (15.7%), and the mean (SD) age was 52.2 (14.5) years. The interviewed sample (n = 1050) was similar but was oversampled for women (n = 210 [20.0%]). Facilitation was associated with improvements in TDM subscales for role clarity (53.4%-68.6%; δ = 15.3; 95% CI, 4.4-26.2; P = .01) and team primacy (50.0%-68.6%; δ = 18.6; 95% CI, 8.3-28.9; P = .001). The percentage of CCM-concordant processes achieved varied, ranging from 44% to 89%. No improvement was seen in veteran self-ratings, including the primary outcome. In post hoc analyses, MCS improved in veterans with 3 or more treated mental health diagnoses compared with others (β = 5.03; 95% CI, 2.24-7.82; P < .001). Mental health hospitalizations demonstrated a robust decrease during facilitation (β = -0.12; 95% CI, -0.16 to -0.07; P < .001); this finding withstood 4 internal validity tests. CONCLUSIONS AND RELEVANCE Implementation facilitation that engages clinicians under typical practice conditions can enhance evidence-based team processes; its effect on self-reported overall population health status was negligible, although health status improved for individuals with complex conditions and hospitalization rate declined. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02543840.
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Affiliation(s)
- Mark S. Bauer
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Miller
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Bo Kim
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Robert Lew
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Biostatistics, Boston University School of Medicine, Boston, Massachusetts
| | - Kelly Stolzmann
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | - Jennifer Sullivan
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Health Policy, Law, & Management, Boston University School of Public Health, Boston, Massachusetts
| | - Rachel Riendeau
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Anthropology, University of Iowa, Iowa City
| | - Jeffery Pitcock
- Behavioral Health Quality Enhancement Research Initiative Program, Central Arkansas Veterans Healthcare System, Little Rock
| | | | - Samantha Connolly
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - A. Rani Elwy
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Jamaica Plain, Massachusetts
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Kendra Weaver
- US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention, Washington, DC
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Platt RE, Spencer AE, Burkey MD, Vidal C, Polk S, Bettencourt AF, Jain S, Stratton J, Wissow LS. What's known about implementing co-located paediatric integrated care: a scoping review. Int Rev Psychiatry 2018; 30:242-271. [PMID: 30912463 PMCID: PMC6499629 DOI: 10.1080/09540261.2018.1563530] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Several studies have demonstrated clinical benefits of integrated care for a range of child and adolescent mental health outcomes. However, there is a significant gap between the evidence for efficacy of integrated care interventions vs their implementation in practice. While several studies have examined large-scale implementation of co-located integrated care for adults, much less is known for children. The goal of this scoping review was to understand how co-located mental health interventions targeting children and adolescents have been implemented and sustained. The literature was systematically searched for interventions targeting child and adolescent mental health that involved a mental health specialist co-located in a primary care setting. Studies reporting on the following implementation outcomes were included: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. This search identified 34 unique studies, including randomized controlled trials, observational studies, and survey/mixed method approaches. Components facilitating implementation of on-site integrated behavioural healthcare included interprofessional communication and collaboration at all stages of implementation; clear protocols to facilitate intervention delivery; and co-employment of integrated care providers by specialty clinics. Some studies found differences in service use by demographic factors, and others reported funding challenges affecting sustainability, warranting further study.
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Affiliation(s)
| | | | | | - Carolina Vidal
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Sarah Polk
- Department of Pediatrics, Johns Hopkins University School of Medicine
| | - Amie F Bettencourt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Sonal Jain
- New York Institute of Technology College of Osteopathic Medicine
| | - Julia Stratton
- Vancouver Coastal Health Authority, Pacific Spirit and Raven Song Child and Youth Mental Health Teams
| | - Lawrence S Wissow
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
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Petersen JJ, Hartig J, Paulitsch MA, Pagitz M, Mergenthal K, Rauck S, Reif A, Gerlach FM, Gensichen J. Classes of depression symptom trajectories in patients with major depression receiving a collaborative care intervention. PLoS One 2018; 13:e0202245. [PMID: 30192786 PMCID: PMC6128457 DOI: 10.1371/journal.pone.0202245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/30/2018] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Collaborative care is effective in improving symptoms of patients with depression. The aims of this study were to characterize symptom trajectories in patients with major depression during one year of collaborative care and to explore associations between baseline characteristics and symptom trajectories. METHODS We conducted a cluster-randomized controlled trial in primary care. The collaborative care intervention comprised case management and behavioral activation. We used the Patient Health Questionnaire-9 (PHQ-9) to assess symptom severity as the primary outcome. Statistical analyses comprised latent growth mixture modeling and a hierarchical binary logistic regression model. RESULTS We included 74 practices and 626 patients (310 intervention and 316 control recipients) at baseline. Based on a minimum of 12 measurement points for each intervention recipient, we identified two latent trajectories, which we labeled 'fast improvers' (60.5%) and 'slow improvers' (39.5%). At all measurements after baseline, 'fast improvers' presented higher PHQ mean values than 'slow improvers'. At baseline, 'fast improvers' presented fewer physical conditions, higher health-related quality of life, and had made fewer suicide attempts in their history. CONCLUSIONS A notable proportion of 39.5% of patients improved only 'slowly' and probably needed more intense treatment. The third follow-up in month two could well be a sensible time to adjust treatment to support 'slow improvers'.
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Affiliation(s)
- Juliana J. Petersen
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
- * E-mail:
| | - Johannes Hartig
- Department of Educational Quality and Evaluation, German Institute for International Educational Research, Frankfurt am Main, Germany
| | - Michael A. Paulitsch
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
| | - Manuel Pagitz
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
| | - Sandra Rauck
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Ferdinand M. Gerlach
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
| | - Jochen Gensichen
- Institute of General Practice, Goethe-University Frankfurt am Main, Frankfurt am Main, Germany
- Institute of General Practice and Family Medicine, Ludwig-Maximilians University Clinic, Munich, Germany
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